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K. pneumoniae Antimicrobial Drug Resistance

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K. pneumoniae Antimicrobial Drug Resistance

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https://wwwnc.cdc.gov/eid/article/19/1/12-0310_article

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Klebsiella pneumoniae is a colonizer of livestock, a contaminant of retail meats and vegetables, and a cause of extraintestinal infections in humans. Antibiotic-resistant strains of K. pneumoniae are becoming increasingly prevalent among hospital and community-acquired infections. Antibiotics are used extensively in conventional food-animal production, where they select for antibiotic-resistant bacteria. Antibiotic-resistant K. pneumoniae has been isolated from livestock as well as from a variety of retail meats, seafood, and vegetables. Furthermore, recent phylogenetic analyses suggest close relationships between K. pneumoniae from humans and livestock. Therefore, it is essential that we quantify the contribution of foodborne K. pneumoniae to antibiotic-resistant human infections.

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Lindsay Tadlock

Lindsay Tadlock began writing in 2010. She has worked as a personal trainer for over three years and shares her fitness and nutrition knowledge in her writings. She graduated from Texas A&M University in 2000 with her Bachelor of Arts in finance and worked for seven years as a commercial lender.

Raising an infant can be difficult. You are always second guessing if a symptom is something that will just pass or if you should take your child to the doctor. A strong urine smell from your infant is most likely a sign of a urinary tract infection, or UTI. According to Kids Health, about 8 percent of girls and 1 to 2 percent of boys have had a UTI by the time they are 5 years old. If your child has a strong urine smell you should see your doctor to determine the cause and treatment needed.

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UTI is caused when bacteria infects the urinary tract, which is made up of the kidneys, bladder, ureters and urethra. These organs each play a role in removing liquid waste from the body. Bacteria can easily enter the urinary tract from the skin around the anus. Bacterial UTIs are not contagious.

In infants and young children, a UTI may be hard to detect because the symptoms are less specific. Sometimes, a fever is the only sign of a UTI in an infant. Infants may seem irritable, begin to feed poorly or vomit. Your infant's urine may have a foul smell and may look cloudy or contain blood.

UTIs are more often seen in girls because the urethra is shorter and closer to the anus. Uncircumcised boys younger than 1 year are also at a higher risk for developing a UTI. Other risk factors include an abnormality in the structure of the urinary tract, the use of bubble baths or a family history of UTIs. According to Kids Health, 30 to 50 percent of infants with a UTI are found to have vesicoureteral reflux. This condition is present at birth and is when the infant has an abnormal backward flow of urine from the bladder toward the kidneys.

UTIs are treatable and it is important to catch them early. Treatment for a UTI includes an antibiotic for your infant. Untreated UTIs may lead to kidney damage, especially in children younger than 6.

Frequent diaper changes can prevent the spread of bacteria in infants. It is important to wipe your girl from front to rear to prevent germs from spreading from the rectum to the urethra. Other prevention includes avoiding bubble baths and washing hands prior to changing your infant's diaper to avoid the spread of bacteria.

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Raising an infant can be difficult. You are always second guessing if a symptom is something that will just pass or if you should take your child to the doctor. A strong urine smell from your infant is most likely a sign of a urinary tract infection, or UTI.

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1. Klebsiella can cause a variety of infections
Many of which are hospital acquired, such as pneumonia, meningitis and urinary tract infections.

2. There are multiple antibiotic resistant strains of Klebsiella pneumonia
The multi drug resistant CRE (which stands for Carbapenem Resistant Enterobacteriaceae) Klebsiella Pneumonia is a relatively new superbug. Due to limited antibiotic treatment diseases caused by this organism can be severe. You can read more about the result of antibiotic resistance here.

3. Klebsiella can be found everywhere
Water, soil, humans, animals, insects and plants are all environments where this organism may naturally occur.

4. The bacteria can spread via person to person contact
For this reason it is important to implement thorough hygiene practices, particularly if you are staying at or visiting a hospital. It is a good idea to wash your hands thoroughly and often when in any area of critical hygiene concern.

5. Yet can also be transmitted via contaminated surfaces
To avoid this, antibacterial surfaces provide the ideal application to stop the bacteria from multiplying on a surface. BioCote’s technology is proven effective against Klebsiella and CRE Klebsiella.

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Klebsiella infections, treatment & management 

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Klebsiella infections, treatment & management 

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Klebsiella Infections Treatment & Management: Medical Care, Surgical Care, Consultations

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The genus Klebsiella belongs to the tribe Klebsiellae, a member of the family Enterobacteriaceae. The organisms are named after Edwin Klebs, a 19th century German microbiologist.

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Pathogenic potential of environmental Klebsiella pneumoniae isolates. - PubMed - NCBI

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Environ Microbiol. 2004 Jun;6(6):584-90. Comparative Study; Research Support, Non-U.S. Gov't

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Preventing  klebsiella pnemonia from spreading!

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Preventing  klebsiella pnemonia from spreading!

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These precautions may include strict adherence to hand hygiene and wearing gowns and gloves when they enter rooms where patients with Klebsiella–related illnesses are housed. Healthcare facilities also must follow strict cleaning procedures to prevent the spread of Klebsiella.

To prevent the spread of infections, patients also should clean their hands very often, including:

*Before preparing or eating food
*Before touching their eyes, nose, or mouth
*Before and after changing wound dressings or bandages
*After using the restroom
*After blowing their nose, coughing, or sneezing
*After touching hospital surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone

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How people with this infection looks like:  

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How people with this infection looks like:  

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Principles and Practice of Infectious Diseases

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After thirty five years, Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 8th Edition is still the reference of choice for comprehensive, global guidance on diagnosing and treating the most challenging infectious diseases. Drs. John E.

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General information on how Klebsiella pneumoniae spread

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General information on how Klebsiella pneumoniae spread

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General Information

Klebsiella [kleb−see−ell−uh] is a type of Gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis. Increasingly, Klebsiella bacteria have developed antimicrobial resistance, most recently to the class of antibiotics known as carbapenems. Klebsiella bacteria are normally found in the human intestines (where they do not cause disease). They are also found in human stool (feces). In healthcare settings, Klebsiella infections commonly occur among sick patients who are receiving treatment for other conditions. Patients whose care requires devices like ventilators (breathing machines) or intravenous (vein) catheters, and patients who are taking long courses of certain antibiotics are most at risk for Klebsiella infections. Healthy people usually do not get Klebsiella infections.

How Klebsiella bacteria are spread

To get a Klebsiella infection, a person must be exposed to the bacteria. For example, Klebsiella must enter the respiratory (breathing) tract to cause pneumoniae, or the blood to cause a bloodstream infection.

In healthcare settings, Klebsiella bacteria can be spread through person-to-person contact (for example, from patient to patient via the contaminated hands of healthcare personnel, or other persons) or, less commonly, by contamination of the environment. The bacteria are not spread through the air.

Patients in healthcare settings also may be exposed to Klebsiella when they are on ventilators (breathing machines), or have intravenous (vein) catheters or wounds (caused by injury or surgery). Unfortunately, these medical tools and conditions may allow Klebsiella to enter the body and cause infection.

Preventing Klebsiella from spreading

To prevent spreading Klebsiella infections between patients, healthcare personnel must follow specific infection control precautions (see: Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007). These precautions may include strict adherence to hand hygiene and wearing gowns and gloves when they enter rooms where patients with Klebsiella-related illnesses are housed. Healthcare facilities also must follow strict cleaning procedures to prevent the spread of Klebsiella.

To prevent the spread of infections, patients also should clean their hands very often, including:

Before preparing or eating food

Before touching their eyes, nose, or mouth

Before and after changing wound dressings or bandages

After using the restroom

After blowing their nose, coughing, or sneezing

After touching hospital surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone

Drug-resistant Klebsiella

Some Klebsiella bacteria have become highly resistant to antibiotics. When bacteria such as Klebsiella pneumoniae produce an enzyme known as a carbapenemase (referred to as KPC-producing organisms), then the class of antibiotics called carbapenems will not work to kill the bacteria and treat the infection. Klebsiella species are examples of Enterobacterales, a normal part of the human gut bacteria, that can become carbapenem-resistant. CRE, which stands for carbapenem-resistant Enterobacterales, are an order of germs that are difficult to treat because they have high levels of resistance to antibiotics. Unfortunately, carbapenem antibiotics often are the last line of defense against Gram-negative infections that are resistant to other antibiotics.

Treating Klebsiella infections

Klebsiella infections that are not drug-resistant can be treated with antibiotics. 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.

What should patients do if they think they have a Klebsiella-related illness?

See a healthcare provider.

What should patients do if they have been diagnosed with a Klebsiella-related illness?

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.

How would someone know if their Klebsiella infection is drug-resistant?

The healthcare provider will order laboratory tests to determine if the Klebsiella infection is drug-resistant.

Can a Klebsiella infection spread to the patient's family members?

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.

Recommendations and Guidelines

For more information about prevention and treatment of HAIs, see the resources below:

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Klebsiella pneumoniae in Healthcare Settings

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Klebsiella [kleb−see−ell−uh] is a type of Gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis. Increasingly, Klebsiella bacteria have developed antimicrobial resistance, most recently to the class of antibiotics known as carbapenems. Klebsiella bacteria are normally found in the human intestines (where they do not cause disease).

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Wake up!! How Klebsiella pnemoniae spread

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Wake up!! How Klebsiella pnemoniae spread

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(VIDEO)

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WAKE UP!!! KLEBSIELLA PNEUMONIAE IN OUR WORLD!!! CRKP!!! How pneumonia starts - YouTube

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Walsh and Hoyt's Clinical Neuro-ophthalmology

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Thoroughly revised and updated for its Sixth Edition, this classic work is the most comprehensive reference on diagnosis and treatment of neuro-ophthalmologic diseases. This edition has two new editors-Valérie Biousse, MD and John B. Kerrison, MD-and has been streamlined from five volumes into three tightly edited volumes with a sharper focus on patient management.

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Example of infection cause by Klebsiella pneumoniae 

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Example of infection cause by Klebsiella pneumoniae 

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Fatal Klebsiella pneumoniae meningitis and concomitant disseminated intravascular coagulation in a patient with diabetes mellitus

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Bacterial meningitis remains a major cause of death and long-term neurologic sequelae worldwide. We present a case of fatal Klebsiella pneumoniae meningitis and concomitant disseminated intravascular coagulation (DIC) in a 72-year-old woman with diabetes ...

