Klebsiella Pneumonia


Article Author:
John Ashurst


Article Editor:
Adam Dawson


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
3/15/2019 10:08:59 AM

Introduction

In 1882, Carl Friedlander first described Klebsiella pneumoniae as an encapsulated bacillus after isolating the bacterium from the lungs of those who had died from pneumonia. Originally named Friedlander's bacillus, it was not until 1886 when the bacterium garnered the name Klebsiella. Klebsiella pneumoniae is a gram-negative, encapsulated, non-motile bacterium that is found in the environment and has been associated with pneumonia in the alcoholic and diabetic patient population. The bacterium typically colonizes human mucosal surfaces of the oropharynx and gastrointestinal (GI) tract. Once the bacterium enters the body, it can display high degrees of virulence and antibiotic resistance. Today, K. pneumoniae pneumonia is considered the most common cause of hospital-acquired pneumonia in the United States and the organism accounts for 3% to 8% of all nosocomial bacterial infections.[1][2]

Etiology

Klebsiella pneumoniae is part of the Enterobacteriaceae family and is described as a gram-negative, encapsulate and non-motile bacterium. Virulence of the bacterium is provided by a wide array of factors that can lead to infection and antibiotic resistance. The polysaccharide capsule of the organism is the most important virulence factor and allows the bacteria to evade opsonophagocytosis and serum killing by the host organism. To date, 77 different capsular types have been studied, and those Klebsiella species without a capsule tend to be less virulent. A second virulence factor is lipopolysaccharides that coat the outer surface of a gram-negative bacteria. The sensing of lipopolysaccharides release an inflammatory cascade in the host organism and has been shown to be a major culprit of the sequela in sepsis and septic shock. Another virulence factor, fimbriae, allows the organism to attach itself to host cells. Siderophores are another virulence factor that is needed by the organism to cause infection in hosts. Siderophores acquire iron from the host to allow propagation of the infecting organism.[3][4]

Klebsiella pneumoniae is one of a handful of bacteria that is now experiencing a high rate of antibiotic resistance secondary to alterations in the core genome of the organism. Alexander Fleming first discovered resistance to beta-lactam antibiotics in 1929 in gram-negative organisms. Since that time, K. pneumoniae has been well studied and has been shown to produce a beta-lactamase that causes hydrolysis of the beta-lactam ring in antibiotics. Extended beta-lactamase (ESBL) K. pneumoniae was seen in Europe in 1983 and the United States in 1989. ESBLs can hydrolyze oxyimino cephalosporins rending third-generation cephalosporins ineffective against treatment. Due to this resistance, carbapenems became a treatment option for ESBL. However, of the 9000 infections reported to the Centers for Disease Control and Prevention (CDC) due to carbapenem-resistant Enterobacteriaceae in 2013, approximately 80% were due to K. pneumoniae. Carbapenem resistance has been linked to an up-regulation in efflux pumps, an alteration of the outer membrane, and increases production in ESBL enzymes in the organism.

Epidemiology

Humans serve as the primary reservoir for K. pneumoniae. In the general community, 5% to 38% of individuals carry the organism in their stool and 1% to 6% in the nasopharynx. However, higher rates of colonization have been reported in those of Chinese ethnicity and those who experience chronic alcoholism. In hospitalized patients, the carrier rate for K. pneumoniae is much higher than that found in the community. In one-study, carrier rates as high as 77% can be seen in the stool of those hospitalized and is felt to be related to the amount of antibiotics that are being given.[5][6]

Pneumonia caused by K. pneumoniae can be broken down into two categories: community-acquired or hospital-acquired pneumonia.  Although community-acquired pneumonia is a fairly common diagnosis, infection with K. pneumoniae is rather uncommon. In the western culture it is estimated that approximately 3% to 5% of all community-acquired pneumonia is related to an infection caused by K. pneumoniae, but in developing countries such as Africa, it can account for approximately 15% of all cases of pneumonia. Overall, K. pneumoniae accounts for approximately 11.8% of all hospital-acquired pneumonia in the world. In those who develop pneumonia while on a ventilator, between 8% to 12% are caused by K. pneumoniae while only 7% occur in those patients who are not ventilated.

History and Physical

The clinical manifestations of pneumonia caused by K. pneumoniae are similar to those seen in community-acquired pneumonia. Patients may present with a cough, fever, pleuritic chest pain and shortness of breath. One stark difference between community-acquired pneumonia caused by Streptococcus pneumoniae and K. pneumoniae is the type of sputum produced. The sputum produced by those with S. pneumoniae is described as “blood tinged” or “rust-colored,” however the sputum produced by those infected by K. pneumoniae is described as “currant jelly.” The reason for this is that K. pneumoniae causes significant inflammation and necrosis of the surrounding tissue.

