Urine analysis and chest X-ray were normal. Blood and urine samples were sent for bacterial culture and antibiotic sensitivity. Within about 18 hours, the blood culture grew K.
Urine culture result was negative. The patient started to improve within the first 24 hours of hospitalization. She had no more fever, the gastrointestinal symptoms had improved and she was able to tolerate oral food intake. Outpatient head CT scan and referral to Ear, Nose, and Throat specialist were arranged due to the nature of this organism. The scan was normal, and the specialist evaluation was unremarkable. It is distinguished from K. It has been implicated as the causative agent of ozena: an atrophic rhinitis marked by a thick mucopurulent discharge, mucosal crusting, and fetor [ 7 ].
This case represents the first report of K. The patient had kidney transplantation long time ago and was on minimum immunosuppression. She presented with symptoms of a blood stream infection, however no localizing symptoms or signs.
A single pathogen, K. Further evaluation did not show any potential source for this particular pathogen. In the literature, only twelve cases have been reported [ 8 — 16 ]. Table 1 summarizes the most important features of these cases.
Patients were old with an average age of The vast majority of these patients were immunocompromised, a clinical situation that ranged from a medical disease to being on medications that suppress immunity.
Chronic rhinitis, which could be the source of the bacteremia, has been reported in some cases. Five out of the eleven patients have died. This high mortality rate could be due to the complicated medical history of these patients, which make them vulnerable to succumb to these conditions even without bacteremia.
Certain risk factors for K. These include chronic rhinitis, old age, prior antibiotic usage, immunosuppression, presence of underlying malignancy, and alcoholism. From one of the biggest K. Antimicrobial susceptibility from previous reports showed that K.
This case showed the same susceptibility. In conclusion, SOT recipients are always at risk of blood stream infection even if they have had the organs for long time and even with minimal immunosuppression.
All potential pathogens should be considered, including unusual ones, such as K. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Article of the Year Award: Outstanding research contributions of , as selected by our Chief Editors. Read the winning articles.
Journal overview. Academic Editor: G. Received 12 Mar Accepted 07 Apr Published 28 Apr Abstract Infections remain a dreadful complication after solid organ transplantation. Introduction Infections are among the commonest causes of morbidity and mortality in solid organ transplant SOT recipients and are the second most cause of death in patients dying with functioning allografts [ 1 ]. Case Report A year-old female, who had a deceased donor kidney transplant 38 years ago, presented to the emergency department with main complaints of fever and gastrointestinal symptoms for 1 day.
Discussion K. The superiority of combinations of third generation cephalosporins and aminoglycosides has been demonstrated in one study but not in others , The clinical outcome when chloramphenicol and aminoglycosides are used in combination has been poor Antimicrobial therapy for nosocomial pneumonia due to K.
Guidelines for therapy of suspected ESBL producers are given in the section on treatment of bacteremia. Although the superiority of combination therapy is debatable, if combination therapy is used for the treatment of Klebsiella pneumonia, a combination of a beta-lactam and an aminoglycoside to which the isolate is susceptible should be chosen rather than a combination of two beta-lactam agents.
In treatment of Gram negative pneumonia with an aminoglycoside, it is very important to dose the drug aggressively Endotracheal aminoglycosides have been used in addition to systemic therapy in the treatment of gram-negative pneumonia Although, pathogens were eradicated from sputum more frequently using this mode of therapy, no significant difference was seen in clinical outcome. Treatment of K. Computed tomography of the chest may be useful in the patient who is slow to respond, in order to exclude entities treated by drainage or debridement for example, empyema or abscess If a patient has rapid improvement on intravenous therapy, sequential therapy with an oral quinolone to which the isolate is susceptible has been shown to be safe in the majority of circumstances 98 , Uncomplicated urinary tract infections UTI with K.
Series, including patients with K. Monotherapy with any of the drugs mentioned is likely to be effective against susceptible urinary tract isolates. One study found that trimethoprim-sulfamethoxazole was more effective and less expensive than nitrofurantoin, cefadroxil or amoxicillin Therapy for three days is sufficient , Complicated urinary tract infections due to K. Once daily administration of intravenous or intramuscular ertapenem is also an option.