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Treatment for Klebsiella pneumoniae infection ( use antibiotic: Carbapenem- Resistant Enterobacteria

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Treatment for Klebsiella pneumoniae infection ( use antibiotic: Carbapenem- Resistant Enterobacteria

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General Information

Klebsiella [kleb−see−ell−uh] is a type of Gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis. Increasingly, Klebsiella bacteria have developed antimicrobial resistance, most recently to the class of antibiotics known as carbapenems. Klebsiella bacteria are normally found in the human intestines (where they do not cause disease). They are also found in human stool (feces). In healthcare settings, Klebsiella infections commonly occur among sick patients who are receiving treatment for other conditions. Patients whose care requires devices like ventilators (breathing machines) or intravenous (vein) catheters, and patients who are taking long courses of certain antibiotics are most at risk for Klebsiella infections. Healthy people usually do not get Klebsiella infections.

How Klebsiella bacteria are spread

To get a Klebsiella infection, a person must be exposed to the bacteria. For example, Klebsiella must enter the respiratory (breathing) tract to cause pneumoniae, or the blood to cause a bloodstream infection.

In healthcare settings, Klebsiella bacteria can be spread through person-to-person contact (for example, from patient to patient via the contaminated hands of healthcare personnel, or other persons) or, less commonly, by contamination of the environment. The bacteria are not spread through the air.

Patients in healthcare settings also may be exposed to Klebsiella when they are on ventilators (breathing machines), or have intravenous (vein) catheters or wounds (caused by injury or surgery). Unfortunately, these medical tools and conditions may allow Klebsiella to enter the body and cause infection.

Preventing Klebsiella from spreading

To prevent spreading Klebsiella infections between patients, healthcare personnel must follow specific infection control precautions (see: Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007). These precautions may include strict adherence to hand hygiene and wearing gowns and gloves when they enter rooms where patients with Klebsiella-related illnesses are housed. Healthcare facilities also must follow strict cleaning procedures to prevent the spread of Klebsiella.

To prevent the spread of infections, patients also should clean their hands very often, including:

Before preparing or eating food

Before touching their eyes, nose, or mouth

Before and after changing wound dressings or bandages

After using the restroom

After blowing their nose, coughing, or sneezing

After touching hospital surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone

Drug-resistant Klebsiella

Some Klebsiella bacteria have become highly resistant to antibiotics. When bacteria such as Klebsiella pneumoniae produce an enzyme known as a carbapenemase (referred to as KPC-producing organisms), then the class of antibiotics called carbapenems will not work to kill the bacteria and treat the infection. Klebsiella species are examples of Enterobacterales, a normal part of the human gut bacteria, that can become carbapenem-resistant. CRE, which stands for carbapenem-resistant Enterobacterales, are an order of germs that are difficult to treat because they have high levels of resistance to antibiotics. Unfortunately, carbapenem antibiotics often are the last line of defense against Gram-negative infections that are resistant to other antibiotics.

Treating Klebsiella infections

Klebsiella infections that are not drug-resistant can be treated with antibiotics. 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.

What should patients do if they think they have a Klebsiella-related illness?

See a healthcare provider.

What should patients do if they have been diagnosed with a Klebsiella-related illness?

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.

How would someone know if their Klebsiella infection is drug-resistant?

The healthcare provider will order laboratory tests to determine if the Klebsiella infection is drug-resistant.

Can a Klebsiella infection spread to the patient's family members?

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.

Recommendations and Guidelines

For more information about prevention and treatment of HAIs, see the resources below:

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Klebsiella pneumoniae in Healthcare Settings

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Klebsiella [kleb−see−ell−uh] is a type of Gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis. Increasingly, Klebsiella bacteria have developed antimicrobial resistance, most recently to the class of antibiotics known as carbapenems. Klebsiella bacteria are normally found in the human intestines (where they do not cause disease).

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Klebsiella pneumoniae is a common form of gram-negative bacteria found in the mouth, skin and intestines. Infections most often afflict those with compromised immune systems. An opportunistic pathogen, Klebsiella pneumoniae is pervasive in hospital settings and difficult to combat. The most significant source of patient infection is contact with feces and contaminated instruments.

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Catherine Schaffer

Catherine Schaffer has been writing since 1990. Her articles have appeared in many medical journals and textbooks. Schaffer holds a Bachelor of Science from Baylor College of Medicine and a physician assistant certificate. She has written health and nutrition articles for various websites and teaches movement and nutrition to help women overcome chronic diseases and obesity.

A urinary tract infection, or UTI, refers to any infection of the kidneys, ureters, bladder or urethra according to MayoClinic. Most infections occurring in the bladder cause burning urination, frequency, urgency and colicky abdominal pain. Kidney infection symptoms include fever, mid to low back pain and possible nausea and vomiting. Klebsiella pneumoniae is a bacterium that causes UTIs. Treatment for Klebsiella UTI can vary, depending on the medication used and the severity of the problem.

Video of the Day

According to Drugs.com, sulfamethoxazole and trimethroprim, or Bactrim, is excreted primarily through the kidneys. Bactrim concentrates in the urine, which makes it an effective antibacterial agent for UTIs. Bactrim comes in double-strength tablets, and is taken twice a day for 5 to 7 days. Bactrim is usually a well-tolerated medication, but it can have side effects. Patients with known sulfa allergies should not take Bactrim. At the first appearance of a rash, Bactrim should be discontinued. Patients may experience cough and respiratory distress as a reaction to Bactrim. Taken during pregnancy, Bactrim, can cause cleft palate.

Ciprofloxacin is a fluoroquinolone and works very well against Klebsiella UTIs. Cipro 250 mg is taken orally twice a day for 7 to 10 days to clear the infection. Cipro should be taken with food. Fluoroquinolones carry a black box warning regarding possible tendinitis and tendon rupture. Patients at greatest risk of this adverse event are kidney, lung or heart transplant patients, patients who take steroid medications and the elderly.

Piperacillin and tazobactam, or Zosyn, is a beta-lactamase inhibitor. This means that the penicillin product has been reinforced with a special medicine that inhibits the release of beta-lactamase enzyme from bacteria. This enzyme, when released from bacteria, makes penicillin ineffective against it. Zosyn must be administered intravenously and is reserved for patients with more complicated kidney infections or those patients who have hospital-acquired UTIs. This medication can cause nausea and vomiting and other gastrointestinal upset in some patients, but it is usually well tolerated. Diarrhea caused by Clostridium difficile can be a serious side effect of Zosyn. Patients who are allergic to penicillin should not take this medication.

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What Are the Treatments for Klebsiella Pneumoniae From a Urine Culture?

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A urinary tract infection, or UTI, refers to any infection of the kidneys, ureters, bladder or urethra according to MayoClinic. Most infections occurring in the bladder cause burning urination, frequency, urgency and colicky abdominal pain. Kidney infection symptoms include fever, mid to low back pain and possible nausea and vomiting.

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Klebsiella: Klebsiella, (genus Klebsiella), any of a group of rod-shaped bacteria of the family Enterobacteriaceae. Klebsiella organisms are categorized microbiologically as gram-negative, facultative anaerobic, nonmotile bacteria. Klebsiella organisms occur in soil and water and on plants, and some strains

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ABSTRACT

An outbreak with a multiresistant Klebsiella pneumoniae (MRKP) strain among seven patients admitted to the adult intensive care unit (ICU) of a regional teaching hospital in The Netherlands was investigated. Epidemiologic investigations revealed a short delay between an operation and the acquisition of the MRKP strain. A case-control study comprising 7 cases and 14 controls was conducted to identify the risk factors associated with the acquisition of the MRKP strain. An operation at each of two operation rooms was strongly associated with the acquisition of the MRKP strain: odds ratio of 36 (95% confidence interval, 2.7 to 481.2; P = 0.003, Fisher exact two-tailed test). Cultures of environmental specimens of the operation rooms revealed contamination of the roll boards used to transport patients from the bed to the operation table with the MRKP strains. Molecular genotyping of the isolates revealed clonal similarity between the isolates of the seven cases, isolates from environmental specimen cultures, and in addition, an MRKP isolate from a repatriated ICU patient from earlier that year. The outbreak ended after cleaning and replacement of the roll boards in the operation rooms and implementation of additional barrier precautions for colonized or infected patients. It was concluded that two operation rooms played a significant role in the transmission of an MRKP strain between ICU patients during the presented outbreak.

MATERIALS AND METHODS

Hospital setting.The studies were performed in a regional 673-bed teaching hospital in The Netherlands. The hospital has an 18-bed ICU divided over three units on one floor. All beds are placed in single rooms; two rooms have an anteroom. The majority of the ICU patients are admitted for surgery, neurosurgery, or internal medicine. The hospital has a special function for neurosurgery and traumatology. The average length of stay in the ICU is 6.8 days for ventilated patients and 2.3 days for nonventilated patients.

Identification of outbreak.In November 2000, three patients in the ICU developed fatal sepsis caused by a K. pneumoniae strain expressing resistance to extended-spectrum cephalosporins by means of ESBL production and additional resistance to gentamicin, tobramycin, and trimethoprim-sulfamethoxazole. The infection control department was alerted, and the infection control practitioner conducted a visit to the ICU. A preliminary review of the patients' characteristics and a search of the microbiology reports of the ICU patients for specimens positive by culture for MRKP for the months of October and November were performed. It was noted that all fatal cases were operated on in one of two operation rooms (ORs; OR-X and OR-Y) within 5 days before the development of sepsis. In response, the infection control practitioner visited the OR complex and took environmental samples from OR-X and OR-Y.

