Klebsiella Infections Clinical Presentation
- Author: Shahab Qureshi, MD; Chief Editor: Michael Stuart Bronze, MD more...
Klebsiellae cause various clinical syndromes. Common klebsiellae infections in humans include (1) community-acquired pneumonia, (2) UTI, (3) nosocomial infection, (4) rhinoscleroma and ozena, (5) chronic genital ulcerative disease, and (6) colonization.
Lobar pneumonia differs from other pneumonias in that it is associated with destructive changes in the lungs. It is a very severe illness with a rapid onset and often-fatal outcome despite early and appropriate antimicrobial treatment.
Patients typically present with an acute onset of high fever and chills; flulike symptoms; and productive cough with an abundant, thick, tenacious, and blood-tinged sputum sometimes called currant jelly sputum.
An increased tendency exists toward abscess formation, cavitation, empyema, and pleural adhesions.
Most pulmonary diseases caused by K pneumoniae are in the form of bronchopneumonia or bronchitis. These infections are usually hospital-acquired and have a more subtle presentation.
Urinary tract infection
Klebsiellae UTIs are clinically indistinguishable from UTIs caused by other common organisms.
Clinical features include frequency, urgency, dysuria, hesitancy, low back pain, and suprapubic discomfort. Systemic symptoms such as fever and chills are usually indicative of a concomitant pyelonephritis or prostatitis.
Important manifestations of klebsiellae infection in the hospital setting include UTI, pneumonia, bacteremia, wound infection, cholecystitis, and catheter-associated bacteriuria. The presence of invasive devices in hospitalized patients greatly increases the likelihood of infection. Patients with these infections have similar presentations to those with infections caused by other organisms.
Other nosocomial infections in which klebsiellae may also be implicated include cholangitis, meningitis, endocarditis, and bacterial endophthalmitis. The latter occurs especially in patients with liver abscesses and diabetes. These infectious presentations are relatively uncommon.
Rhinoscleroma and ozena
K rhinoscleromatis and K ozaenae cause rhinoscleroma and ozena, respectively. Both are rare in the United States and are associated with upper respiratory infection.
Rhinoscleroma is a chronic granulomatous infection. Patients present with a purulent nasal discharge with crusting and nodule formation that leads to respiratory obstruction. Diagnosis is aided by histology findings and positive results from blood culture.
Ozena is a primary atrophic rhinitis that often occurs in elderly persons. Common symptoms include nasal congestion and a constant nasal bad smell. Patients also may complain of headache and symptoms attributable to chronic sinusitis. Unlike rhinoscleroma, nasal congestion is not a prominent feature.
Chronic genital ulcerative disease
K granulomatis infection can result in granuloma inguinale or donovanosis, although these are uncommon in developed temperate countries. The mode of transmission is uncertain but is believed to be sexually transmitted. The incubation period is 1-3 weeks.
Ulcerative infection is likely transmitted by contact with microabraded skin. Nonulcerative infection is probably transmitted transepithelially.
Coinfection with other sexually transmitted diseases (STDs) is common.
Klebsiella chronic genital ulcerative disease presents as a firm papule or subcutaneous nodule that later ulcerates. An ulcerogranulomatous presentation is most common and is characterized as a beefy red ulcer. A hypertrophic or verrucous presentation may mimic condylomata acuminate. A necrotic presentation is characterized by a deep ulcer. Sclerotic and cicatricial presentations are rare.
Diagnosis is based on clinical suspicion. Direct microscopy shows intracytoplasmic bipolar staining inclusion bodies (Donovan bodies).
Differentiating nosocomial colonization from infection presents a formidable challenge in clinical practice. It is a common problem in patients with indwelling catheters.
Duration of catheterization is the most important risk factor for the development of bacteriuria. Keeping catheter systems closed and removing catheters as soon as possible are ways to prevent development of bacteriuria.
Most catheter-related UTIs are asymptomatic; the usual complaints of frequency, urgency, dysuria, hesitancy, low back pain, and suprapubic discomfort typically are absent. Therefore, demonstration of bacteriuria is necessary to make a diagnosis. A density of 100,000 colony-forming units per milliliter is usually required to make a diagnosis. Concomitant presence of pyuria is usually present in patients with catheter-associated infection as opposed to those with colonization.
