This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
StatPearls [Internet].
Show detailsContinuing Education Activity
In 1882, Carl Friedlander first described Klebsiella pneumoniae as an encapsulated bacillus after isolating the bacterium from the lungs of those who had died from pneumonia. Originally named Friedlander's bacillus, it was not until 1886 that the bacterium garnered the name Klebsiella. Klebsiella pneumoniae is a gram-negative, encapsulated, non-motile bacterium found in the environment and has been associated with pneumonia in patient populations with alcohol use disorder or diabetes mellitus. The bacterium typically colonizes human mucosal surfaces of the oropharynx and gastrointestinal (GI) tract. Once the bacterium enters the body, it can display high degrees of virulence and antibiotic resistance. Today, K. pneumoniae pneumonia is considered the most common cause of hospital-acquired pneumonia in the United States, and the organism accounts for 3% to 8% of all nosocomial bacterial infections. This activity reviews the evaluation and treatment of patients with Klebsiella pneumonia and the interprofessional team's role in managing patients with this condition.
Objectives:
- Describe the pathophysiology of Klebsiella.
- Identify the most common cause of hospital-acquired pneumonia in the United States.
- Recall patients most likely to get Klebsiella pneumonia.
- Review the evaluation and treatment of patients with Klebsiella pneumonia and the interprofessional team's role in managing patients with this condition.
Introduction
In 1882, Carl Friedlander described Klebsiella pneumoniae for the first time. He described it as an encapsulated bacillus after isolating the bacterium from the lungs of those who had died from pneumonia. Originally named Friedlander's bacillus, it was not until 1886 that the bacterium garnered the name Klebsiella. Klebsiella pneumoniae is a gram-negative, encapsulated, non-motile bacterium found in the environment and has been associated with pneumonia in patient populations with alcohol use disorder or diabetes mellitus. The bacterium typically colonizes human mucosal surfaces of the oropharynx and gastrointestinal (GI) tract. Once the bacterium enters the body, it can display high degrees of virulence and antibiotic resistance. Today, K. pneumoniae pneumonia is considered the most common cause of hospital-acquired pneumonia in the United States, and the organism accounts for 3% to 8% of all nosocomial bacterial infections.[1][2]
Etiology
Klebsiella pneumoniae belongs to the Enterobacteriaceae family and is described as a gram-negative, encapsulate, and non-motile bacterium. Virulence of the bacterium is provided by a wide array of factors that can lead to infection and antibiotic resistance. The polysaccharide capsule of the organism is the most important virulence factor and allows the bacteria to evade opsonophagocytosis and serum killing by the host organism. To date, 77 different capsular types have been studied, and those Klebsiella species without a capsule tend to be less virulent. A second virulence factor is lipopolysaccharides that coat the outer surface of a gram-negative bacteria. The sensing of lipopolysaccharides releases an inflammatory cascade in the host organism and has been a major culprit of the sequela in sepsis and septic shock. Another virulence factor, fimbriae, allows the organism to attach itself to host cells. Siderophores are another virulence factor that is needed by the organism to cause infection in hosts. Siderophores acquire iron from the host to allow propagation of the infecting organism.[3][4]
Klebsiella pneumoniae is one of a handful of bacteria that are now experiencing a high rate of antibiotic resistance secondary to alterations in the core genome of the organism. Alexander Fleming first discovered resistance to beta-lactam antibiotics in 1929 in gram-negative organisms. Since that time, K. pneumoniae has been well studied and has been shown to produce a beta-lactamase that causes hydrolysis of the beta-lactam ring in antibiotics. Extended-spectrum beta-lactamase (ESBL) K. pneumoniae was seen in Europe in 1983 and the United States in 1989. ESBLs can hydrolyze oxyimino cephalosporins rendering third-generation cephalosporins ineffective against treatment. Due to this resistance, carbapenems became a treatment option for ESBL. However, of the 9000 infections reported to the Centers for Disease Control and Prevention (CDC) due to carbapenem-resistant Enterobacteriaceae in 2013, approximately 80% were due to K. pneumoniae. Carbapenem resistance has been linked to an up-regulation in efflux pumps, alteration of the outer membrane, and increased production of ESBL enzymes in the organism.
