Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Klebsiella Infections Workup

  • Author: Shahab Qureshi, MD; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Oct 06, 2015
 

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.
Next

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.

Previous
Next

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.

The Clinical and Laboratory Standards Institute recently updated their susceptibility criteria.

European Committee clinical breakpoints for susceptibility are available online from European Committee on Antimicrobial Susceptibility Testing (EUCAST).[7] Reduced breakpoints eliminate the need for phenotypic modified Hodge test.

DNA microarray technology may allow rapid identification of TEM, SHV, and CTX-M ESBLs and KPC in clinical isolates.[8]

Infection-control practices include early detection by providing screening swabs, cultures, contact precautions, patient cohorting, dedicated staffing, antimicrobial stewardship, and limited use of invasive devices (eg, urinary catheters).[9]

Previous
Next

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.

Previous
 
 
Contributor Information and Disclosures
Author

Shahab Qureshi, MD Attending Physician in General Internal Medicine, St Catharine's General Hospital; Associate Clinical Professor (Adjunct), McMaster University School of Medicine, Canada

Shahab Qureshi, MD is a member of the following medical societies: College of Physicians and Surgeons of Ontario, Ontario Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks 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, Association of Subspecialty Professors, American Society for Microbiology, Infectious Diseases Society of America, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

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: Received salary from Gilead Sciences for management position.

Acknowledgements

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.

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.

References
  1. Mandell. Enterobacteriaceae. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 7th ed. Churchill Livingstone, An Imprint of Elsevier; 2009.

  2. 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].

  3. 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].

  4. Livermore DM. Fourteen years in resistance. Int J Antimicrob Agents. 2012 Apr. 39(4):283-94. [Medline].

  5. 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].

  6. 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].

  7. 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].

  8. 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].

  9. 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].

  10. 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].

  11. 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].

  12. 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].

  13. 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].

  14. 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].

  15. Anderson MJ, Janoff EN. Klebsiella endocarditis: report of two cases and review. Clin Infect Dis. 1998 Feb. 26(2):468-74. [Medline].

  16. 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].

  17. 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].

  18. 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].

  19. 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.

  20. 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.

  21. Fisman DN, Kaye KM. Once-daily dosing of aminoglycoside antibiotics. Infect Dis Clin North Am. 2000 Jun. 14(2):475-87. [Medline].

  22. 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].

  23. 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].

  24. 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].

  25. 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].

  26. 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].

  27. 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].

  28. 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].

  29. Liam CK, Lim KH, Wong CM. Community-acquired pneumonia in patients requiring hospitalization. Respirology. 2001 Sep. 6(3):259-64. [Medline].

  30. Lucente FE. Rhinitis and nasal obstruction. Otolaryngol Clin North Am. 1989 Apr. 22(2):307-18. [Medline].

  31. 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].

  32. 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].

  33. 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].

  34. 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].

  35. 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.

  36. 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].

  37. 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].

  38. Prince SE, Dominger KA, Cunha BA, Klein NC. Klebsiella pneumoniae pneumonia. Heart Lung. 1997 Sep-Oct. 26(5):413-7. [Medline].

  39. Restuccia PA, Cunha BA. Klebsiella. Infect Control. 1984 Jul. 5(7):343-7. [Medline].

  40. Rice L. Evolution and clinical importance of extended-spectrum beta-lactamases. Chest. 2001 Feb. 119(2 Suppl):391S-396S. [Medline].

  41. 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].

  42. 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].

  43. Sahly H, Podschun R, Ullmann U. Klebsiella infections in the immunocompromised host. Adv Exp Med Biol. 2000. 479:237-49. [Medline].

  44. 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].

  45. 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].

  46. 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].

  47. 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].

  48. 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].

  49. Urban AW, Craig WA. Daily dosage of aminoglycosides. Curr Clin Top Infect Dis. 1997. 17:236-55. [Medline].

  50. Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents. 2001 Apr. 17(4):299-303. [Medline].

  51. Zohar Y, Talmi YP, Strauss M, et al. Ozena revisited. J Otolaryngol. 1990 Oct. 19(5):345-9. [Medline].

  52. 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].

 
Previous
Next
 
This scanning electron micrograph (SEM) reveals some of the ultrastructural morphologic features of Klebsiella pneumoniae. Courtesy of CDC/Janice Carr.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.