The role of oral carbapenems for example, faropenem remains to be determined. In general treatment should be with intravenous agents until fever has resolved - oral therapy with a quinolone can then follow for a total duration of days Correction of the underlying anatomical abnormality or removal of a urinary catheter is also frequently necessary. After the urinary tract, the biliary tree is the most common portal of entry of K. The combination of a beta-lactam and an aminoglycoside has been the gold standard of empiric treatment of cholangitis for many years, although there are few comparative studies available to determine that this is indeed the optimal treatment Most studies of therapeutic efficacy in this group of patients include multiple different organisms and are not specific for K.
Ciprofloxacin as monotherapy has been found to be as effective as combination therapy with ampicillin , ceftazidime and metronidazole in the treatment of acute suppurative cholangitis Ciprofloxacin produces higher biliary concentrations than ceftazidime, cefoperazone, imipenem or netilmicin Biliary decompression is often required as adjunctive treatment of the underlying cause of the cholangitis. Antibiotics should be administered for a minimum of 10 days.
In Asian countries particularly, K. Successful treatment usually consists of appropriate antibiotics plus percutaneous drainage. Imipenem as monotherapy is another alternative. We recommend that a third-generation cephalosporin instead of first generation cephalosporin be given for two to four weeks for a solitary abscess or as long as six weeks for multiple abscesses 54 , 55 , The precise duration of therapy can be determined by ultrasonagraphic progress and resolution of fever and leukocytosis.
No randomized controlled treatment trials have been carried out, but it seems probable that, in the absence of ESBL production, third generation cephalosporins would be the drugs of choice for K.
The reasons for this are their superior penetration into the cerebrospinal fluid CSF 61 and their excellent activity against the organism. One animal study 29 has suggested that ceftriaxone is superior to cefotaxime , but this has not been confirmed in studies in humans. However, there is more published clinical experience with cefotaxime than with ceftriaxone for K.
Cherubin 60 has described successful use of cefotaxime in 14 cases of K. Large doses are traditionally used - for cefotaxime up to 2 G every four hours, and ceftriaxone 2 G twice per day. No studies have been conducted on duration of treatment, although three weeks has been recommended due to significant relapse rates in those treated with shorter courses of therapy.
Although dexamethasone may be used as an adjunct to antibiotics in treatment of bacterial meningitis, there is no data on its use in K. Cefotaxime is the preferred therapy. This is because there is greater clinical experience with the drug than with ceftriaxone 85 , Cefotaxime should not be used alone as empiric treatment of neonatal meningitis, because of lack of coverage against Listeria monocytogenes.
However, because of its superior CSF penetration it is preferred over aminoglycosides in the treatment of neonatal meningitis when the bacteriologic diagnosis of K. If ceftriaxone or cefotaxime can not be used, meropenem is a good alternative. Meropenem is very active against K. In addition it has a low incidence of neurologic side-effects such as seizures when used in the treatment of bacterial meningitis , , Ventriculoperitoneal shunt infections due to K.
In this study ceftriaxone use resulted in faster CSF sterilization than intravenous aminoglycosides. Trimethoprim-sulfamethoxazole effectively penetrates into the CSF and is generally microbiologically active against K.
Recent published experience with this drug is limited, but papers from the early s have documented both clinical success , and failure , There is a small amount of published experience with imipenem in the treatment of K. In the presence of meningeal inflammation, CSF concentrations of imipenem of 0.
This exceeds the MIC90 0. However, the most serious toxicity seen with imipenem, seizures, is more likely in patients with central nervous system disorders There are two case reports of successful use in K.
In one of these studies the imipenem was given only for three days, with cefotaxime and pefloxacin being given for a further 18 days There are numerous instances of relapse of meningitis when chloramphenicol has been used for K.
Some have attributed chloramphenicol failure to antibiotic antagonism 39 , In vitro chloramphenicol interfered with the activity of cefotaxime and several other beta-lactams One case report of clinical failure in meningitis described use of chloramphenicol plus cefotaxime There are single case reports of K.
However, for a variety of pharmacokinetic reasons, use of these drugs would only be attempted in K. Another patient with postneurosurgical meningitis failed imipenem and ceftazidime, but substitution of these antibiotics with meropenem was successful Ventriculitis has been successfully treated with imipenem administered directly into the ventricles A patient from New York City with post neurosurgical meningitis due to a multiply resistant K.
The polymyxin B was continued for a total of 7 days and the meropenem for a total of 21 days. The patient recovered Based on in vitro activity and pharmacokinetics, meropenem should be considered the agent of choice for meningitis due to ESBL producing K. An appropriate dose for a patient with normal renal function is 2 grams every 8 hours administered intravenously. Neurosurgical "hardware" should also be removed. Therapy should be continued for a minimum of 21 days; follow-up cerebrospinal fluid culture to confirm cure should be performed prior to discontinuation of treatment.