Epidemiology
Humans serve as the primary reservoir for K. pneumoniae. In the general community, 5% to 38% of individuals carry the organism in their stool and 1% to 6% in the nasopharynx. The main reservoirs of infection are the patient's gastrointestinal tract and the hands of hospital personnel. It can lead to a nosocomial outbreak. However, higher rates of colonization have been reported in those of Chinese ethnicity and those who experience chronic alcoholism. In hospitalized patients, the carrier rate for K. pneumoniae is much higher than that in the community. In one study, carrier rates as high as 77% can be seen in the stool of those hospitalized and are related to the number of antibiotics given.[5][6]
Pneumonia caused by K. pneumoniae can be broken down into community-acquired or hospital-acquired pneumonia. Although community-acquired pneumonia is a fairly common diagnosis, infection with K. pneumoniae is uncommon. In Western culture, it is estimated that approximately 3% to 5% of all community-acquired pneumonia is related to an infection caused by K. pneumoniae, but in developing countries such as Africa, it can account for approximately 15% of all cases of pneumonia. Overall, K. pneumoniae accounts for approximately 11.8% of all hospital-acquired pneumonia in the world. In those who develop pneumonia while on a ventilator, between 8% to 12% are caused by K. pneumoniae, while only 7% occur in those patients who are not ventilated. Mortality ranges from 50% to 100% in patients with alcoholism and septicemia.
Pathophysiology
Host protection from bacterial invasion mainly depends on two things: polymorphonuclear granulocytes, which phagocytose the bacteria, and serum complement proteins, which are bactericidal. The alternate pathway of complement activation is more active in Klebsiella pneumoniae infection. Neutrophil myeloperoxidase and lipopolysaccharide-binding protein facilitate in defense against Klebsiella pneumoniae infection.
Bacteria have a polysaccharide capsule made up of complex acidic polysaccharides and determine their pathogenicity. The capsule protects bacteria from phagocytosis and serum bactericidal proteins. It adheres to host cells with many fimbrial and non-fimbrial adhesions, which is critical to the infectious process.
History and Physical
The presentation of pneumonia caused by K. pneumoniae is similar to that seen in community-acquired pneumonia. Patients may have a cough, fever, pleuritic chest pain, and shortness of breath. One stark difference between community-acquired pneumonia caused by Streptococcus pneumoniae and K. pneumoniae is the type of sputum produced. The sputum produced by those with S. pneumoniae is described as “blood-tinged” or “rust-colored,” however, the sputum produced by those infected by K. pneumoniae is described as “currant jelly.” The reason for this is that K. pneumoniae results in significant inflammation and necrosis of the surrounding tissue.
Klebsiella pneumonia usually affects the upper lobes but can involve the lower lobes as well. The examination usually reveals unilateral signs of consolidation, such as crepitation, bronchial breathing, and increased vocal resonance, mostly in the upper lobe. In the case of nosocomial infections, the presence of burn sites, wounds, and invasive devices should be searched.
Host factors that predispose to colonization and infection are as follows:
- Admission to an intensive care ward
- Prolonged use of invasive devices
- Poor infection control strategies
- Immunocomproside especially alcoholics and diabetics
- Prolonged use of broad-spectrum antibiotics
Bacteria enter the host either by direct inoculation or by following oropharyngeal aspiration.
Evaluation
Laboratory analysis will typically show leukocytosis, and this alone is unable to aid the clinician in diagnosing the organism that caused a patient’s pneumonia. Chest radiographs, however, can aid the physician in narrowing their differential diagnosis to include K. pneumoniae as a cause for the patient’s condition. Pneumonia caused by K. pneumoniae typically causes a lobar infiltrate in the posterior aspect of the right upper lung. K. pneumoniae infections rarely cause lung abscesses in those with pneumonia but can commonly be associated with empyema. Another non-specific sign of K. pneumoniae on a chest radiograph is the bulging fissure sign. This is related to the large amount of infection and inflammation that the organism can cause. Although these findings can be used to aid the clinician in narrowing their differential diagnosis, they should not be thought of as indicative of pneumonia caused by K. pneumoniae. In the setting of pneumonia, infection with K. pneumoniae is confirmed by either sputum culture analysis or blood culture analysis.[7][8]
Treatment / Management
Given the low occurrence of K. pneumoniae in the community, the treatment of pneumonia should follow standard guidelines for antibiotic therapy. Once infection with K. pneumoniae is either suspected or confirmed, antibiotic treatment should be tailored to local antibiotic sensitivities. Current regimens for community-acquired K. pneumoniae pneumonia include a 14-day treatment with either a third or fourth-generation cephalosporin as monotherapy or a respiratory quinolone as monotherapy or either of the previous regimes in conjunction with an aminoglycoside. If the patient is penicillin-allergic, then a course of aztreonam or a respiratory quinolone should be undertaken. For nosocomial infections, a carbapenem can be used as monotherapy until sensitivities are reported.[9][10][11]
When ESBL is diagnosed, carbapenem therapy should be initiated due to its rate of sensitivity across the globe. When CRE (carbapenem-resistant Enterobacteriaceae) is diagnosed, infectious disease consultation should be obtained to guide treatment. Several antibiotic options to treat CRE include antibiotics from the polymyxin class, tigecycline, fosfomycin, aminoglycosides, or dual therapy carbapenems. Combination therapy of two or more of the agents, as mentioned earlier, may decrease mortality as compared to monotherapy alone.
