Transcript Case Study Pathogenic Bacteriology 2009 Case #13 Team

Case #13
Team Members: Jae
Kim, Roubina Tatavosian,
James Muro
Case Summary
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The patient is a 40 year-old male with
multisystem failure secondary to bilaterial
pneumonia.
Complained to physician three days before
transfer to a hospital via helicopter of fevers,
malaise, and vague respiratory symptoms.
He was given amantadine for suspected
influenza.
The patients condition became progressively
worse, with shortness of breath a fever to 40.5
0C, and he was admitted to an outside hospital
24 h prior to transfer.
Key Information Pointing to
Diagnosis
A
laboratory examination revealed
liver and renal functions.
 Therapy with Timentin and
trimethoprim-sulfamethoxazole was
begun.
 On admission, he underwent a
bronchoscopic examination which
revealed mildly inflamed airways
containing thin, watery secretions.
The Diagnosis for Case #13
A Gram stain of bronchial washings was
obtained.
 Bronchial washings is a procedure in which
isotonic saline is instilled through a
bronchioscope and fluid containing cells,
microorganisms, or other material from
the upper airways --- trachea, bronchi,
bronchioles, is aspirated into a trap; the
material is then centralized to concentrate
the cells, stained, and examined by
microscopy or cultured if infection is
suspected.
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Diagnosis for Case #13
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The genus Klebsiella belongs to the tribe
Klebsiellae, a member of the family
Enterobacteriaceae.
Klebsiella pneumonia is a Gram-negative, nonmotile, encapsulated, lactose fermenting,
facultative anaerobic, rod shaped bacterium
found in the normal flora of the mouth, skin, and
intestines.
It is the most important member of the Klebsiella
genus of Enterobacteriaceae; it is closely related
to K. oxytoca from which it is distinguished by
being indole negative.
Klebsiella pneumoniae
Scientific classification
 Kingdom: Bacteria
 Phylum: Protobacteria
 Class: Gamma Proteobacteria
 Order: Enterobacteriales
 Family: Enterobacteriaceae
 Genus: Klebsiella
 Species: K. pneumoniae
 Binomial Names: Klebsiella pneumoniae
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Classification, Gram Stain Results,
and Microscopic Appearance of
Klebsiella pneumoniae
K. Pneumoniae is a communityacquired bacterial pneumoniae but S.
pneumoniae is the most common
cause of bacterial pneumoniae.
Diseases and Pathogenesis of
Disease Caused by Klebsiella
pneumoniae
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K. pneumoniae has been a recognized pulmonary pathogen since
its discovery more than 100 years ago.
A striking clinical finding concerning a new manifestation of
community-acquired K. pneumoniae infections has been
documented.
An unusual presentation of K. pneumoniae infection, primary
bacteremic liver abscess, has been described by numerous
investigators in Asia.
A third striking clinical observation is the preponderance of K.
pneumoniae as a community-acquired bacterial meningitis in
adults in Taiwan, even in the absence of liver abscess or other
sites of infection..
Diagnosis/Isolation/Identification/of
Klebsiella pneumoniae
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Klebsiella
NF of GI tract, but potential pathogen in other
areas
TSI A/A+gas
LIA K/K
Urea +
Citrate +
MR-, VP+
Motility –
Has both O and K antigens
EMB – blue colonies on black agar
Therapy, Prevention and Prognosis
of Patient Infected with Klebsiella
pneumoniae
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Virulence factors
Capsule
Adesions
Iron capturing ability
Clinical Significance
--Causes pneumoniae, mostly in immunocompromised
hosts
--Permanent lung damage is a frequent occurrence (rare in
other types of bacteria pneumonia)
--A major cause of nosocomial infections as septicemia and
meningitis
Therapy, Prevention and Prognosis
of Patient Infected with K.
pneumoniae
 Antibiotic
Selection
Cephalosporins
Carbapenems
Aminoglycosides
Quinolones
Trimethoprim/sulfamethoxazole
Deterrence/Prevention
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Follow hospital protocol for infection
control to limit spread of infection and
resistance
Proper hand washing is crucial for prevent
transmission from patient to patient via
medical personnel
Contaminated nebulizers are a major
source of hospital-acquired infection; this
source has been eliminated through the
use of disposable devices
Primary Research Article
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Struve, Carson, et al, 2008, Characterization of Klebsiella pneumoniae Type 1 Fimbriae by
Detection of Phase Variation during Colonization and Infection and Impact on Virulence, Infection
and Immunity, vol: 4055-4065.
Experimental setup used bacterial strains and mouse models.
What did they find:
They found that most clinical isolates
produce vast amounts of capsular
polysaccharide covering the bacterial
surface. The capsule protects the
bacteria against opsonization and phagocytosis,
and the significance of the capsule in K. pneumoniae virulence
has been demonstrated in several studies
This article relates and supports my case that K. pneumoniae is the second most common agent of
gram-negative sepsis as epidemiological studies have revealed that the first step of K. pneumoniae
infections is the colonization of the patient’s gastrointestinal tract.
Take Home Message
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K. pneumoniae typically affects middle-aged and older men with
debilitating diseases such as alcoholism, diabetes, or chronic
bronchopulmonary disease
Typical symptoms include pneumonia, bacteremia,
thrombophlebitis, urinary tract infection, cholecystitis, diarrhea,
upper respiratory tract infections, wound infections, osteomyelitis,
and meningitis
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Diagnostics tests include McKonkey agar, Indole, Eosin-methylene
Blue Agar, PCR.
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Therapy is based on a third generation cephalosporins and
aminoglycosides
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Prognosis for K. pneumoniae has a 50% mortality rate, even with
adequate therapy. The prognosis is worse in patients with
alcoholism and bacteremia
Take Home Message
 Preventive
strategies and early
diagnosis and treatment help to
reduce morbidity.
 Transmission
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is via air droplets.
threat is serious in hospitals and
for individuals that are diabetic and
alcoholics.
References
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Mahon, Connie R., and et al. (2007). Textbook of Diagnostic Microbiology
(3rd ed.). Missouri: Saunders ElSevier, Inc.
Patterson, David L., and et al. (2002). Community-Acquired Klebsiella
pneumoniae Bacteremia: Global Difference in Clinical Patterns. CDC, 8,
1-15.
Struve, Carsten, Bojer, M., & Krogfelt, K. (2008). Characterization of
Klebsiella pneumoniae Type I Fimbriae by Detection of Phase Variation
during Colonization and Infection and Impact on Virulence. Infection and
Immunity, 76, 4055-4065.
Umeh, Oblaamiwe. (2006). Klebsiella Infections: Treatment &
Medication [Electronic version]. eMedicine 7(5), 1-5. Retrieved March
10, 2009, from http://emedicine.medscape.com/article/219907treatment.