Download Klebsiella Pneumoniae

Klebsiella pneumoniae
Presented by: Holly R. Wheeler
Objectives
Following this presentation the learner will be able to :
 Confirm the identification of Klebsiella pneumoniae based upon
the results of the biochemical reactions, gram stain, colony
morphology, and antigen classification.
 Relate K. pneumoniae to specific causes.
 Correlate K. pneumoniae with particular routes of transmission.
 Evaluate the symptoms associated with a K. pneumoniae
infection.
 Assess diagnostic techniques for a K. pneumoniae infection.
 Evaluate who is most at risk for a K. pneumoniae infection and
how the world has been affected.
 Evaluate the treatment options for a K. pneumoniae infection.
 Summarize preventative techniques taken against K.
pneumoniae.
Defining Characteristics
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Gram Stain: Gram negative rod.
Biochemical Reactions:
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Oxidase: Negative
Citrate: Positive
Ferment inositol
Hydrolyzes urea
Do not produce ornithine decarboxylase
Does not produce hydrogen sulfide
Colony morphology: The presence of their polysaccharide capsule
gives rise to large mucoid colonies on solid media.
Antigen Classification: 8 O antigens and 77 K antigens and the
virulence of all serotypes appears to be similar. There are no H
antigens present because K. pneumoniae is non-motile.
Media requirements: K. pneumoniae will grow on routine lab media
(BAP, CHOC, and MAC). Citrate-containing media can be used to
isolate this organism because this organism utilizes citrate has it’s
sole carbon source.
Gram Stain
Being viewed at 100x
Specific Causes
• K. pneumoniae is considered to be apart normal enteric
flora.
• Considered to be pathogenic when it isolated from sterile
sources especially body fluids.
• Most commonly associated with nosocomial infections.
• An international survey of K. pneumoniae bacteremia in
critical care patients revealed that 43% of isolates
produced extended spectrum β-lactamases (ESBLs).
Although this rate may be lower in North America the
possibility for an ESBL-producing organism must always
be taken into consideration especially for all critical care
patients.
• K. pneumoniae has also been associated with Mycotic
aneurysms of the internal carotid artery (ICA).*
Routes of Transmission
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Hand carriage is generally regarded as the most
common mode of transmission. K. pneumoniae has also
been identified on environmental sources such as: blood
pressure monitoring systems, ventricular traps, dialysate,
ultrasonography coupling gel, and even hand
disinfectant.
K. pneumoniae has also been reported as being spread
from newborn intensive care units to adult intensive care
units; these reports have also been documented within
international hospitals as well as domestic.
K. pneumoniae is second only to Escherichia coli for
nosocomial infections.
Symptoms
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Symptoms from a K. pneumoniae infection can vary based upon the
site of the infection.
Symptoms from a pulmonary (pneumonia) infections can be:
coughing, production of copious, thick purulent secretions and the
formation of pulmonary abscesses.
Appendicitis: abdominal pain, loss of appetite, nausea, vomiting,
abdominal swelling, constipation, and fever.
Pancreatic abscesses: a swollen and tender abdomen, nausea and
vomiting, fever, a rapid pulse.
Bacteremia: fever, chills, nausea, vomiting, and confusion.
Cystitis (lower UTI): urinary frequency, fever, and flank pain.
Pyeonephritis (upper UTI): fever, flank pain, and NO increased
urinary frequency.
Diagnosis
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Cultures for diagnosis can be obtained from blood, material from the
trachea, ear canal, throat, and other external sites.
Isolation can occur on routine lab media.
Once K. pneumoniae has been isolated from the laboratory media
it’s identification can be determined by biochemical testing.
Biochemical testing can be conducted in test tubes, an API 20 strip
or by the MicroScan.
Modified Hodge Test (MHT) is a test that is conducted in the
laboratory to detect carbapenemase production in isolates of the
family Enterobacteriaceae. Of all the bacteria in the family
Enterobacteriaceae Klebsiella pneumoniae carbapenemase (KPC)
is the most commonly isolated.