Evaluation

Laboratory analysis will typically show leukocytosis and is this alone is unable to aid the clinician in diagnosing the organism that caused a patient’s pneumonia. Chest radiograph, however, can aid the physician in narrowing their differential diagnosis to include K. pneumoniae as a cause for the patient’s condition. Pneumonia caused by K. pneumoniae typically causes a lobar infiltrate that is in the posterior aspect of the right upper lung. K. pneumoniae infections rarely cause lung abscesses in those with pneumonia but can commonly be associated with empyema. Another non-specific sign of K. pneumoniae on chest radiograph is the bulging fissure sign. This is related to the large amount of infection and inflammation that the organism can cause. Although these are findings can be used to aid the clinician in narrowing their differential diagnosis, they should not be thought of as indicative of pneumonia caused by K. pneumoniae. In the setting of pneumonia, infection with K. pneumoniae is confirmed by either sputum culture analysis or blood culture analysis.[7][8]

Treatment / Management

Given the low occurrence of K. pneumoniae pulmonary infections in the community, treatment of pneumonia should follow standard guidelines for antibiotic therapy. Once infection with K. pneumoniae is either suspected or confirmed, antibiotic treatment should be tailored to local antibiotic sensitivities. Current regimes for community-acquired K. pneumoniae pneumonia include a 14-day treatment with either a third or fourth generation cephalosporin as monotherapy or a respiratory quinolone as monotherapy or either of the previous regimes in conjunction with an aminoglycoside. If the patient is penicillin allergic, then a course of aztreonam or a respiratory quinolone should be undertaken. For nosocomial infections, a carbapenem can be used as monotherapy until sensitivities are reported.[9][10][11]

When ESBL is diagnosed, carbapenem therapy should be initiated due to its rate of sensitivity across the globe. When CRE is diagnosed, infectious disease consultation should be obtained to guide treatment. Several antibiotic options to treat CRE include antibiotics from the polymyxin class, tigecycline, fosfomycin, aminoglycosides or dual therapy carbapenems. Combination therapy of two or more of the agents as mentioned earlier may decrease mortality as compared to monotherapy alone.

Differential Diagnosis

The differential diagnosis for pneumonia caused by K. pneumoniae should include all organisms that typically cause community-acquired and hospital-acquired pneumonia. Other things to consider include tuberculosis, Aspergillus infection, cancer, and acute respiratory distress syndrome (ARDS).

Complications

Pneumonia caused by K. pneumoniae can be complicated by bacteremia, lung abscesses, and the formation of an empyema.

Pearls and Other Issues

  • Klebsiella pneumonia is a gram-negative bacteria that typically cause nosocomial infections and shows a great deal of antibiotic resistance.
  • Radiograph findings should not be used to make a diagnosis of Klebsiella pneumoniae infection definitively. 
  • “Currant jelly” sputum is a hallmark of infection with Klebsiella pneumoniae.
  • K. pneumoniae infections can carry a high degree of antibiotic resistance and lead to a significant amount of patient mortality.

Enhancing Healthcare Team Outcomes

Klebsiella pneumonia is a serious infection, and even with adequate treatment, the mortality rates remain high. This infection is best looked after a multidisciplinary team that includes an infectious disease expert, pharmacists, nurses, intensivist, dietitian, pulmonologist and respiratory therapist. Nurses who look after these patients should maintain strict infection control protocols to prevent the spread of the organism. Hand washing is crucial for both medical personnel and visitors. Nurses should only ensure that only devices are only used once to minimize transmission from contaminated devices. The pharmacist should ensure that empirical antibiotic prescribing is not carried out, as this only leads to the development of drug resistance. Since many of these patients are frail, a dietary consult should be sought to optimize the calorie intake. Finally, since many of these patients are bedridden, a physical therapy consult should be considered to help with mobility and prevent stiffness of the joints.[6][12] (Level V)

Outcomes

Klebsiella pneumonia usually signals a grim prognosis. Even with optimal therapy, this infection of the lung carries a mortality of 30-50%. The prognosis is usually worse in diabetics, the elderly and those who are immunocompromised. Even those who survive, they often have residual impaired lung function, and recovery can take months. [13][14](Level V)


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Klebsiella Pneumonia - Questions

Take a quiz of the questions on this article.

Take Quiz
In a patient with a pyogenic liver abscess caused by Klebsiella pneumoniae, which organ system must be carefully followed to ensure no complication occurs?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
An elderly female is admitted with fevers and chills. Two days ago, she developed flu-like symptoms and a productive cough with thick blood tinged sputum. The intern on the team describes the sputum as currant jelly like. She may have a pneumonia caused by which of the following?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Klebsiella pneumoniae is classified as which of the following?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following can be a complication of Klebsiella pneumonia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 67-year-old female presented to the emergency department with a high fever, blood-tinged sputum, productive cough, and tenacious sputum. She had not been feeling well for at least 3-5 days. She has a decreased appetite and feels weak. Her past medical history includes type 2 diabetes mellitus, hypertension, and gout. She is currently on enalapril, metformin, and allopurinol. She is a heavy smoker and drinks alcohol every day. Her vitals are stable except for a temperature of 101.3 F. Auscultation reveals wheezing and bronchial breath sounds. While blood work is pending, a chest-x-ray is ordered, which is shown below. In the meantime, the sputum gram stain reveals a short, plump gram-negative bacillus. Based on this, what particular feature about this patient’s pathology has been demonstrated by the red line on the x-ray?