In general, the presence of symptoms in conjunction with bacteriological evidence of infection helps distinguish infection, in which organisms cause disease, from colonization, in which organisms coexist without causing harm.
Klebsiella pneumonia characteristically affects one of the upper lobes of the lung, although infection of the lower lobes is not uncommon.
Examination of patients with community-acquired pneumonia usually reveals unilateral chest signs, predominantly in the upper lobes. When these signs are observed in a patient such as described in History, the diagnosis of Klebsiella pneumonia is strongly suggested.
Clinical signs observed in patients with extrapulmonary disease depend on the organ system involved. In cases of nosocomial infections, physical examination should include a search for factors that predispose the individual to the development of such infections. These should include inspection for the presence and duration of invasive devices, wounds, and burn sites.
Host factors that lead to colonization and infection include the following:
Hospitalization (especially admission to an intensive care unit)
Immunocompromised states (eg, diabetes, alcoholism)
Prolonged use of invasive medical devices
Inadequate infection control practices
Severe illness, including major surgery
The organism gains access to the body either by direct inoculation through breached epithelial surfaces or following aspiration of oropharyngeal organisms.
Mandell. Enterobacteriaceae. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 7th ed. Churchill Livingstone, An Imprint of Elsevier; 2009.
Nordmann P, Cuzon G, Naas T. The real threat of Klebsiella pneumoniae carbapenemase-producing bacteria. Lancet Infect Dis. 2009 Apr. 9(4):228-36. [Medline].
Won SY, Munoz-Price LS, Lolans K, Hota B, Weinstein RA, Hayden MK. Emergence and Rapid Regional Spread of Klebsiella pneumoniae Carbapenemase-Producing Enterobacteriaceae. Clin Infect Dis. 2011 Sep. 53(6):532-540. [Medline].
Livermore DM. Fourteen years in resistance. Int J Antimicrob Agents. 2012 Apr. 39(4):283-94. [Medline].
Miftode E, Dorneanu O, Leca D, Teodor A, Mihalache D, Filip O, et al. [Antimicrobial resistance profile of E. coli and Klebsiella spp. from urine in the Infectious Diseases Hospital Iasi]. Rev Med Chir Soc Med Nat Iasi. 2008 Apr-Jun. 113(2):478-82. [Medline].
Tu YC, Lu MC, Chiang MK, Huang SP, Peng HL, Chang HY, et al. Genetic requirements for Klebsiella pneumoniae-induced liver abscess in an oral infection model. Infect Immun. 2009 May 11. [Medline].
Munoz-Price LS, Poirel L, Bonomo RA, Schwaber MJ, Daikos GL, Cormican M, et al. Clinical epidemiology of the global expansion of Klebsiella pneumoniae carbapenemases. Lancet Infect Dis. 2013 Sep. 13(9):785-96. [Medline].
Fevre C, Passet V, Deletoile A, Barbe V, Frangeul L, Almeida AS, et al. PCR-based identification of Klebsiella pneumoniae subsp. rhinoscleromatis, the agent of rhinoscleroma. PLoS Negl Trop Dis. 2011 May. 5(5):e1052. [Medline]. [Full Text].
Gupta N, Limbago BM, Patel JB, Kallen AJ. Carbapenem-resistant Enterobacteriaceae: epidemiology and prevention. Clin Infect Dis. 2011 Jul 1. 53(1):60-7. [Medline].
Doyle D, Peirano G, Lascols C, Lloyd T, Church DL, Pitout JD. Laboratory detection of Enterobacteriaceae that produce carbapenemases. J Clin Microbiol. 2012 Dec. 50(12):3877-80. [Medline]. [Full Text].
Weisenberg SA, Morgan DJ, Espinal-Witter R, Larone DH. Clinical outcomes of patients with Klebsiella pneumoniae carbapenemase-producing K. pneumoniae after treatment with imipenem or meropenem. Diagn Microbiol Infect Dis. 2009 Apr 1. [Medline].
Chan YR, Liu JS, Pociask DA, Zheng M, Mietzner TA, Berger T, et al. Lipocalin 2 is required for pulmonary host defense against Klebsiella infection. J Immunol. 2009 Apr 15. 182(8):4947-56. [Medline].
Adams-Haduch JM, Potoski BA, Sidjabat HE, Paterson DL, Doi Y. Activity of Temocillin against KPC-Producing Klebsiella pneumoniae and Escherichia coli. Antimicrob Agents Chemother. 2009 Mar 30. [Medline].