Microbiological methods.In addition to the culture of samples for clinical indications, samples for surveillance cultures (respiratory material, urine, drains, and wounds) were obtained from all patients on artificial ventilation and were performed twice a week as standard procedure at the ICU. All identification and susceptibility tests were performed according to the CLSI (formerly the National Committee for Clinical Laboratory Standards). K. pneumoniae strains were identified by conventional CLSI-recommended biochemical methods, completed with an API 20E test kit (bioMerieux SA, Lyon, France). Antibiotic susceptibility testing was performed by a microdilution method in microtiter panels containing 11 antibiotics: amoxicillin, amoxicillin-clavulanate, and ceftazidime (GlaxoSmithKline CH, Zeist, The Netherlands); cefuroxime (Pharmachemie, Haarlem, The Netherlands); ceftriaxone (Roche, Mijdrecht, The Netherlands); ciprofloxacin (Bayer, Mijdrecht, The Netherlands); ofloxacin (Aventis Pharma, Hoevelaken, The Netherlands); trimethoprim-sulfamethoxazole and tobramycin (Sigma-Aldrich Chemie BV, Zwijndrecht, The Netherlands); meropenem (Astra Zeneca, Zoetermeer, The Netherlands); and gentamicin (Bufa BV, Uitgeest, The Netherlands). ESBL production was tested by disk diffusion tests (Oxoid Ltd., Basingstoke, England), as follows: cefpodoxime (10 μg), ceftazidime (30 μg), and cefotaxime (30 μg) were plated with and without clavulanate at 1 μg, 10 μg, and 10 μg, respectively. ESBL production was confirmed by a clavulanate-induced increase in the zone size of ≥5 mm. Environmental specimens for culture were taken with cotton swabs and were plated on blood agar and cultured for 2 days at 35°C. The choice of sites for culture was guided by preliminary investigations of the nature of the outbreak, information presented in the literature, and previous experiences in our hospital.

Case-control study.A case-control study was conducted to investigate risk factors and possible transmission routes in the November 2000 outbreak in the ICU. Cases were defined as patients who were admitted to the ICU for >24 h in November 2000 and who were positive for MRKP by culture of specimens taken between 1 November 2000 and 31 December 2000. Samples for culture were taken from specific infection sites or for surveillance, and samples from both colonized and infected patients were included. Case finding was conducted by a retrospective review of all microbiology culture reports from this period. Seven cases were recorded, and subsequently, 14 unmatched controls were randomly selected from a pool of all patients admitted to the ICU for >24 h in November 2000.

Data for the cases and the controls were collected by retrospective chart review and included age; gender; hospital admission dates; ICU admission dates; Apache score at the time of admission to the ICU; attending specialty; wards attended by the patient before and after admission to the ICU; units attended during the ICU admission; mortality at end of the ICU admission; mortality at end of the hospital admission; number of days of artificial ventilation; presence of urinary catheter, artery catheter and central venous catheter; presence of drains; presence of open wounds; surgery during hospital admission; OR number; operating team; antibiotic use; number of specimens presented for culture taken during the study period; date of first MRKP-positive culture; and the MRKP-positive culture sites.

Molecular genotyping.Molecular genotyping was performed by multienzyme amplified fragment length polymorphism (ME-AFLP) analysis, as described previously ( 24). In short, the genomic DNA of each isolate was extracted with a QiAmp DNA minikit (QIAGEN, Hilden, Germany). After addition of 5 μl of RNase (1 U; Sigma), the concentration of DNA was determined with a spectrophotometer (260 nm; Genequant, Pharmacia, United Kingdom). The restriction-ligation reaction was performed with 500 ng of DNA in a final volume of 30 μl. The reaction mixture consisted of the restriction enzymes EcoRI, PstI, XbaI, and NheI (2 U each; Roche Molecular Biochemicals); 3 μl of T4 ligase buffer; 1 U of T4 ligase (Roche Molecular Biochemicals); and 20 pmol of oligonucleotide adaptors. The restriction-ligation mixture was incubated at 37°C for 3 h. DNA was precipitated by using 2.5 M of ammonium acetate in 100 μl chilled absolute ethanol. After the DNA was washed with 70% ethanol, it was resuspended in 100 μl of TE (Tris-EDTA) buffer and stored at 4°C. PCRs were carried out with Ready-To-Go beads (Amersham Pharmacia, Little Chalfont, United Kingdom) supplemented with 1 μl MgCl ₂ (25 mM). Each primer (10 pmol) and 100 ng of chromosomal template DNA were used in a final reaction volume of 25 μl. In a DNA thermocycler (GeneAmp PCR system 2400; Perkin-Elmer), the reaction mixtures were preheated for 4 min at 94°C. Thirty-three amplification cycles of 1 min at 94°C, 1 min at 60°C, and 2.5 min at 72°C were performed. Analysis of 10 μl of each PCR product was performed by agarose gel electrophoresis on a 1.5% agarose gel (MP agarose; Roche Molecular Biochemicals). Marker DNA (100-bp ladder; Gibco BRL, Life Technologies, Scotland) was loaded after every four samples. Analysis of the banding patterns on gel images was performed with the software program Gelcompar II, which is included in Bionumerics software (Applied Maths, Kortrijk, Belgium). Cluster analysis of the fingerprints was performed by the unweighted pair group method with arithmetic averages, and similarities between AFLP patterns were calculated by using the Pearson product-moment correlation coefficient ( 25). The patterns of the strains analyzed were considered identical when there was 90 to 100% homology.

A computer-based search for positive cultures of K. pneumoniae resistant to extended-spectrum cephalosporins and aminoglycosides at our hospital was performed for the years 1998, 1999, and 2000. Most of these isolates were stored at −80°C and could be included for molecular typing (one isolate per patient).

Data analysis.Univariate analysis was performed by Fisher's exact test for categorical variables, Student's t test, or the Mann-Whitney U test for continuous variables (EpiCalc 2000, version 1.02). Odds ratios were calculated when possible. Statistical significance was defined a priori as a P value of <0.05 (two tailed).

RESULTS

Description of cases and index.The course of the outbreak is depicted in Fig. 1, and patient characteristics are summarized in Table 1. Case 1 was admitted to the surgery ward on 24 October for an elective cholecystectomy. On 26 October she was admitted to ICU-A after a postoperative laparotomy in OR-Y and again on 29 October. An MRKP strain was cultured in the discharge from the abdominal wounds sampled on 2 November. Since it was a surveillance culture and there were no indications for infection, no antibiotic treatment for the MRKP infection was given. Case 1 recovered and was transferred to the surgery ward on 7 November.

Case 2 was admitted to ICU-A on 4 November after an operation for an acute subdural empyema in OR-X. An MRKP strain was recovered from a surveillance culture of sputum sampled on 6 November. No antibiotics were given. Case 2 was transferred to the neurosurgery ward on 8 November and was discharged from the hospital on 30 November. In between he received a second operation in OR-X on 11 November and postoperatively stayed in ICU-A one night.

Case 3 was a patient with multiple traumas admitted to ICU-A on 7 November. He received laporotomies three times: immediately after admission and on 9 and 12 November in OR-Y, OR-Y, and OR-X, respectively. An MRKP strain was isolated from blood sampled on 11 November and an abdominal discharge sampled on 12 November. Cefuroxime and tobramycin treatment was started as empirical therapy on 10 November and was changed to ofloxacin on 12 November. Case 3 died postoperatively of sepsis with multiorgan failure on 13 November.

Case 4, who had pancreatitis, was admitted to the internal medicine ward on 27 October and transferred to ICU-A on 30 October, where he stayed until his death on 21 November. A laporotomy was performed on 3 November in OR-X, on 17 November in OR-X, and on 20 November in OR-Z. Case 4 was treated with cefuroxime for an infected pancreas and was in stable condition. An MRKP isolate was first isolated from discharge from the ear sampled on 18 November and from abdominal rinsing fluid and abdominal drains sampled on 19 November. On November 21 he developed a fatal sepsis, and an MRKP strain was isolated from blood sampled on that day.

Case 5 was admitted to the surgery ward on 17 October; operated upon on 18 October (esophageal resection, OR-Z); and transferred to ICU-C, then to ICU-B (from 25 October), and then to ICU-A (from 7 November). On 14 November an explorative thoracotomy was performed in OR-Y. Case 5 received trimethoprim-sulfamethoxazole and vancomycin from 15 November. An MRKP strain was first isolated from discharge from a thorax drain sampled on 18 November, and 2 days later multiple thoracic drainage sites were positive for MRKP. On 21 November the patient developed a fatal sepsis and an MRKP strain was isolated from the blood sampled on that day.

Case 6 was admitted to ICU-C on 12 October after a thoracic operation in a different hospital. On 18 October he was transferred to the surgery department of St. Elisabeth Hospital but was readmitted to ICU-C on 7 November after an explorative laparotomy in OR-X. On 11 November, case 6 was transferred to ICU-A, where he stayed until 14 December. Since it was a surveillance culture and there were no indications for infection, no antibiotic treatment for the MRKP infection was given. Case 6 was discharged from the hospital on 20 December.

Case 7, who had subarachnoidal bleeding, was admitted to ICU-A from 24 to 28 November, to the neurosurgery ward from 28 November until 20 December, and to ICU-C from 20 December until death on 24 December. An MRKP strain was first isolated from cerebrospinal fluid sampled on 19 December. Case 7 was not operated upon but received a spinal catheterization for pain relief 6 days prior to the positive culture. This procedure was performed in the recovery ward of the OR complex by an anesthetist who had not been involved in any of the operations on the other cases. Case 7 was treated with meropenem but died as a result of infection with the MRKP strain.

The index patient was a trauma patient repatriated from Morocco and admitted to ICU-A on 18 September. The patient was not operated upon in our hospital. Respiratory specimens, blood, and a thorax drain sampled at admission were culture positive for an MRKP strain. Treatment was started with meropenem. This patient recovered and was transferred to the surgery ward on October 9. Barrier isolation was imposed at both the ICU and the surgery ward during admission of the index patient. Identification of the index case was inferred from molecular genotyping of the MRKP isolates from this patient. The typing patterns of the MRKP isolates from this patient were identical to the typing patterns of the outbreak strains.

