Monday, August 10, 2015

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

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