Al-Rabea AA, Burwen DR, Eldeen MA, et al. Klebsiella pneumoniae bloodstream infections in neonates in a hospital in the Kingdom of Saudi Arabia. Infect Control Hosp Epidemiol. 1998 Sep. 19(9):674-9. [Medline].
Anderson MJ, Janoff EN. Klebsiella endocarditis: report of two cases and review. Clin Infect Dis. 1998 Feb. 26(2):468-74. [Medline].
Blaser J, Konig C, Simmen HP, Thurnheer U. Monitoring serum concentrations for once-daily netilmicin dosing regimens. J Antimicrob Chemother. 1994 Feb. 33(2):341-8. [Medline].
Bodey GP, Elting LS, Rodriquez S, Hernandez M. Klebsiella bacteremia. A 10-year review in a cancer institution. Cancer. 1989 Dec 1. 64(11):2368-76. [Medline].
Branger J, Florquin S, Knapp S. LPS-binding protein-deficient mice have an impaired defense against Gram-negative but not Gram-positive pneumonia. Int Immunol. 2004 Nov. 16(11):1605-11. [Medline].
Einstein BI. Enterobacteriaceae. In: Mandell GL, Bennett JE, Dolin E, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Vol 2. 5th ed. New York, NY: Churchill Livingstone; 2000:. 2294-310.
Farmer JJ. Enterobacteriaceae: Introduction and identification. In: Murray PR, Baron, EJ, Pfaller MA, eds. Manual of Clinical Microbiology. 7th ed. Washington, DC: American Society for Microbiology; 1999:. 438-47.
Fisman DN, Kaye KM. Once-daily dosing of aminoglycoside antibiotics. Infect Dis Clin North Am. 2000 Jun. 14(2):475-87. [Medline].
Gamea AM, el-Tatawi FA. The effect of rifampicin on rhinoscleroma: an electron microscopic study. J Laryngol Otol. 1990 Oct. 104(10):772-7. [Medline].
Hirche TO, Gaut JP, Heinecke JW. Myeloperoxidase plays critical roles in killing Klebsiella pneumoniae and inactivating neutrophil elastase: effects on host defense. J Immunol. 2005 Feb 1. 174(3):1557-65. [Medline].
Kaye KS, Fraimow HS, Abrutyn E. Pathogens resistant to antimicrobial agents. Epidemiology, molecular mechanisms, and clinical management. Infect Dis Clin North Am. 2000 Jun. 14(2):293-319. [Medline].
Khimji PL, Miles AA. Microbial iron-chelators and their action on Klebsiella infections in the skin of guinea-pigs. Br J Exp Pathol. 1978 Apr. 59(2):137-47. [Medline].
Kobashi Y, Fujita K, Karino T, et al. [Clinical analysis of community-acquired pneumonia requiring hospitalization in a community hospital--comparison of elderly and non-elderly patients]. Kansenshogaku Zasshi. 2000 Jan. 74(1):43-50. [Medline].
Kobashi Y, Ohba H, Yoneyama H, et al. [Clinical analysis of patients with community-acquired pneumonia requiring hospitalization classified by age group]. Kansenshogaku Zasshi. 2001 Mar. 75(3):193-200. [Medline].
Korvick JA, Bryan CS, Farber B, et al. Prospective observational study of Klebsiella bacteremia in 230 patients: outcome for antibiotic combinations versus monotherapy. Antimicrob Agents Chemother. 1992 Dec. 36(12):2639-44. [Medline].
Liam CK, Lim KH, Wong CM. Community-acquired pneumonia in patients requiring hospitalization. Respirology. 2001 Sep. 6(3):259-64. [Medline].
Lucente FE. Rhinitis and nasal obstruction. Otolaryngol Clin North Am. 1989 Apr. 22(2):307-18. [Medline].
Mentec H, Vallois JM, Bure A, et al. Piperacillin, tazobactam, and gentamicin alone or combined in an endocarditis model of infection by a TEM-3-producing strain of Klebsiella pneumoniae or its susceptible variant. Antimicrob Agents Chemother. 1992 Sep. 36(9):1883-9. [Medline].
Merino S, Camprubi S, Alberti S, et al. Mechanisms of Klebsiella pneumoniae resistance to complement-mediated killing. Infect Immun. 1992 Jun. 60(6):2529-35. [Medline].