Case-control study.Seven cases and 14 unmatched controls were defined, and the data for these individuals are summarized in Table 2. Comparable values of the baseline characteristics were found between the cases and the controls; these included gender, age, and Apache score. The mean length of stay in the ICU, in total (17.0 ± 14.33 days) and prior to the acquisition of an MRKP strain (12.0 ± 11.18 days), was longer for the cases than for the controls (7.3 ± 1.39 days). Also, the cases received ventilatory support, both in total and prior to the acquisition of MRKP, for longer periods than controls. None of these differences was statistically significant (Table 2). An operation performed in OR-X or OR-Y was found to have the strongest association with the acquisition of an MRKP strain, with an odds ratio of 36.0 (95% confidence interval, 2.7 to 481.2; P = 0.003). All six cases had undergone an operation before the acquisition of an MRKP strain (Table 1). These six operations were performed by 17 operation team members in total, 12 of which attended only one operation and 5 of which attended two operations. The average number of days between the operation and the subsequent culturing of MRKP was 4.8 (standard deviation, ±5.19; Table 1).

The numbers of patients who had undergone an operation were 6 of 7 cases and 9 of 14 controls. Among the cases, the mean number of operations prior to the acquisition of an MRKP strain (1.7 ± 1.25 days) and during hospitalization (2.3 ± 1.38 days) was higher than that for the controls (0.9 ± 1.07 days). A significant difference in the mean total number of operations during the hospital admission was found ( P = 0.022, t test), but when that number was corrected for the number of operations prior to MRKP acquisition, statistical significance was not reached (Table 2). Among the cases, three patients died in the ICU, whereas one patient in the control group died in the ICU. This difference did not reach statistical significance ( P = 0.088). However, when statistical analysis was restricted to patients who had had an operation, i.e., six cases and nine controls, it was found that an operation in OR-X or OR-Y was associated with an increased risk for mortality in the ICU ( P = 0.044). The presence of drains ( P = 0.017), the presence of open wounds ( P = 0.026), and admission to ICU-A ( P = 0.047) also had a significant association with the acquisition of an MRKP strain (Table 2).

Infection control measures.Because the fatal cases had all had an operation in OR-X or OR-Y less than 5 days prior to the development of sepsis caused by an MRKP strain, environmental samples were taken from these ORs. In both OR-X and OR-Y, K. pneumoniae was isolated from the roll boards used to transport patients from the bed to the operation table (Fig. 2). The multiresistant K. pneumoniae outbreak strain was defined as being resistant to aminoglycosides and trimethoprim-sulfamethoxazole and ESBL positive. Resistance to ciprofloxacin and ofloxacin varied from susceptible to resistant both within patients and between patients. The roll boards were disinfected thoroughly or replaced, if it was worn out. In addition, barrier precautions for colonized or infected patients were reinforced on the ICU. The outbreak ended after these interventions were implemented.

Molecular genotyping.Figure 3 shows the results of molecular genotyping of the K. pneumoniae strains. The ME-AFLP patterns of MRKP isolates from cases 1 to 7 and the two MRKP isolates from the OR room roll boards (OR-X and OR-Y) were grouped within one cluster, with similarities ranging from 90 to 100%. A multiresistant K. pneumoniae strain isolated from a patient admitted to the ICU in September fell within the same cluster (index case). The ME-AFLP patterns of five other K. pneumoniae strains resistant to extended-spectrum cephalosporins and aminoglycosides all fell in different clusters. Four of these strains (strains R1 to R4) were isolated earlier in 2000, and one strain (strain R5) was isolated in January 2001. ME-AFLP patterns C1 to C3 are the patterns of susceptible Klebsiella pneumoniae strains and served as controls (Fig. 3).

DISCUSSION

An outbreak caused by a multiresistant Klebsiella pneumoniae strain occurred in the ICU of the St. Elisabeth Hospital in Tilburg, The Netherlands. Seven patients at the ICU became colonized or infected, and in four cases the death of the patient was considered to be caused by infection with the outbreak strain.

A large number of risk factors for the acquisition of ESBL-producing K. pneumoniae strains have been reported, including the length of hospital stay ( 2, 10), the length of ICU stay ( 4), mechanical ventilation ( 2, 10, 17), urinary catheterization ( 2, 10), arterial catheterization ( 2), the presence of a central venous catheter ( 10, 19), prior antibiotic treatment ( 10, 16, 19), and more.

In the present study, a number of risk factors for the acquisition of the MRKP strain agreed with those that had been reported previously. We found that (i) the mean length of stay at the ICU was longer, (ii) the number of patients receiving ventilatory support was higher, and (iii) the number of central venous catheters and artery catheters was higher in cases than in the controls.

Our case-control study showed that an operation in OR-X or OR-Y was associated with a 36-fold increased risk of acquiring an MRKP strain and hence presented a significant risk factor for mortality due to infection with MRKP. Also, a short period of time (mean number of days, 4.8) between an operation in OR-X or OR-Y prior to the acquisition of MRKP was found. The contribution of OR-X and OR-Y to the outbreak was supported by the recovery of MRKP from cultures of environmental samples of the roll boards in OR-X and OR-Y. The similarity of these environmental isolates to the outbreak strain was confirmed by molecular typing. Moreover, the outbreak was contained after thorough disinfection and/or replacement of the roll boards in the ORs. Thus, the present study indicated a transmission route which differentiated this outbreak from previously reported outbreaks with multiresistent Klebsiella pneumoniae strains.

A minority of the cases could not be related to OR-X or OR-Y. One case had not been operated upon. In a second case, the time between the operation and the first isolation of MRKP took 15 days. The index case patient also did not have an operation, and other than admission to ICU-A, no clear connection could be found between this patient and any of the cases.

It is conceivable that secondary to the transmission at the ORs, cross contamination within the ICU occurred. Six of the seven cases were admitted to unit ICU-A at the time that MRKP was isolated for the first time. In the case-control study, ICU-A was found to be a risk factor for the acquisition of the MRKP strain. Unfortunately, no environmental samples for culture were taken from ICU-A. If, however, an environmental source was present in ICU-A and this source did play a significant role in the outbreak, the outbreak would probably not have been controlled after the interventions taken in the ORs.

To our knowledge, this study is the first to report on the contamination of roll boards in ORs with multiresistant Enterobacteriaceae. Roll boards usually do not come into contact with the intact mucosal barriers or sterile tissue, and these utensils are expected to impose only a small risk for the transmission of microorganisms. Prompt cleaning and decontamination are done on a regular basis, e.g., when blood or other potentially infectious material is spilled on the surface. This procedure is regarded to be sufficient and according to Dutch and international guidelines for infection control ( 2a).

From the results of this study it may be recommended that the construction of roll boards be improved to facilitate effective decontamination; they should have smooth surfaces instead of loosening fibers and open ball bearings. Alternatively, more frequent cleaning and disinfection procedures for roll boards in ORs might be considered to decrease the risk of unwanted infection by a pathogen from environmental sites.

ACKNOWLEDGMENTS

We are indebted to Eveline Thijssen, Marco Janssens, and Niels Steer for technical assistance and Ruud Snoeren for assistance with the chart reviews.

FOOTNOTES

Received 17 February 2005.

Returned for modification 11 April 2005.

Accepted 27 June 2005.

↵*Corresponding author. Mailing address: Department of Clinical Microbiology, St. Elisabeth Hospital, P.O. Box 747, 5000 AS Tilburg, The Netherlands. Phone: 31 (0)13 5392676. Fax: 31 (0)13 5391264. E-mail: a.buiting{at}elisabeth.nl .

REFERENCES

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Outbreak of Infection with a Multiresistant Klebsiella pneumoniae Strain Associated with Contaminated Roll Boards in Operating Rooms

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An outbreak with a multiresistant Klebsiella pneumoniae (MRKP) strain among seven patients admitted to the adult intensive care unit (ICU) of a regional teaching hospital in The Netherlands was investigated. Epidemiologic investigations revealed a short delay between an operation and the acquisition of the MRKP strain.

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https://www.cdc.gov/HAI/organisms/klebsiella/klebsiella.html

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Other articles where Klebsiella pneumoniae is discussed: Klebsiella: Klebsiella pneumoniae, also called Friedländer's bacillus, was first described in 1882 by German microbiologist and pathologist Carl Friedländer. K. pneumoniae is best known as a pathogen of the human respiratory system that causes pneumonia. The disease is usually seen only in patients with underlying medical...

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Abstract

Invasive Klebsiella pneumoniae with hypermucoviscosity phenotype (HMV K. pneumoniae) is an emerging human pathogen that, over the past 20 y, has resulted in a distinct clinical syndrome characterized by pyogenic liver abscesses sometimes complicated by bacteremia, meningitis, and endophthalmitis. Infections occur predominantly in Taiwan and other Asian countries, but HMV K. pneumoniae is considered an emerging infectious disease in the United States and other Western countries. In 2005, fatal multisystemic disease was attributed to HMV K. pneumoniae in African green monkeys (AGM) at our institution. After identification of a cluster of subclinically infected macaques in March and April 2008, screening of all colony nonhuman primates by oropharyngeal and rectal culture revealed 19 subclinically infected rhesus and cynomolgus macaques. PCR testing for 2 genes associated with HMV K. pneumoniae, rmpA and magA, suggested genetic variability in the samples. Random amplified polymorphic DNA analysis on a subset of clinical isolates confirmed a high degree of genetic diversity between the samples. Environmental testing did not reveal evidence of aerosol or droplet transmission of the organism in housing areas. Further research is needed to characterize HMV K. pneumoniae, particularly with regard to genetic differences among bacterial strains and their relationship to human disease and to the apparent susceptibility of AGM to this organism.

AGM, African green monkey; HMV Abbreviations: K. pneumoniae, invasive Klebsiella pneumoniae with hypermucoviscosity phenotype; NHP, nonhuman primate; RAPD, random amplification of polymorphic DNA

Klebsiella pneumoniae is an enteric, gram-negative, lactose-fermenting bacillus with a prominent capsule. This bacterium has been associated with peritonitis, septicemia, pneumonia, and meningitis in both Old and New World primates, although it also is reported to constitute normal fecal and oral flora in many nonhuman primates (NHP). Pathogenic strains associated with the upper respiratory tract typically are heavily encapsulated. Over the past several decades, human medical literature indicates the emergence of an invasive K. pneumoniae disease in Taiwan and other Asian countries, in which community-acquired pyogenic liver abscesses have been attributed to strains of invasive K. pneumoniae with a unique hypermucoviscous phenotype (HMV K. pneumoniae). The hypermucoviscous phenotype has also been associated with other serious complications, including bacteremia, meningitis, and endophthalmitis. This strain of Klebsiella has become an emerging cause of pyogenic liver abscesses in some nonAsian countries, including the United States. The majority of clinical cases of HMV K. pneumoniae are in the Asian population, particularly in patients with diabetes mellitus. Determination of the HMV phenotype typically is based on a positive string test.