Countercurrent immunoelectrophoresis or a Quellung test can also
be used to aide in the identification of K. pneumoniae.
In situ hybridization techniques have been used to identify K.
pneumoniae in phagocytes from blood specimens.
Resistriction enzyme analysis and ribotyping of isolates have also
been used to characterize the spread of more resistant strains.
Prognosis
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Aggressive initial therapy directly correlates with
survival. By limiting the duration of broadspectrum therapy greatly reduces the likelihood
of drug resistant pathogens immerging; not only
for the critical care patient but for the hospital
and society as a whole.
Numerous studies over the past two decades
have demonstrated that that inadequate
antimicrobial therapy leads to increased
mortality, prolonged lengths of stay, and more
undesirable outcomes.
Survival rates can be decreased by 7.6% for
every hour that treatment is delayed.
Risk Factors
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Who is the most at risk?
K. pneumoniae is commonly highlighted as a pathogen of
debilitated adults and alcoholics. By 1985 nearly 50% of
all reported Klebsiella outbreaks were in neonatal intensive
care units. However, if any patient is immunocompromised
in any way they are placed at a higher risk for contracting
a K. pneumoniae infection.
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How has the world been affected?
K. Pneumoniae infections are primarily opportunistic
nosocomial infections but because this infection is so easily
spread it has become international health risk as well.
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Treatment
Drug of Choice:
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Fluoroquinolones:
 Levofloxacin (Levaquin)
 Moxifloxacin-oral (Avelox)
 Sulfamethoxazole/Trimethoprim (Bactrim, Septra).
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The treatment varies based upon the patients current
treatment and their medical history.
 Example: Cancer patients infected with multiple
strains have been treated successfully with a
cephalosporin plus an aminoglycoside. Whereas
patients infected with a single strain respond to
treatment with a cephalosporin alone.
Treatment (continued)
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Resistance:
 Klebsiella pneumoniae is characteristically resistant to Ampicillin.
 Plasma mid-mediated resistance to aminoglycosides also occurs
commonly.
 Antimicrobial therapy has been made problematic due to certain strains
emerging as ESBLs. ESBLs are widely distributed and their
susceptibility patterns are dependant upon their regional differences.
 The outer-membrane of certain ESBLs have protein changes and porin
changes that can create resistance to third-generation cephalosporins.
 There has also been significant correlation between Klebsiella ESBLs
and ciprofloxacin resistance.
 Carbapenems, like Imipenem or Meropenem, are normally considered
the agent of choice when treating a ESBL-producing Klebsiella
pneumoniae. However, with Klebsiella pneumoniae carbapenemase
(KPC)-producing organisms now emerging each isolate most be
carefully and correctly identified so the patient can be treated quickly
and effectively.*
Prevention
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The best way to prevent a K. pneumoniae infection is using proper
hand washing techniques. Sterilization of instrumentation that has
direct patient contact can also aide against the spread of infection.
Step 1: Apply soap to hands
Step 2: Lather soap and
wash for 15-30 seconds
Step 3: Rinse
hands under running
water
Epidemiology
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K. pneumoniae infections occur primarily as
pathogens of the urinary tract, respiratory tract,
biliary tract, bloodstream, and account for less
than 10% of hospitalized cases of pneumonia in
adults.
A survey conducted by the Centers for Disease
Control and Prevention (CDC) found that the
nosocomial K. Pneumoniae infection rate was
16.7 infections per 10,000 patients discharged.
