eMedicine Specialties > Infectious Diseases > Bacterial Infections

Klebsiella Infections: Differential Diagnoses & Workup

Author: Obiamiwe Umeh, MBBS, Fellow, Center for AIDS Research and Education, David Geffen School of Medicine at UCLA
Coauthor(s): Leonard B Berkowitz, MD, Chief, Divisions of Infectious Diseases and HIV/AIDS Services, Brooklyn Hospital Center; Clinical Assistant Professor, Department of Medicine, State University of New York at Brooklyn
Contributor Information and Disclosures

Updated: May 15, 2009

Differential Diagnoses

Other Problems to Be Considered

Community-acquired pneumonia
Staphylococcal pneumonia (see Staphylococcal Infections)
Pneumococcal pneumonia (see Pneumococcal Infections)
Legionellosis
Pleuropulmonary empyema (see Empyema, Pleuropulmonary)
Lung Abscess

Urinary tract infection
Urinary Tract Infection, Females
Urinary Tract Infection, Males
Pseudomonas infection (see Pseudomonas Aeruginosa Infections)
Cholecystitis

Nosocomial infection
Pseudomonas infection (see Pseudomonas Aeruginosa Infections)
Acinetobacter infection (see Acinetobacter)
Serratia infection (see Serratia)

Rhinoscleroma and ozena
Pseudomonas mallei infection (rare in humans) (see Pseudomonas Infection)
Viral rhinitis (eg, rhinovirus infection) (see Rhinoviruses)

Workup

Laboratory Studies

  • A complete blood cell count usually reveals leukocytosis with a left shift, but this is not invariably present. Persistence of leukocytosis may signify empyema formation.
  • Obtain a sputum sample for Gram stain. Klebsiellae appear as short, plump, gram-negative bacilli. They are usually surrounded by a capsule that appears as a clear space.
  • Serology results are not useful for detection of infection with Klebsiella organisms.
  • Cultures should be obtained from possible sites (eg, wounds, peripheral or central intravenous access sites, urinary catheters, respiratory support equipment).
    • Klebsiellae may be isolated from blood, urine, pleural fluid, and wounds.
    • Klebsiellae are microaerophilic and, thus, can grow in the presence of oxygen or in its absence. They have no special culture requirements. Most species can use citrate and glucose as sole carbon sources; thus, they grow well on most ordinary media.
    • Klebsiellae are lactose-fermenting, urease-positive, and indole-negative organisms, although K oxytoca and some strains of K pneumoniae are exceptions. Klebsiellae do not produce hydrogen sulfide, and they yield positive results on both Voges-Proskauer and methyl red tests.
    • Wounds may be infected with Klebsiella organisms as the sole pathogens or as a component of a multipathogenic infection. Swabs for Gram stain and culture taken from possible sites may aid in establishing the diagnosis.

Imaging Studies

  • Chest radiography
    • The organism usually involves one of the upper lobes; however, involvement of lower lobes is not uncommon.
    • The affected lobe typically appears swollen, producing the bulging fissure sign. This presentation is not necessarily exclusive to Klebsiella infection. Other organisms, such as H influenzae, may produce a similar radiographic appearance.
    • Cavitation, especially in the presence of a unilateral necrotizing pneumonia, strongly supports the possibility of a Klebsiella organism as the etiologic agent.
    • Pleural effusion, empyema, abscess formation, and pleural adhesions occur with increased frequency in patients with Klebsiella pneumonia.
  • Chest tomography
    • Chest tomography may be required for patients with nonresolving or slowly responding cases of pneumonia.
    • The findings from this imaging test help exclude entities that are treatable with drainage or debridement such as empyema and respiratory tract obstruction caused by K rhinoscleromatis infection.