Some authors have considered that carbapenems alone may be insufficient therapy because of the potential for advent of carbapenem resistance during therapy These authors have suggested adding intraventricular aminoglycosides or polymyxin B as adjunctive therapy.
There have been numerous reports of K. There is also a strong association between K. The prognosis for a good visual recovery after treatment for K. The few successfully treated patients have been characterized by correct diagnosis within 24 hours of ocular disease presentation and aggressive antimicrobial therapy 57 , Each of the previously reported patients who have had successful treatment for K.
Local ocular therapy has been with intravitreal antibiotics in all but two of the patients who have had successful treatment. Some authors have successfully used combination intravitreal therapy with cefazolin 2mg and gentamicin 4mg , whereas others have used monotherapy with intravitreal amikacin 0.
Ceftazidime 2. In view of the generally poor results with this infection, both intravitreal and intravenous antibiotics should be used to treat K. The penetration of systemically given antibiotics into the eye is variable, however.
Aminoglycosides penetrate the vitreous reasonably well after repetitive systemic dosing Oral ciprofloxacin can achieve vitreous concentrations of 0. A single dose of 0. Of the above choices, clinical experience in treating endophthalmitis with intravenous antibiotics has been greatest with ceftazidime or aminoglycosides, particularly amikacin Fifty cases have recently been reviewed 6. The mortality rate tended to be lower for patients who underwent valve replacement during the course of their infections than for those who did not.
Early consideration of cardiac surgery is essential. Klebsiella endocarditis should be treated with a combination of intravenous aminoglycoside and beta-lactam antibiotic, most likely a third generation cephalosporin. There is little data on which to guide duration of therapy but at least six weeks would appear reasonable Outpatient therapy should be considered only with great caution because rapid deterioration may occur without prior warning.
Serial echocardiograms can aid management. Antibiotic susceptibilities and treatment guidelines for K. Outcomes are very similar to K. The mortality rate at 14 days of K.
It is not known if serious infections with K. Treatment of rhinoscleroma consists of a combination of prolonged antimicrobial therapy at least weeks, but sometimes for months or years and surgical debridement to relieve obstruction of the respiratory tract or cosmetic deformity 7. There are no randomized controlled trials that have determined optimal antimicrobial therapy. Non-antibiotic treatments that have been used include mercurials, caustics for example, zinc chloride, silver nitrate and salicylic acid , arsenicals and methylene blue 7.
Streptomycin was the first antibiotic successfully employed, but suffers from need for intravenous or intramuscular use, nephrotoxicity and ototoxicity 7. Combination with tetracycline has allowed lower doses of streptomycin to be used, therefore lowering toxicity 2. Failure with this regimen has been reported The use of aminoglycosides other than streptomycin has rarely been mentioned.
Despite reported clinical failure of sulfonamides in the s , TMP-SMX has been successfully used 5 , , A number of case reports of use of quinolones in the treatment of rhinoscleroma have been published 12 , 15 , , Avery 12 reported a patient who had partially responded to six weeks of tetracycline and TMP-SMX, but who achieved pathologic and bacteriologic resolution during treatment with oral ciprofloxacin mg twice daily for three months.
Trautmann described a patient who had been unsuccessfully treated with streptomycin and tetracycline, but who responded to a three month course of oral ciprofloxacin mg every twelve hours. The granuloma was then surgically removed. The ofloxacin was continued for 60 days with clinical cure. Badia 15 described a young patient with nasal rhinoscleroma who achieved complete resolution after treatment with oral ciprofloxacin.
Despite high cost, the quinolone class and ciprofloxacin in particular would appear to have a number of advantages over other antibiotics in the treatment of K. I believe it should be regarded as the drug of choice for rhinoscleroma. Ciprofloxacin is the most effective antibiotic in vitro , achieves high concentrations in nasal secretions 71 , can be orally administered, and can concentrate and kill microorganisms within macrophages From the limited data available, response should be expected after one month of therapy although two to three months would be a reasonable total duration of therapy because of the tendency of the condition to relapse There have been no randomized trials in the treatment of K.