Several virulence factors have been associated with HMV K. pneumoniae. Klebsiella spp. generally develop prominent polysaccharide capsules which increase virulence by protecting the bacteria from phagocytosis and preventing destruction by bactericidal serum factors. Capsular serotypes K1 or K2 have been reported as the major virulence determinants for human HMV K. pneumoniae liver abscesses. In addition, the mucoviscosity-associated gene magA, which encodes a structural outer membrane protein of the K1 serotype, and rmpA (regulator of the mucoid phenotype gene; located on a plasmid) have been proposed as virulence factors. Recently, it was suggested that 2 clones, CC23 K1 and CC82 K1, are strongly associated with primary liver abscess and respiratory infection, respectively.

Over a period of several months in 2005 to 2006, 7 African green monkeys (AGM; Chlorocebus aethiops) in the US Army Medical Research Institute of Infectious Diseases research colony developed abscesses in multiple locations and either died or were euthanized when the abscesses were determined to be nonresectable. HMV K. pneumoniae of the K2 serotype and carrying rmpA was determined to be the cause of the infection in 1 case, and the 6 other cases had similar clinical and pathologic features. This report is the only documentation, to our knowledge, of natural infection with HMV K. pneumoniae in NHP. As a result of these cases, the US Army Medical Research Institute of Infectious Diseases instituted policies to exclude HMV K. pneumoniae from the colony. The organism was included as a specific pathogen-free requirement for vendors, and K. pneumoniae culture results were reported during quarantine periods and on routine semiannual examination for all colony NHP.

Case Study

In March 2008, a 3.5-kg male rhesus macaque tested positive for HMV K. pneumoniae on an oropharyngeal sample obtained during routine semiannual physical examination. This animal was not assigned to an experimental protocol and had not been used in any previous experimental protocols. The macaque was serologically negative for cercopithecine herpesvirus 1, simian type D retrovirus, SIV, and simian T-cell leukemia virus 1 and tested negative for parasites by fecal flotation and direct smear. Although this animal showed no clinical signs of disease, concerns about transmission of HMV K. pneumoniae, which had previously caused fatal disease in AGM at the facility, led to the decision to euthanize the macaque.

Approximately 3 wk after the index case was identified and euthanized, the other 35 rhesus macaques that were housed in same room were cultured by using oropharyngeal and rectal swabs in an effort to increase sensitivity of testing. Culture results were positive for HMV K. pneumoniae in 3 male rhesus macaques in the room; 2 of the 3 animals were positive on both oropharyngeal and rectal culture, and the remaining macaque was positive on oropharyngeal culture only. At 5 wk after the index case, a 5.2-kg male cynomolgus macaque, located in a separate building and with no history of direct contact with the infected rhesus macaques, tested positive for HMV K. pneumoniae on a rectal culture during medical screening for an experimental protocol to which the animal had been assigned. This animal had cleared a 6-wk quarantine, during which he tested serologically negative for cercopithecine herpesvirus 1, simian type D retrovirus, SIV, and simian T-cell leukemia virus 1; tested culture negative by oral swab for Klebsiella spp., Salmonella spp., and Shigella spp.; and tested negative for parasites by fecal flotation and direct smear. Because of the severity of disease previously associated with this organism in AGM in our colony and because the pathogen had now been found in 2 separate buildings, we initiated screening of the entire NHP colony for HMV K. pneumoniae.

Here we describe an epidemiologic investigation of cynomolgus and rhesus macaques in our research colony that were infected with HMV K. pneumoniae. Our investigation included bacteriology, PCR, and random amplified polymorphic DNA (RAPD) typing of HMV K. pneumoniae,; we also tested the hypothesis that aerosols or droplets created during cage cleaning were responsible, in part, for transmission of the organism.

Materials and Methods

Animals.

The animals described in this report were maintained in AAALAC-accredited facility. All research was conducted as part of protocols approved by our institutional animal care and use committee and adhered to the Guide for the Care and Use of Laboratory Animals.

The NHP colony consisted of 307 animals (51 AGM, 125 cynomolgus macaques, and 131 rhesus macaques). Rooms housing NHP contained only 1 species at a time, but multiple species were housed within a single wing or corridor of the NHP hallways and there was no defined entry order for the rooms. Semiannual evaluations of NHP included physical examination; complete blood counts and blood chemistry; serologic testing for measles, cercopithecine herpesvirus 1, simian type D retrovirus, SIV, and simian T-cell leukemia virus 1 in macaques; serologic testing for measles virus, SIV, simian T-cell leukemia virus 1, African green α herpesvirus, and rotavirus (group A) in AGM; culture of the oropharynx; and screening for parasites via fecal flotation and direct smear. Until identification of the 1st infected macaque, rectal cultures were not performed routinely unless an NHP showed clinical signs of enteric disease. All NHP were housed in 4.5-ft ² or 6.0-ft ² cages with 4 cages per rack (Allentown Caging Equipment, Allentown, NJ). The environmental conditions were maintained as recommended in the Guide for the Care and Use of Laboratory Animals (temperature, 16 to 29 °C; humidity, 30% to 70%; and 12:12-h light:dark cycle). Animals were fed a standard primate diet (diet 8714, Harlan Teklad, Madison, WI) supplemented with fruit and other food treats. Fresh water, provided ad libitum, was chlorinated at the municipal level and filtered (Edstrom Industries, Waterford, WI). Environmental enrichment (Challenge Ball, Kong, and Hercules Dental Device, Bio-Serv, Frenchtown, NJ) was provided, and cages were arranged so that the animals were facing each other across the room.

Bacteriology.

Oropharyngeal and rectal swabs were taken from 307 cynomolgus macaques, rhesus macaques, and AGM. Any animal that tested positive was removed from the room and housed in a room that contained only NHP that cultured positive for HMV K. pneumoniae. The rooms from which these NHP originated then underwent 6 wk of quarantine, during which weekly oropharyngeal and rectal swabs were cultured in an effort to eliminate all infected NHP from general housing. A total of 2297 oropharyngeal and rectal samples were collected and cultured from midMarch to early September 2008.

All swabs were collected by using culture collection and transport systems (BBL Culture Swab, Becton Dickinson, Franklin Lakes, NJ). The swabs were delivered to the microbiology laboratory, used to inoculate MacConkey agar plates, and incubated at 35 °C without CO ₂. The plates were examined the day after inoculation for the presence of hypermucoviscous, lactose-fermenting, gram-negative rods. All suspect colonies were analyzed by using an automated bacterial identification system (Vitek 2, bioMerieux, Hazelwood, MI) and subcultured on a 5% sheep blood agar plate to ensure purity. Any isolate yielding a probability of 90% or greater for K. pneumoniae was further analyzed through the string test, in which a bacterial loop was touched to a suspect colony on a 5% sheep blood agar plate and withdrawn slowly. Bacteria forming a 'string' of at least 5 mm were determined to be positive (). Isolates determined to be HMV K. pneumoniae were boiled and the resulting DNA was frozen at −70 °C for molecular analysis.

Real-time PCR.

Rapid real-time PCR assays ( TaqMan and TaqMan Minor Groove Binder assays, Applied Biosystems, Foster City, CA) were used to detect rmpA and magA, genes that are highly associated with the HMV phenotype; all HMV K. pneumoniae cultures from midMarch 2008 to September 2008 were tested as described previously. A total of 78 HMV K. pneumoniae samples were tested via PCR for the magA and rmpA genes as part of the current epidemiologic study.

RAPD analysis.

Bacterial genomic DNA was extracted (Illustra Genomic Prep Mini Spin Kit, GE Healthcare, Buckinghamshire, UK) according to the manufacturer's instructions. RAPD analysis (Ready-To-Go RAPD Beads, GE Healthcare) was performed by using a primer provided in the kit (primer 2, 5′ GTT TCG CTC C 3′); we tested six different random 10mer primers provided and selected primer 2 because it yielded easily readable patterns and the most bands that were well separated. Ampli Taq polymerase, dNTPs (0.4 mM each), bovine serum albumin (2.5 µg), buffer (3 mM MgCl ₂, 30 mM KCl, 10 mM Tris [pH 8.3]), and Stoffel fragment were provide as dried beads that were stable at room temperature. Primer 2 (10 µL; 5 pmol/µL), template DNA (10 µL; 5 ng/µL), and 5 µL sterile distilled water were added to the reaction beads for a total reaction volume of 25 µL. PCR amplification was performed in a thermocycler (Mastercycler, Eppendorf, Hamburg, Germany) by using 5 min at 95 °C followed by 45 cycles of 95 °C for 1 min, 36 °C for 1 min, and 72 °C for 2 min. PCR products were separated on a 1.5% agarose gel, which was stained with ethidium bromide and visualized by UV transillumination. DNA fragment patterns were compared by visual inspection.

Environmental testing.

A total of 326 samples were collected from various NHP housing rooms in the facility and divided among 3 test methods. For the first test, 258 environmental swabs were collected from predetermined sites over 6 wk. Swabs were taken at midday, after rooms had been cleaned and sanitized by the animal caretaker. Each week, 42 swabs were taken from the door knob, room corner, drain cover, handle of hose spray nozzle, lixit, air handling vent, and rubber surface of floor squeegee in 6 NHP housing rooms (total, 252 swabs). These rooms contained either infected, quarantined (HMV K. pneumoniae status unknown), or culture-negative animals. During week 5, additional swabs were taken from cage fronts of 3 different NHP cages in the room housing infected animals, and during week 6, swabs were taken from feces in pans of 3 infected macaques (total, 6 swabs).

The second test involved affixing 14 MacConkey plates to the wall and on the surfaces of 2 banks of cages in a grid pattern ( and ), removing lids, allowing the caretaker to spray solid and liquid organic material out of 1 bank of cages, and then promptly removing the culture plates. This test was performed twice: once while the first bank of cages was sprayed out, and then again when the second bank of cages was sprayed. A total of 28 MacConkey plates were submitted for culture by using this test method.

