Klebsiella Infections

• Common klebsiellae infections in humans include (1) community-acquired pneumonia, (2) UTI, (3) nosocomial infection, (4) rhinoscleroma and ozena, (5) chronic genital ulcerative disease, and (6) colonization
• Most pulmonary diseases caused by K pneumoniae are in the form of bronchopneumonia or bronchitis. These infections are usually hospital-acquired and have a more subtle presentation
• important manifestations of klebsiellae infection in the hospital setting include UTI, pneumonia, bacteremia, wound infection, cholecystitis, and catheter-associated bacteriuria

Treatment

• Cephalosporins have been widely used as monotherapy and in combination with aminoglycosides. 
• Cephalosporins should be avoided if ESBL strains are present. 
• carbapenems, especially imipenem, are effective in ESBL
• Aztreonam and quinolones are useful in patients allergic to penicillin,
• rifampin has been used for treatment of rhinoscleroma. 
• TMP/SMZ is not used in primary treatment of pneumonia. They may be used as initial treatment in uncomplicated UTI

Disease	Treatment
Community-acquired pneumonia ·       very severe illness with a rapid onset and often-fatal outcome ·       acute onset of high fever and chills; flulike symptoms; and productive cough with an abundant, thick, tenacious, and blood-tinged sputum sometimes called currant jelly sputum ·       increased tendency exists toward abscess formation, cavitation, empyema, and pleural adhesions	·  Third-generation cephalosporins or quinolones ·  In one study, combination therapy with aminoglycosides was shown to be superior; this benefit was not observed in other studies. ·  Macrolides have no useful activity against K pneumoniae. ·  Antibiotic therapy should be implemented for at least 14 days
Urinary Tract Infection ·       frequency, urgency, dysuria, hesitancy, low back pain, and suprapubic discomfort ·       Systemic symptoms such as fever and chills are usually indicative of a concomitant pyelonephritis or prostatitis	Uncomplicated ·  may be treated with most oral agents except ampicillin. ·  Monotherapy is effective, and therapy for 3 days is sufficient Complicated ·  oral quinolones or with intravenous aminoglycosides, imipenem, aztreonam, third-generation cephalosporins, or piperacillin/tazobactam. ·  Duration of treatment is usually 14-21 days. Intravenous agents are used until the fever resolves ·  correction of an anatomical abnormality or removal of a urinary catheter.
Nosocomial ·       UTI, pneumonia, bacteremia, wound infection, cholecystitis, and catheter-associated bacteriuria ·       similar presentations to those with infections caused by other organisms. ·       may also be implicated include cholangitis, meningitis, endocarditis, and bacterial endophthalmitis	·  A regimen that includes imipenem, third-generation cephalosporins, quinolones, or aminoglycosides may be used alone or in combination ·  Always confirm susceptibility ·  Treatment should last at least 14 days ·  In patients who rapidly respond to intravenous therapy, switching to an oral quinolone is regarded as safe so long as the isolate is susceptible.
Rhinoscleroma and ozena ·       purulent nasal discharge with crusting and nodule formation that leads to respiratory obstruction ·       primary atrophic rhinitis that often occurs in elderly persons. ·        Common symptoms include nasal congestion and a constant nasal bad smell	·  combination antimicrobial therapy for 6-8 weeks. ·  Therapeutic choices include aminoglycosides, tetracycline, sulfonamides, rifampin, and quinolones. ·  Ozena may be treated with a 3-month course of ciprofloxacin. Intravenous aminoglycosides and trimethoprim/sulfamethoxazole are also useful in the treatment of these conditions.
Chronic genital ulcerative disease ·       presents as a firm papule or subcutaneous nodule that later ulcerates. ·       ulcerogranulomatous presentation is most common and is characterized as a beefy red ulcer	·  doxycycline for 3 weeks and until the lesions are healed. ·  Consider adding gentamicin if no improvement is noted within the first 36-72 hours. ·  Alternative antibiotics include azithromycin, ciprofloxacin, erythromycin, and trimethoprim/sulfamethoxazole
Colonization ·       common problem in patients with indwelling catheters. ·       Most catheter-related UTIs are asymptomatic; the usual complaints of frequency, urgency, dysuria, hesitancy, low back pain, and suprapubic discomfort typically are absent
Cholangitis	·  Combination therapy with a beta-lactam antibiotic and an aminoglycoside ·  Ciprofloxacin monotherapy is as effective as combination therapy for acute suppurative cholangitis. ·  Antimicrobials are administered for at least 10 days. Biliary decompression may be required

Resistant Pattern in Malaysia

• The resistance rates to third generation cephalosporins i.e cefotaxime and ceftazidime have increased from 2011 to 2013. 
• The resistance to cefoperazone/sulbactam has also increased to 10.2% in 2012 compared to only 6.4% in 2011. 
• Gentamicin resistance has increased to 15.3% in 2013, from 14.3% in 2011. 
• There was an increase in meropenem resistance from 0.3% in 2011 to 1.7% in 2012. 

references:

1. NAG 2014
2. http://emedicine.medscape.com