Ozena has been successfully treated with ciprofloxacin for a period of months and with intravenous aminoglycosides 77 , The clinical outcome and treatment of patients with serious infections with K. As the data are limited, treatment should be based on antibiotic susceptibility results and consideration of the site of infection.
Treatment in children should follow the same guidelines as in adults. With regard to ESBL producing Klebsiellae in neonatal intensive care units, imipenem has been shown to be well-tolerated in the treatment of preterm and severely ill neonates with ESBL producing K. Of the seventy neonates reported in one study only two 2. Both of these infants had underlying cranial abnormalities.
Meropenem would also be a good choice in neonates with serious infections due to ESBL producing organisms. Guidelines for treatment in patients who cannot take the first choice agents due to penicillin allergy are given in Table 5.
As noted above, early surgical consultation is necessary in patients with Klebsiella endophthalmitis or endocarditis. Interventional radiologists should be consulted in patients with primary Klebsiella liver abscess for drainage of the abscess.
Patients with recurrent Klebsiella bacteremia need thorough radiologic work-up with drainage of collections of pus. Generally, standard clinical endpoints are used for determining the adequacy of therapy for K. After initiation of therapy, a favorable response is signified by resolution of systemic and local symptoms and signs of infection. In patients with primary or secondary bacteremia, blood cultures should become negative. For urinary tract infections, urine cultures should become negative.
Repeat sputum culture to show clearance of the pathogen is rarely necessary for patients with pneumonia, and chronic colonization is not an indication for continuation of therapy. Chest x-rays frequently take weeks to resolve completely. In patients with Klebsiella meningitis, a repeat spinal tap after 48 to 72 hours may be helpful to document microbiologic clearance.
The duration of therapy after an initial favorable clinical response is generally empiric. Pneumonia, bacteremia and urinary tract infections require at least 10 days of therapy. Meningitis should be treated for 21 days, and endocarditis for at least 42 days. If fever recurs during therapy, then a superinfection or a drug allergy should be considered.
Many of the patients infected with K. Outbreaks of Klebsiella infections, particularly in neonatal intensive care units, have been known for more than 30 years. Klebsiell a spp. More than 50 studies have been performed in which molecular epidemiologic techniques have been applied to investigation of outbreaks of infection with ESBL producing Klebsiella spp. In every report, genotypic evidence existed of horizontal transfer of Klebsiella from patient to patient. Outbreaks emanating from a common environmental source have been described but are extremely uncommon.
Some outbreaks are monoclonal but in some hospitals a more complicated situation exists in which multiple strains are circulating at any one time. Restriction of third generation cephalosporins or even restriction of cephalosporins as a class has been successfully implemented as a control strategy , I believe that contact isolation precaution measures should accompany changes in antibiotic policy as a mode of control of spread of ESBL producing Klebsiella. Such an approach requires the identification of asymptomatic carriers of the organism and then accommodation of such individuals in single rooms or cohorting with other colonized patients.
Asymptomatic carriers of ESBL producing organisms can be easily identified by plating rectal swabs onto selective media as described in the section "Laboratory Diagnosis" above. Use of contact isolation precautions has been successful in arresting outbreaks of infection and in reducing new infections in areas in which ESBL producing organisms are endemic , As is the case with acute-care hospitals, patient to patient spread of ESBL producing organisms is a frequent occurrence in nursing homes.
Nursing homes may also serve as a reservoir of infection for the acute-care hospitals to which they send patients Interventions similar to those used in acute-care hospitals would appear warranted in some nursing homes. Abbott S. Klebsiella , Enterobacter, Citrobacter, and Serratia.
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Infections caused by KPC-producing bacteria can be difficult to treat because fewer antibiotics are effective against them. In such cases, a microbiology laboratory must run tests to determine which antibiotics will treat the infection. They must follow the treatment regimen prescribed by the healthcare provider.
If the healthcare provider prescribes an antibiotic, patients must take it exactly as the healthcare provider instructs. Patients must complete the prescribed course of medication, even if symptoms are gone.
If treatment stops too soon, some bacteria may survive and the patient may become re-infected. Patients must wash their hands as often as possible and follow all other hygiene recommendations.
The healthcare provider will order laboratory tests to determine if the Klebsiella infection is drug-resistant. If family members are healthy, they are at very low risk of acquiring a Klebsiella infection.
It is still necessary to follow all precautions, particularly hand hygiene. Klebsiella bacteria are spread mostly by person-to-person contact and hand hygiene is the best way to prevent the spread of germs.
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