The third test involved exposing MAC culture plates, placed on trays throughout the room immediately after the caretaker cleaned the cages by using a high-pressure spray. Culture plates remained in place for various periods of time. Tray stands were constructed by using polyvinyl chloride material and contained 2 trays each: 1 at the height of upper cages, and the other at the height of the lower cages. The tray stands were placed in the center of the room, at 5-ft intervals along the length of the room (). Each tray held 2 culture plates. One set of 10 plates (position A in ) was left in place from the completion of spraying to 60 min afterward. The second set of 10 plates (position B in ) was in place from the completion of spraying until 5 min after spraying; these plates then were replaced with 10 additional plates that remained in place from 5 min to 10 min after spraying. The plates were exchanged again; the final set of plates was placed in position B from 10 min to 60 min after spraying. A total of 40 culture plates were submitted for culture by using this third test method.

Results

Bacteriology.

From midMarch 2008 to early September 2008, a total of 2297 swabs from 307 rhesus macaques, cynomolgus macaques, and AGM were tested by oropharyngeal and rectal culture for HMV K. pneumoniae. Although 195 samples were positive for K. pneumoniae, only 81 of those samples were of the HMV phenotype. The 81 HMV K. pneumoniae samples represented 19 infected animals, of which 14 had multiple positive cultures during the monthly physical examinations. The single index animal (a macaque) was euthanized promptly after yielding a single positive sample, and another NHP had a single positive culture and then tested negative on multiple subsequent cultures. Another 3 animals were swabbed and then moved into biocontainment as part of an experimental protocol; positive results were identified after the animals were in biocontainment, which made further evaluation inadvisable. As a result, 78 positive HMV K. pneumoniae isolates were evaluated as part of this study.

PCR gene analysis.

Real-time PCR testing of the 78 HMV K. pneumoniae samples resulted in 49 / isolates, 17 isolates, and 12 / isolates. PCR results from 16 NHP (the index case and 15 NHP that were available for repeated cultures) are presented in . In some cases, an animal had PCR results that were variable between culture sites or over time.

Table 1.

RAPD analysis.

A subset of 18 isolates, identified as HMV K. pneumoniae in light of bacteriology and phenotypic analysis, was characterized by RAPD typing in an attempt to confirm genetic variability suggested by the PCR results. Visual inspection readily distinguished multiple RAPD types among the HMV K. pneumoniae isolates (). Patterns were considered to be distinct if 2 or more bands were present or absent between 2 isolates. According to this criterion, 4 clusters (A, B, C, D) were identified. There was no apparent association of RAPD patterns with animal species, given that rhesus macaques were infected with 3 different types (A, D, B), and cynomolgus macaques were infected with 2 different types (C and B). Likewise, RAPD pattern was not associated with rmpA/ magA status. However, RAPD pattern related loosely to vendor or vendor shipment cohort. For example, cluster A was uniquely associated with vendor 1. However, these associations were not absolute: shipment cohort 2 from vendor 2 contained animals infected with HMV K. pneumoniae of both clusters B and D.

A single animal, Cy4 from research institute 1, yielded 2 different strains isolated from rectal swabs taken about 3 wk apart. The first isolate appeared similar to cluster C bacteria, but the second isolate was unique and did not correlate with any other identified cluster. The HMV K. pneumoniae isolated from an abscess in 2005 from an AGM with fatal multisystemic disease appeared to be a minor variant of cluster A from vendor 1 ().

Environmental testing.

In the first test method, 252 environmental swabs were taken from predetermined locations in NHP rooms over 6 wk, and none of those samples cultured positive for HMV K. pneumoniae. Six additional environmental swabs were added during weeks 5 and 6. HMV K. pneumoniae was cultured during week 5 from the cage front of an infected macaque in the room housing known infected animals, and HMV K. pneumoniae was cultured from feces in pans of 3 infected macaques during week 6.

The second test method, which used a grid system of MacConkey culture plates affixed to the walls and cages in the room housing known infected animals, yielded only 1 positive culture. The plate that was placed in position 8 () during spray-down of cage bank 1 yielded HMV K. pneumoniae.

The final test method, which involved uncovering culture plates for different times after completion of spray down of organic material from cages in the room housing known infected NHP, yielded no samples that were positive for K. pneumoniae.

Discussion

Although HMV K. pneumoniae has emerged as an important pathogen of humans, causing pyogenic liver abscesses and other metastatic lesions, this organism previously caused fatal abdominal abscesses in AGM at our facility. To our knowledge, these cases reflect the only documented cases of clinical disease attributed specifically to HMV K. pneumoniae in NHP. After a subclinically infected rhesus macaque was identified in March 2008, subsequent screening and testing of 307 NHP resulted in the collection of 2297 oropharyngeal and rectal swabs and 326 environmental swabs over 7 mo. The HMV phenotype was found in 81 samples, representing a total of 19 subclinically infected macaques. Three samples, obtained from animals that were moved into biocontainment, were unavailable for further analysis, leaving a total of 78 samples. In addition, 2 of the 326 environmental swabs tested positive for HMV K. pneumoniae.

Fifteen of the 19 infected animals were isolated and monitored clinically with monthly evaluations, which included physical exam, hematology and serum chemistry, and oropharyngeal and rectal culture. The infected macaques, regardless of species, remained asymptomatic from the time they were diagnosed through early September 2008, when they were used on a separate research protocol to further characterize HMV K. pneumoniae.

Asymptomatic carriers of Klebsiella are common in both animals and humans. In 1 study, prevalence of fecal shedding in healthy adult dairy cows was over 80%. In humans, fecal carriage of Klebsiella is also common, ranging in prevalence from 5% to 38% in the general population to 77% in hospital settings. Rates of Klebsiella-positive cultures from the human nasopharynx range from 1% to 6% in the general population to 19% in hospital settings. In our study, the index case was identified by positive results from an oropharyngeal swab, which was the standard sampling site before the detection of infection within the colony. Once colony screening began, both oropharyngeal and rectal swabs were submitted for culture. This procedural change likely altered the sensitivity of testing, perhaps resulting in improved detection of subclinical carriers of HMV K. pneumoniae.

Four of the 15 infected NHP had PCR results that varied from culture to culture. A study using RAPD typing to characterize fecal Klebsiella shedding in dairy cows showed marked variation in strains within and between fecal samples collected from individual cows on multiple consecutive days. Two cows were found to harbor multiple strains of Klebsiella in fecal samples taken on a single day. In our study, a single cynomolgus macaque (Cy4) had 2 different strains, as determined by RAPD typing, isolated from rectal samples taken 3 wk apart. Although the study evaluating dairy cows examined Klebsiella species in general and not HMV K. pneumoniae specifically, its findings of coinfection with multiple strains may still help to explain the variable PCR results in our current study. Here, pure culture isolates were generated by picking a single bacterial colony based on phenotype and performing a boil preparation for PCR. If various strains coinfect a single animal, several phenotypically similar colonies from those strains may grow on a plate from which only a single colony would have been selected. Depending on the genotype of the colony selected, PCR results would vary from culture to culture. An additional consideration is that, once diagnosed as positive for HMV K. pneumoniae, each animal was moved into a single room that housed all infected macaques, regardless of genotype. The potential for coinfection or superinfection with different strains was increased during that period.

A persistent carrier status did not appear to exist in dairy cows; instead a transient presence of Klebsiella was evidenced by the large variety of Klebsiella strains found within samples and between samples collected from individual animals on multiple consecutive days. The suggestion that infection in dairy cows is transient differs from literature on Klebsiella spp. in other species, which indicates that the organism colonizes the mucosal surfaces of mammals including humans, horses, and swine. HMV K. pneumoniae infections in macaques do not appear to be as transient as those in the dairy cows previously described. Most macaques in the current study maintained infection with at least 1 strain of K. pneumoniae for weeks to months; however, some animals appeared to clear the organism, testing positive once or twice and then subsequently testing negative.

In our facility, animals from an individual quarantine group (shipment cohort) generally stay grouped together until they are assigned to an experimental protocol. There appear to be some broad (but not absolute) cohort associations with regard to rmpA and magA gene status (). However some building renovation projects in our facility in the months preceding identification of the index case necessitated moving NHP into different rooms. As a result, identifying all NHP that an individual animal might have been exposed to during this time was impossible. Consequently, an NHP may have had unknown exposure to an NHP with a subclinical infection of HMV K. pneumoniae.

Table 2.

The RAPD technique has been used frequently to study genetic variability in populations. Unlike PCR, which requires well-defined and specific DNA sequences as primers, the RAPD technique uses primers of arbitrary nucleotide sequence to access random segments of genomic DNA to reveal polymorphisms. In epidemiologic studies, although pulsed-field gel electrophoresis generally is considered to be the 'gold standard', it is technically demanding, requires specialized equipment, and is time-consuming. Both pulsed-field gel electrophoresis and RAPD typing have proved useful for differentiating between groups of epidemiologically related extended-spectrum-β-lactamase-producing K. pneumoniae. Whereas pulsed-field gel electrophoresis was more discriminating, RAPD typing proved to be more efficient for screening of clonally related isolates. In our current study, the RAPD technique was applied to a subset of HMV K. pneumoniae-positive cultures to further elucidate some of the variability seen in PCR results. Cohort associations identified on PCR appeared to hold relatively consistent with RAPD banding patterns. Two different isolates from the same cynomolgus macaque (Cy4) underwent RAPD testing. During PCR analysis, the 28 April 2008 positive rectal culture from Cy4 was , whereas that on 20 May 2008 was (). The RAPD genotypes of those 2 isolates showed banding patterns that differed from each other: 1 of the isolates had a banding pattern consistent with cluster C, but the other isolate appeared unique and did not fit into any other cluster grouping ().

In the initial stages of this epidemiologic investigation, a great deal of attention was given to the potential for environmental spread of this organism within the NHP colony and to concerns about human health. K. pneumoniae is ubiquitous in nature, existing in surface water, sewage, and soil and on plants, and it is well known to exist in biofilms. In addition, K. pneumoniae is a common cause of nosocomial infections in the human healthcare systems. It is an opportunistic pathogen that has a survival time of 4 to 27 d (median, 7.5 d) in common hospital materials.