(Move Mouse on Image to Enlarge)
  • Image 11333 Not availableImage 11333 Not available
    Image courtesy O.Chaigasame
Attributed To: Image courtesy O.Chaigasame



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Klebsiella Pneumonia - References

References

Jondle CN,Gupta K,Mishra BB,Sharma J, Klebsiella pneumoniae infection of murine neutrophils impairs their efferocytic clearance by modulating cell death machinery. PLoS pathogens. 2018 Oct 1     [PubMed]
Aghamohammad S,Badmasti F,Solgi H,Aminzadeh Z,Khodabandelo Z,Shahcheraghi F, First Report of Extended-Spectrum Betalactamase-Producing Klebsiella pneumoniae Among Fecal Carriage in Iran: High Diversity of Clonal Relatedness and Virulence Factor Profiles. Microbial drug resistance (Larchmont, N.Y.). 2018 Oct 2     [PubMed]
Rønning TG,Aas CG,Støen R,Bergh K,Afset JE,Holte MS,Radtke A, Investigation of an outbreak caused by antibiotic susceptible Klebsiella oxytoca in a neonatal intensive care unit in Norway. Acta paediatrica (Oslo, Norway : 1992). 2018 Sep 20     [PubMed]
Tsereteli M,Sidamonidze K,Tsereteli D,Malania L,Vashakidze E, EPIDEMIOLOGY OF CARBAPENEM-RESISTANT KLEBSIELLA PNEUMONIAE IN INTENSIVE CARE UNITS OF MULTIPROFILE HOSPITALS IN TBILISI, GEORGIA. Georgian medical news. 2018 Jul-Aug     [PubMed]
Esposito EP,Cervoni M,Bernardo M,Crivaro V,Cuccurullo S,Imperi F,Zarrilli R, Molecular Epidemiology and Virulence Profiles of Colistin-Resistant {i}Klebsiella pneumoniae{/i} Blood Isolates From the Hospital Agency     [PubMed]
Walter J,Haller S,Quinten C,Kärki T,Zacher B,Eckmanns T,Abu Sin M,Plachouras D,Kinross P,Suetens C,Ecdc Pps Study Group, Healthcare-associated pneumonia in acute care hospitals in European Union/European Economic Area countries: an analysis of data from a point prevalence survey, 2011 to 2012. Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin. 2018 Aug     [PubMed]
Para RA,Fomda BA,Jan RA,Shah S,Koul PA, Microbial etiology in hospitalized North Indian adults with community-acquired pneumonia. Lung India : official organ of Indian Chest Society. 2018 Mar-Apr     [PubMed]
Ergul AB,Cetin S,Altintop YA,Bozdemir SE,Ozcan A,Altug U,Samsa H,Torun YA, Evaluation of Microorganisms Causing Ventilator-Associated Pneumonia in a Pediatric Intensive Care Unit. The Eurasian journal of medicine. 2017 Jun     [PubMed]
Liu C,Guo J, Characteristics of ventilator-associated pneumonia due to hypervirulent {i}Klebsiella pneumoniae{/i} genotype in genetic background for the elderly in two tertiary hospitals in China. Antimicrobial resistance and infection control. 2018     [PubMed]
Mitharwal SM,Yaddanapudi S,Bhardwaj N,Gautam V,Biswal M,Yaddanapudi L, Intensive care unit-acquired infections in a tertiary care hospital: An epidemiologic survey and influence on patient outcomes. American journal of infection control. 2016 Jul 1     [PubMed]
Thakuria B,Singh P,Agrawal S,Asthana V, Profile of infective microorganisms causing ventilator-associated pneumonia: A clinical study from resource limited intensive care unit. Journal of anaesthesiology, clinical pharmacology. 2013 Jul     [PubMed]
Claeys KC,Zasowski EJ,Trinh TD,Lagnf AM,Davis SL,Rybak MJ, Antimicrobial Stewardship Opportunities in Critically Ill Patients with Gram-Negative Lower Respiratory Tract Infections: A Multicenter Cross-Sectional Analysis. Infectious diseases and therapy. 2018 Mar     [PubMed]
Luan Y,Sun Y,Duan S,Zhao P,Bao Z, Pathogenic bacterial profile and drug resistance analysis of community-acquired pneumonia in older outpatients with fever. The Journal of international medical research. 2018 Jan 1     [PubMed]
Venkataraman R,Divatia JV,Ramakrishnan N,Chawla R,Amin P,Gopal P,Chaudhry D,Zirpe K,Abraham B, Multicenter Observational Study to Evaluate Epidemiology and Resistance Patterns of Common Intensive Care Unit-infections. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine. 2018 Jan     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Podiatry Cert Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Podiatry Cert Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Podiatry Cert Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Podiatry Cert Medicine. When it is time for the Surgery-Podiatry Cert Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Podiatry Cert Medicine.