Other Tests

  • Susceptibility testing for ESBL-producing organisms
    • The rising importance of ESBL-producing organisms has mandated effective screening methods for their detection. Use of aztreonam or ceftazidime resistance as a marker misses approximately 15-20% of ESBL-producing organisms. Resistance to cefpodoxime as a screening method, with sensitivity breakpoints of >2 mcg/mL by minimal inhibitory concentration or <22 mm by disk diffusion (for a 30-mcg cefpodoxime disk), has a sensitivity of at least 98% for ESBL detection.
    • Different tests that help confirm ESBL susceptibility are available. One test involves using disks that contain cefotaxime and ceftazidime alone and disks containing a combination of clavulanic acid with these antibiotics. These are placed on Mueller-Hinton agar. A positive test result is defined as a 5-mm or greater increase in the size of the zone diameter for either cefotaxime or ceftazidime tested in combination with clavulanic acid versus the zone for either antibiotic tested alone. Another method is the E-test screen, which evaluates third-generation cephalosporins with and without a beta-lactamase inhibitor. Finally, the Vitek ESBL test, which is an automated broth microdilution test, uses cefotaxime and ceftazidime alone and in combination with clavulanic acid.
    • A good screening strategy might include a cefpodoxime screen followed by confirmatory disk diffusion for screen-positive isolates. The Vitek test has sensitivity of at least 99.5% and specificity of 100%. It is a reliable single-test alternative.

Procedures

  • Diagnostic thoracocentesis may be performed if a pleural fluid pocket is large enough for aspiration.
  • Bronchoalveolar lavage with fiberoptic bronchoscopy may be helpful in occasional cases in which the diagnosis cannot be made by other means and can be used to ascertain the microbial organisms involved.

More on Klebsiella Infections

Overview: Klebsiella Infections
Differential Diagnoses & Workup: Klebsiella Infections
Treatment & Medication: Klebsiella Infections
Follow-up: Klebsiella Infections
Multimedia: Klebsiella Infections
References
Further Reading
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Further Reading

Clinical guidelines

2006 national guideline for the management of lymphogranuloma venereum.
British Association for Sexual Health and HIV - Medical Specialty Society. 1999 Aug (revised 2006 May). 14 pages. NGC:006016

Best practice policy statement on urological surgery antimicrobial prophylaxis.
American Urological Association Education and Research, Inc. - Medical Specialty Society. 2007 Jan. 46 pages. NGC:006297

Management of multidrug-resistant organisms in healthcare settings, 2006.
Centers for Disease Control and Prevention - Federal Government Agency [U.S.]. 2006. 74 pages. NGC:005592

Clinical trials

Risk Factors for Quinolone Resistance Among ESBL Producing Klebsiella Species

Community - Associated Extended-Spectrum Beta-Lactamases (ESBL)

Efficacy and Safety of Colistin for Therapy of Infections Caused by ESBL Producing K.Pneumoniae or E.Coli

Related eMedicine topics

Rhinoscleroma

Urinary Tract Infection, Females

Proteus Infections

Pregnancy, Postpartum Infections

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Keywords

Klebsiella pneumoniae, K pneumoniae, Klebsiella ozaenae, K ozaenae, Klebsiella rhinoscleromatis, K rhinoscleromatis, Klebsiella oxytoca, K oxytoca, Klebsiella planticola, K planticola, Klebsiella terrigena, K terrigena Klebsiella ornithinolytica, K ornithinolytica, community-acquired pneumonia, CAP, nosocomial infection, urinary tract infection, rhinoscleroma, ozena, colonization, extended-spectrum beta-lactamase, ESBL, neonatal septicemia, neonatal bacteremia, bronchopneumonia, bronchitis, catheter-associated bacteriuria, lung infection

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Contributor Information and Disclosures

Author

Obiamiwe Umeh, MBBS, Fellow, Center for AIDS Research and Education, David Geffen School of Medicine at UCLA
Obiamiwe Umeh, MBBS is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Leonard B Berkowitz, MD, Chief, Divisions of Infectious Diseases and HIV/AIDS Services, Brooklyn Hospital Center; Clinical Assistant Professor, Department of Medicine, State University of New York at Brooklyn
Leonard B Berkowitz, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, Infectious Diseases Society of America, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

David Hall Shepp, MD, Program Director, Fellowship in Infectious Diseases, Department of Medicine, North Shore University Hospital; Associate Professor, New York University School of Medicine
David Hall Shepp, MD is a member of the following medical societies: Infectious Diseases Society of America
Disclosure: Gilead Sciences Salary Management position

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

John W King, MD, Professor of Medicine, Section of Infectious Diseases, Louisiana State University Health Sciences Center; Director, Viral Therapeutics Clinics for Hepatitis; Consulting Staff, Department of Infectious Diseases, Overton Brook Veterans Affairs Medical Center
John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi
Disclosure: emedicine $50.00 author of chapter

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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