Because of these characteristics, requirements regarding personal protective equipment were enhanced at our facility, and investigators, caretakers, technicians, and veterinary staff working with NHPs were trained about the human health risks associated with HMV K. pneumoniae. Concerns about the zoonotic potential of this known human pathogen led to the decision to initiate environmental surveillance for Klebsiella. Because we were able to culture HMV K. pneumoniae from the feces of 3 infected macaques, a potential for fecal-oral transmission existed. Screening involved taking cultures from areas in 6 different NHP rooms that we considered most likely to support the growth of K. pneumoniae. The results of these screenings revealed that environmental contamination was not a major factor in transmission of this agent between NHP rooms. As a primary respiratory pathogen, K. pneumoniae is known for droplet or aerosol transmission. Accordingly, 2 experiments were initiated to determine how readily K. pneumoniae was dispersed both during and after high-pressure spraying of cages within the room housing known infected NHP. The results of each experiment failed to support a theory of widespread droplet or aerosol transmission of the bacteria either during or immediately after high-pressure cage wash by animal caretakers.

Although HMV K. pneumoniae has been documented to cause abdominal abscesses in AGM and pyogenic liver abscesses (sometimes with bacteremia, endophthalmitis, and meningitis) in humans in Taiwan and other Asian countries, the organism was maintained as a subclinical infection in a colony of macaques at our facility. Despite initial concerns about clonal spread of the organism through environmental, aerosol, or droplet contamination within the colony, environmental testing did not suggest widespread contamination in the environment. In addition, PCR and RAPD testing verified the existence of multiple genotypes which could broadly be associated with vendor cohort groups. Infection with multiple strains appeared likely in cohoused, infected macaques through a fecal-oral transmission pattern. As a result of this study, our institute has initiated procedures to increase physical separation between AGM and macaque species, including designation of room entry order and changes of personal protective equipment between species.

Future research efforts should focus on immunologic changes that result in macaques from subclinical infection with HMV K. pneumoniae and the potential for use as a research model for human disease. In addition, further characterization of the organism in AGM, a species that appears particularly susceptible to clinical disease resulting from infection with HMV K. pneumoniae, may prove to be valuable by providing insight into virulence factors and potential immune-evading measures used by this pathogen in infected AGM and humans.

Acknowledgments

We are grateful to Laurie Hartman, Dave Kulesh, Jeanne Geyer, and Mark Wolcott (Diagnostic Systems Division, US Army Medical Research Institute of Infectious Diseases) for developing the rmpA and magA assays and for providing technical expertise and support during this project. We also thank the technicians from the Nonhuman Primate Section and the technicians and staff from Clinical Laboratory for plating, subculturing, and reading results from cultures during a 6-mo timeframe that saw the microbiologic workload triple from that of the entire previous year.

Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the US Army. The authors do not have a commercial or other association that would pose a conflict of interest. This work was presented in part at the Association of Primate Veterinarians 36 th Annual Workshop, Indianapolis, IN, 6-8 November 2008.

The research described herein was sponsored by the US Army Medical Research Institute of Infectious Diseases under Research Plan Number 150874. It was supported in part by an appointment to the Student Research Participation Program at the US Army Medical Research Institute for Infectious Diseases administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the US Department of Energy and USAMRMC.

References

7. Descheemaeker P, Lammens C, Pot B, Vandamme P, Goossens H. 1997. Evaluation of arbitrarily primed PCR analysis and pulsed-field gel electrophoresis of large genomic DNA fragments for identification of enterococci important in human medicine. Int J Syst Bacteriol 47:555-561

11. Gastmeier P, Schwab F, Bärwolff S, Rüden H, Grundmann H. 2006. Correlation between the genetic diversity of nosocomial pathogens and their survival time in intensive care units. J Hosp Infect 62:181-186

12. Gibson SV. 1998. Bacterial and mycotic diseases, p 73-75. Bennett BT, Abee CR, Hendrickson R, editors. Nonhuman primates in biomedical research: diseases. San Diego (CA): Academic Press

13. Gonzalo A, Montoyo E. 1991. Klebsiella pneumoniae infection in a New World nonhuman primate center. Lab Primate Newslett 30:13-20

15. Hartman LJ, Selby EE, Whitehouse CA, Coyne SR, Jaissle JG, Twenhafel NA, Burke RL, Kulesh DA. 2009. Rapid real-time PCR assays for detection of [ Klebsiella pneumoniae with the rmpA or magA genes associated with the hypermucoviscosity phenotype: screening of nonhuman primates. J Mol Diagn 11:464-471 PMC free article]

22. Mah TF, O'Toole GA. 2001. Mechanisms of biofilm resistance to antimicrobial agents. Trends Microbiol 9:34-39

28. National Research Council 1996. Guide for the care and use of laboratory animals. Washington (DC): National Academies Press

31. Struve C, Bojer M, Nielsen EM, Hansen DS, Krogfelt KA. 2005. Investigation of the putative virulence gene magA in a worldwide collection of 495 Klebsiella isolates: magA is restricted to the gene cluster of Klebsiella pneumoniae capsule serotype K1. J Med Microbiol 54:1111-1113

33. Tsai FC, Huang YT, Chang LY, Wang JT. 2008. Pyogenic liver abscess as endemic disease, Taiwan. Emerg Infect Dis 14:1592-1600 [ PMC free article]

38. Yeh KM, Kurup A, Siu LK, Koh YL, Fung CP, Lin JC, Chen TL, Chang FY, Koh TH. 2007. Capsular serotype K1 or K2, rather than [ magA and rmpA, is a major virulence determinant for Klebsiella pneumoniae liver abscess in Singapore and Taiwan. J Clin Microbiol 45:466-471 PMC free article]

39. Yu VL, Hansen DS, Ko WC, Sagnimeni A, Klugman KP, von Gottberg A, Goossens H, Wagener MM, Benedi VJ, International Virulence characteristics of [ Klebseilla Study Group 2007. Klebsiella and clinical manifestations of K. pneumoniae bloodstream infections. Emerg Infect Dis 13:986-993 PMC free article]

41. Yu WL, Ko WC, Cheng KC, Lee HC, Ke DS, Lee CC, Fung CP, Chuang YC. 2006. Association between rmpA and magA genes and clinical syndromes caused by Klebsiella pneumoniae in Taiwan. Clin Infect Dis 42:1351-1358

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Epidemiology of Invasive Klebsiella pneumoniae with Hypermucoviscosity Phenotype in a Research Colony of Nonhuman Primates

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Invasive Klebsiella pneumoniae with hypermucoviscosity phenotype (HMV K. pneumoniae) is an emerging human pathogen that, over the past 20 y, has resulted in a distinct clinical syndrome characterized by pyogenic liver abscesses sometimes complicated by bacteremia, meningitis, and endophthalmitis. Infections occur predominantly in Taiwan and other Asian countries, but HMV K.

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Klebsiella pneumoniae - symptom and healthcare

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Klebsiella pneumoniae - symptom and healthcare

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Klebsiella pneumoniae is a bacterium that normally lives inside human intestines, where it doesn't cause disease.

However, if K. pneumoniae gets into other areas of the body, it can cause a range of different illnesses.

These include:

How Klebsiella Pneumoniae Spreads

K. pneumoniae infections are typically "nosocomial" infections, which means they're contracted in a hospital or healthcare setting.

People who have weakened immune systems, or sick or injured people who are undergoing procedures for various health issues, are more likely to get a Klebsiella infection.

Healthy people usually don't have to worry about getting K. pneumoniae infections, according to the Centers for Disease Control and Prevention (CDC).

The bacteria are not airborne, so you can't contract a K. pneumoniae infection by breathing the same air as an infected person.

Instead, K. pneumoniae is spread through direct person-to-person contact, such as when someone with contaminated hands touches a wound.

Infections can also occur through the use of contaminated medical equipment.

For example, people on ventilators can contract Klebsiella pneumonia if breathing tubes are contaminated with the bacteria.

Similarly, the use of contaminated intravenous catheters can lead to bloodstream infections.

Taking antibiotics over a long course of time can also increase a person's risk of getting a Klebsiella infection.

Symptoms of K. Pneumoniae Infections

The symptoms of a K. pneumoniae infection differ depending on where the infection is located, and are similar to symptoms of the same diseases caused by other microbes.

For instance, meningitis from K. pneumoniae produces the hallmark symptoms of bacterial meningitis, including fever, confusion, neck stiffness, and sensitivity to bright lights.

Bloodstream infections (bacteremia and sepsis) from Klebsiella cause fever, chills, rash, light-headedness, and altered mental states.

Pneumonia from K. pneumoniae can result in:

Fevers and chills

Flu-like symptoms

Cough, which may produce mucus that's yellow, green, or bloody

Breathing issues

Treatment of Klebsiella Infections

Doctors typically use antibiotics to treat K. pneumoniae infections.

However, the rise of antibiotic-resistant strains of the bacteria has complicated matters.

Some "superbug" strains of K. pneumoniae are resistant to most antibiotics, including carbapenems, which are considered last-resort drugs.

These bacteria produce enzymes called Klebsiella pneumoniae carbapenemases (KPC), which render the antibiotics ineffective.

These hardy, high-threat-level microbes are part of a group called carbapenem-resistant Enterobacteriaceae, or CRE.

Carbapenem-resistant Klebsiella is the most common type of CRE, and is responsible for about 7,900 infections and 520 deaths each year, according to the CDC.

To treat CRE, doctors rely on several powerful antibiotics that still have some effectiveness against the bacteria, particularly when used in combination, according to a January 2013 report in the journal Diagnostic Microbiology & Infectious Disease.

These drugs include:

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Klebsiella pneumoniae is a bacterium that normally lives inside human intestines, where it doesn't cause disease. However, if K. pneumoniae gets into other areas of the body, it can cause a range of different illnesses. These include: K. pneumoniae infections are typically "nosocomial" infections, which means they're contracted in a hospital or healthcare setting.