Nicolau DP, Freeman CD, Belliveau PP, et al. Experience with a once-daily aminoglycoside program administered to 2,184 adult patients. Antimicrob Agents Chemother. 1995 Mar. 39(3):650-5. [Medline].
Paterson DL. Recommendation for treatment of severe infections caused by Enterobacteriaceae producing extended-spectrum beta-lactamases (ESBLs). Clin Microbiol Infect. 2000 Sep. 6(9):460-3. [Medline].
Paterson DL, Trenholme GM. Klebsiella species. In: Yu VL, Merigan TC, Barriere SL, eds. Antimicrobial therapy and vaccines. Baltimore, Md: Williams & Wilkins; 1999:. 239-48.
Podschun R, Ullmann U. Klebsiella spp. as nosocomial pathogens: epidemiology, taxonomy, typing methods, and pathogenicity factors. Clin Microbiol Rev. 1998 Oct. 11(4):589-603. [Medline].
Prabaker K, Lin MY, McNally M, Cherabuddi K, Ahmed S, Norris A. Transfer from high-acuity long-term care facilities is associated with carriage of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae: a multihospital study. Infect Control Hosp Epidemiol. 2012 Dec. 33(12):1193-9. [Medline].
Prince SE, Dominger KA, Cunha BA, Klein NC. Klebsiella pneumoniae pneumonia. Heart Lung. 1997 Sep-Oct. 26(5):413-7. [Medline].
Restuccia PA, Cunha BA. Klebsiella. Infect Control. 1984 Jul. 5(7):343-7. [Medline].
Rice L. Evolution and clinical importance of extended-spectrum beta-lactamases. Chest. 2001 Feb. 119(2 Suppl):391S-396S. [Medline].
Riser E, Noone P, Howard FM. Epidemiological study of klebsiella infection in the special care baby unit of a London hospital. J Clin Pathol. 1980 Apr. 33(4):400-7. [Medline].
Sahly H, Podschun R. Clinical, bacteriological, and serological aspects of Klebsiella infections and their spondyloarthropathic sequelae. Clin Diagn Lab Immunol. 1997 Jul. 4(4):393-9. [Medline].
Sahly H, Podschun R, Ullmann U. Klebsiella infections in the immunocompromised host. Adv Exp Med Biol. 2000. 479:237-49. [Medline].
Sedor J, Mulholland SG. Hospital-acquired urinary tract infections associated with the indwelling catheter. Urol Clin North Am. 1999 Nov. 26(4):821-8. [Medline].
Segal-Maurer S, Mariano N, Qavi A, et al. Successful treatment of ceftazidime-resistant Klebsiella pneumoniae ventriculitis with intravenous meropenem and intraventricular polymyxin B: case report and review. Clin Infect Dis. 1999 May. 28(5):1134-8. [Medline].
Sidjabat H, Nimmo GR, Walsh TR, Binotto E, Htin A, Hayashi Y, et al. Carbapenem resistance in Klebsiella pneumoniae due to the New Delhi Metallo-ß-lactamase. Clin Infect Dis. 2011 Feb. 52(4):481-4. [Medline].
Toivanen P, Hansen DS, Mestre F. Somatic serogroups, capsular types, and species of fecal Klebsiella in patients with ankylosing spondylitis. J Clin Microbiol. 1999 Sep. 37(9):2808-12. [Medline].
Tomas JM, Benedi VJ, Ciurana B, Jofre J. Role of capsule and O antigen in resistance of Klebsiella pneumoniae to serum bactericidal activity. Infect Immun. 1986 Oct. 54(1):85-9. [Medline].
Urban AW, Craig WA. Daily dosage of aminoglycosides. Curr Clin Top Infect Dis. 1997. 17:236-55. [Medline].
Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents. 2001 Apr. 17(4):299-303. [Medline].
Zohar Y, Talmi YP, Strauss M, et al. Ozena revisited. J Otolaryngol. 1990 Oct. 19(5):345-9. [Medline].
Moore PP, McGowan GF, Sandhu SS, Allen PJ. Klebsiella pneumoniae liver abscess complicated by endogenous endophthalmitis: the importance of early diagnosis and intervention. Med J Aust. 2015 Oct 5. 203 (7):300-1. [Medline].