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References
Klebsiella pneumoniae. [Photograph]. In Encyclopedia Britannica. Retrieved from
http://www.britannica.com/EBchecked/media/100173/Gram-negative-bacilli-Klebsiellapneumoniae-isolated-from-a-lung-abscess
CDC. (Photographer). (1976). Klebsiella pneumoniae 6689. [Photograph]. Atlanta, GA;
CDC. Retrieved April 1, 2011 from http://phil.cdc.gov/phil/details.asp
CDC. (Photographer). (1985). Klebsiella pneumoniae 6609. [Photograph]. Atlanta, GA;
CDC. Retrieved April 1, 2011 from http://phil.cdc.gov/phil/details.asp
The National Digestive Diseases Information Clearinghouse (NDDIC), Initials. (2008,
November). Appendicitis. Retrieved from
http://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/#symptoms
The National Digestive Diseases Information Clearinghouse (NDDIC), Initials. (2008, July).
Pancreatitis. Retrieved from http://digestive.niddk.nih.gov/ddiseases/pubs/pancreatitis/
O'Connell, JB, Darcy, S, & Reil, T. (2009). Extracranial internal carotid artery mycotic
aneurysm: case report and review. Vascular & Endovascular Surgery, 43(4), Retrieved
from http://ves.sagepub.com/content/43/4/410.full.pdf+html *
Arnold, RS, Thom, KA, Sharma, S, Phillips, M, & Kristie Johnson, J. (2011). Emergence of
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e=S.sh.16%7c1%7c1
References (continued)
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Fisher, B.G. (2009). Klebsiella. In R. Feigin, G. Demmler-Harrison, J. Cherry, & S. Kaplan
(Eds.), Textbook of pediatric infectious diseases (pp. 1541-1545). Philadelphia, PA:
Saunders Elsevier.
Ahuja, D., Britt, B.B., Bryan, C.S. (2009). Selection of antibiotics in critical care. In B.
Cunha (Ed.), Infectious diseases in critical care medicine (pp. 487-496). New York,
NY: Informa Healthcare USA, Inc.
Modified Hodge Test for Carbapenemase Detection in Enterobacteriacea. (n.d.) In
Department of health and human resources centers for disease control and prevention.
Retrieved from http://www.ndhealth.gov/microlab/Uploads/HodgeTest.pdf
Smith, Kimberly (Photographer). (2004). Hand Washing Procedure Image 5739
[Photograph]. Atlanta, GA; CDC. Retrieved March 29, 2011, from
http://phil.cdc.gov/phil/details.asp
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[Photograph]. Atlanta, GA; CDC. Retrieved March 29, 2011, from
http://phil.cdc.gov/phil/details.asp
Smith, Kimberly (Photographer). (2004). Hand Washing Procedure Image 5744
[Photograph]. Atlanta, GA; CDC. Retrieved March 29, 2011, from
http://phil.cdc.gov/phil/details.asp
Buxton, Rebecca (Photographer). (2010). Fig 32 [Photograph]. Salt Lake City, Utah;
University of Utah. Retrieved March 29, 2011, from http://microbelibrary.org/images/atlasmac/klebsiella%20pneumoniae%20fig32.jpg
References (continued)
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Pneumonia Symptoms. (2006). Klebsiella pneumoniae. Retrieved from
http://www.pneumoniasymptoms.org/klebsiella-pneumonia/klebsiella-pneumonia.html
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CDC. (2010, November 24). Klebsiella pneumoniae in healthcare settings. Retrieved from
http://www.cdc.gov/HAI/organisms/klebsiella/klebsiella.html
Leavitt, A Navon-Venezia, S, Chmelnitsky, I, Schwaber, M, & Carmeli, Y (2007).
Emergence of KPC-2 and KPC-3 in Carbapenem-Resistant Klebsiella pneumoniae Strains
in an Israeli Hospital. Antimicrobial Agents and Chemotherapy, 51(8). retrieved March 30,
2011, from http://aac.asm.org/cgi/content/full/51/8/3026 *
Allen, M. (Photographer). (2005). Figure 32 klebsiella pneumoniae. [Photograph].
Retrieved from
http://archive.microbelibrary.org/asmonly/details_print.asp?id=1976&Lang=&ISkip=20
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