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Abstract

Nosocomial infections with resistant gram-negative organisms, particularly strains of Klebsiella pneumoniae, have become a significant problem at a time when there is a lack of promising new antimicrobial agents on the horizon [ 1, 2]. In response to the prevalence of extended-spectrum β-lactamases, carbapenem use increased, and carbapenem resistance soon followed. In 2001, Yigit et al. [ 3] reported a novel β-lactamase termed " K. pneumoniae carbapenemase" (KPC-1) in North Carolina. Soon after, strains of KPC-producing Klebsiella species were reported in New York City and then upstate New York [ 4-6]. We report 2 cases of infection with highly resistant, KPC-producing K. pneumoniae at a tertiary care hospital in New York City. The isolates were resistant to all antibiotic agents tested, including the carbapenems, polymyxin B, and tigecycline. To our knowledge, there have been no previously reported cases of infection due to panresistant K. pneumoniae in the United States.

Case report 1. In July 2007, a 70-year-old woman was admitted to the hospital with a urinary tract infection. She was residing in a nursing home after a recent hospitalization for pneumonia due to KPC-producing K. pneumoniae treated with tigecycline and polymyxin B. An indwelling bladder catheter had been placed at the nursing facility. During admission to the hospital, she reporting having dysuria and suprapubic pain for 2 days. A urinalysis revealed nitrites and a white blood cell count >100 cells per high-power field. Her examination was notable for a temperature of 37.4°C and suprapubic tenderness. A urine culture showed >100,000 colony-forming units (cfu) per mL of a highly resistant, KPC-producing K. pneumoniae strain. The minimum inhibitory concentration (MIC) was 4 µg/mL for tigecycline and 96 µg/mL for polymyxin B. The patient's catheter was removed, and she began treatment with tigecycline and rifampin. She developed a rash, and the rifampin was discontinued. Her urinalysis results remained unchanged, and her urine culture again showed the presence of >100,000 cfu/mL of K. pneumoniae, which now had an MIC >8 µg/mL for tigecycline. Tigecycline was discontinued after 10 days of treatment, and the patient was discharged to home with persistent dysuria. She subsequently had spontaneous resolution of symptoms, although the last available urine culture specimen, obtained >1 year later, continued to show >100,000 cfu/mL of the panresistant K. pneumoniae.

Case report 2. In March 2008, a 67-year-old man underwent a Whipple procedure at another hospital. Postoperatively, he developed a hepatic abscess. Enterobacter cloacae and K. pneumoniae grew from cultures of samples from the liver abscess. Both organisms were resistant to carbapenem but susceptible to polymyxin B and tigecycline. He was given treatment with tigecycline and empirical treatment with daptomycin and caspofungin. The patient's postoperative course was prolonged and complicated by multiple organ system dysfunction.

In May 2008, the patient was transferred to our institution. On the day of admission, the patient was febrile, with a temperature of 38.7°C. He arrived sedated and with mechanical ventilation via tracheostomy and an abdominal drain in place. The peripheral white blood cell count was 5.6×10 ³ cells/mm ³(neutrophil percentage, 77.1%), and the serum creatinine level was 4.2 mg/dL. Blood cultures of specimens obtained at admission showed no growth. Computed tomography of the abdomen and pelvis showed a large perihepatic abscess and a drain suboptimally positioned. On the basis of the prior culture results, daptomycin and caspofungin were discontinued from the treatment regimen, and polymyxin B was added to tigecycline. The abdominal drain was replaced, and culture specimens were sent to the laboratory.

On hospital day 5, the patient remained febrile and developed hypotension requiring vasopressor support. Cultures of samples from the hepatic abscess showed E. cloacae, K. pneumoniae, and Enterococcus faecium. Both the K. pneumoniae and the E. cloacae isolates were identified as producers of KPC by polymerase chain reaction (PCR) testing. The K. pneumoniae strain was resistant to all antibiotics tested, including tigecycline, and had an elevated MIC for polymyxin B. The E. cloacae strain was similarly resistant, with the exception of an intermediate result for tigecycline (MIC, 4 µg/mL). The patient was taken to the operating room for irrigation and debridement of infected material.

Postoperatively, the patient's condition continued to deteriorate. Blood cultures of specimens collected on hospital day 8 grew a KPC-producing K. pneumoniae strain resistant to all tested antibiotics except polymyxin B (MIC, 0.75 µg/mL). Daily blood cultures continued to grow K. pneumoniae. On hospital day 12, blood cultures showed a K. pneumoniae strain with a MIC for polymyxin B of 12 µg/mL. Over the next few days, the patient's condition worsened despite supportive care and continuation of treatment with tigecycline and polymyxin B. He developed worsening sepsis and shock. On hospital day 14, the patient died.

Discussion. Infection with KPC-producing K. pneumoniae has become prevalent in New York City. However, there have been no reports of KPC-producing K. pneumoniae isolates that are also resistant to polymyxin and tigecycline in the United States. There are published reports of highly resistant K. pneumoniae isolates in Greece with decreased susceptibility to the polymyxins, but these isolates were not tested for resistance to tigecycline [ 7-9]. We present our experience with these 2 patients to afford a glimpse of a future of potentially untreatable infections and to highlight some unique challenges in dealing with KPC-producing organisms.

We have termed these isolates "panresistant," but because there is no generally accepted definition for this term, we present the antimicrobial susceptibility data for both isolates in table 1. The isolates were tested using a custom gram-negative card for the automated system Vitek 2 (bioMérieux) that included tigecycline. They were also tested for bla KPC genes by real-time PCR. Susceptibility to polymyxin B was determined using a commercially available Etest.

Clinicians need accurate susceptibility data to provide effective therapy. However, automated susceptibility systems may be unreliable for detection of carbapenem resistance [ 10, 11]. A review of several automated systems showed that they incorrectly labeled up to 87% of carbapenemase-producing K. pneumoniae isolates as susceptible to imipenem, as well as reporting varying susceptibilities for the same isolate from day to day [ 10]. Ertapenem resistance seems to be a marker for carbapenemase production when automated testing methods are used [ 10, 11]. In our second patient, automated testing reported the MIC for imipenem as ⩽1 µg/mL, but the MIC for ertapenem was elevated. PCR testing was used to confirm the presence of KPC genes. PCR testing for bla KPCgenes can be a useful method of confirming resistance to carbapenem in the United States, where metallo-β-lactamases are not a common mechanism of resistance. If resources are limited, an elevated MIC for ertapenem could be used as a screening method to determine which isolates need further testing [ 10, 11]. A phenotypic testing method, such as a carbapenem inactivation assay (Hodge test), can also be a reliable method of detecting carbapenemase-producing organisms for laboratories not equipped for PCR [ 10]. Clinicians must be aware of the testing methods at their institution and their possible limitations.

Currently, the therapeutic options for highly resistant, carbapenemase-producing organisms are limited. Polymyxin B and tigecycline both seem to have reliable efficacy, although this report suggests that resistance to them is emerging.

Susceptibility testing for tigecycline can be readily done using automated systems, and gram-negative cards containing tigecycline are commercially available. Testing can also be done using Etest, which has been shown to have relatively good agreement with broth microdilution methods and few major errors in results for K. pneumoniae, although some questions have been raised regarding the reliability of the tigecycline Etest for other organisms [ 12].

Currently, the Vitek 2 system offers automated testing for polymyxin E (colistin) but not for polymyxin B. However, an Etest is available for polymyxin B. The Clinical and Laboratory Standards Institute (CLSI) provides limited guidance with regard to polymyxin B, leaving individual laboratories to determine appropriate methods and cutoffs. The CLSI document M100-S18 update does note that susceptibility testing for polymyxin B for Enterobacteriaceae and Acinetobacter species should be done by MIC methodologies [ 13]. These include broth microdilution or Etest. There is published evidence to suggest that disk-diffusion methods are unreliable and should be avoided [ 14]. CLSI, however, does not provide MIC cutoff values for Enterobacteriaceae. Some authors recommend using ⩾4 µg/mL, which is the CLSI cutoff for Acinetobacter species [ 13, 14].

Perhaps the most important challenge in dealing with resistant gram-negative pathogens is the lack of new antibiotic agents. Prudent antimicrobial use becomes increasingly important as we are faced with a shrinking armamentarium of effective drugs. A recent review of polymyxin-resistant pathogens found that the only significant risk factor for polymyxin resistance was previous polymyxin use [15]. Both of our patients developed progressive increases in the MIC for polymyxin B while they were receiving therapy. This is worrisome, because polymyxin use has been steadily increasing in our institution because of the prevalence of carbapenem-resistant gram-negative organisms. In the face of resistance to the polymyxins and tigecycline, we are unaware of any effective alternative therapies for infection caused by carbapenemase-producing Enterobacteriaceae.

It is a rarity for a physician in the developed world to have a patient die of an overwhelming infection for which there are no therapeutic options. These cases were the first instance in our clinical experience in which we had no effective treatment to offer. Trends in urban hospitals are often the harbinger of the future. We share these cases to highlight some troubling issues that soon may be relevant to increasing numbers of physicians and patients across the United States.

Acknowledgments

Potential conflicts of interest. All authors: no conflicts.

References

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Infection with Panresistant Klebsiella pneumoniae: A Report of 2 Cases and a Brief Review of the Literature | Clinical Infectious Diseases | Oxford Academic

# data[].attributes.attachment_link.description
Nosocomial infections with resistant gram-negative organisms, particularly strains of Klebsiella pneumoniae, have become a significant problem at a time when there is a lack of promising new antimicrobial agents on the horizon [ 1, 2]. In response to the prevalence of extended-spectrum β-lactamases, carbapenem use increased, and carbapenem resistance soon followed.

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MAJOR SYMPTOMS WHEN INFECTED BY K. pneumoniae

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MAJOR SYMPTOMS WHEN INFECTED BY K. pneumoniae

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The most common symptoms of bacterial pneumonia are:

a cough with thick yellow, green, or blood-tinged mucus.

chest pain that worsens when coughing or breathing.

sudden onset of chills.

fever of 102°F or above (fever lower than 102°F in older persons)

headache.

muscle pain.

breathlessness or rapid breathing.

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http://emedicine.medscape.com/article/219907-overview

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https://www.statnews.com/2017/01/12/nevada-woman-superbug-resistant/

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http://popplet.com/app/#/3902465

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Popplet is the best app for sharing visual ideas.

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Our first Zoom meeting :)

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Uploaded by Dineshwaran Naidu Subramaniam on 2017-03-10.