Differential Diagnosis
The differential diagnosis for pneumonia caused by K. pneumoniae should include;
- All organisms that typically cause community-acquired and hospital-acquired pneumonia, such as Staphylococcus, Pneumococcus, Pseudomonas, Acinetobacter, and Legionella.
- Tuberculosis
- Aspergillus infection
- Malignancy
- Acute respiratory distress syndrome (ARDS)
- Lung abscess
- Empyema and other pleuropulmonary infections
Surgical Oncology
Surgical debridement or drainage is sometimes required in patients with lung abscess, empyema, and lung gangrene.
Prognosis
The prognosis of Klebsiella pneumonia is poor, especially in patients who have alcohol use disorder, diabetes mellitus, nosocomial infection, or septicemia. Mortality from this type of pneumonia is above 50%.
Complications
Pneumonia caused by K. pneumoniae can be complicated by bacteremia, lung abscesses, and the formation of an empyema.
Consultations
- Infectious disease consultant
- Microbiologist
- Surgeon
Pearls and Other Issues
- Klebsiella pneumonia is a gram-negative bacteria that typically cause nosocomial infections and shows a great deal of antibiotic resistance.
- Radiograph findings should not be used to make a diagnosis of Klebsiella pneumoniae infection definitively.
- “Currant jelly” sputum is a hallmark of infection with Klebsiella pneumoniae.
- K. pneumoniae infections can carry a high degree of antibiotic resistance and lead to a significant amount of patient mortality.
Enhancing Healthcare Team Outcomes
Klebsiella pneumonia is a serious infection, and even with adequate treatment, the mortality rates remain high. This infection is best looked after by an interprofessional healthcare team that includes an infectious disease expert, pharmacists, nurses, intensivists, dietitians, pulmonologists, and respiratory therapists. Nurses who look after these patients should follow strict infection control protocols to prevent the spread of the organism. Hand washing is crucial for medical personnel and visitors. Nurses should only ensure that devices are only used once to minimize transmission. The pharmacist should ensure that an empirical antibiotic prescription is not carried out, as this only leads to the development of drug resistance. Since many of these patients are frail, a dietary consult should be sought to optimize their calorie intake. Finally, since many of these patients are bedridden, a physical therapy consult should be considered to help with mobility and prevent stiffness of the joints.[6][12] [Level 5]
Outcomes
Klebsiella pneumonia usually signals a grim prognosis. Even with optimal therapy, this infection of the lung carries a mortality of 30 to 50%. The prognosis is usually worse in diabetics, the elderly, and those who are immunocompromised. Even those who survive often have residual impaired lung function, and recovery can take months.[13][14] [Level 5]
References
- 1.
- Jondle CN, Gupta K, Mishra BB, Sharma J. Klebsiella pneumoniae infection of murine neutrophils impairs their efferocytic clearance by modulating cell death machinery. PLoS Pathog. 2018 Oct;14(10):e1007338. [PMC free article: PMC6181436] [PubMed: 30273394]
- 2.
- Aghamohammad S, Badmasti F, Solgi H, Aminzadeh Z, Khodabandelo Z, Shahcheraghi F. First Report of Extended-Spectrum Betalactamase-Producing Klebsiella pneumoniae Among Fecal Carriage in Iran: High Diversity of Clonal Relatedness and Virulence Factor Profiles. Microb Drug Resist. 2020 Mar;26(3):261-269. [PubMed: 30277830]
- 3.
- Rønning TG, Aas CG, Støen R, Bergh K, Afset JE, Holte MS, Radtke A. Investigation of an outbreak caused by antibiotic-susceptible Klebsiella oxytoca in a neonatal intensive care unit in Norway. Acta Paediatr. 2019 Jan;108(1):76-82. [PubMed: 30238492]
- 4.
- Tsereteli M, Sidamonidze K, Tsereteli D, Malania L, Vashakidze E. EPIDEMIOLOGY OF CARBAPENEM-RESISTANT KLEBSIELLA PNEUMONIAE IN INTENSIVE CARE UNITS OF MULTIPROFILE HOSPITALS IN TBILISI, GEORGIA. Georgian Med News. 2018 Jul-Aug;(280-281):164-168. [PubMed: 30204118]
- 5.
- Esposito EP, Cervoni M, Bernardo M, Crivaro V, Cuccurullo S, Imperi F, Zarrilli R. Molecular Epidemiology and Virulence Profiles of Colistin-Resistant Klebsiella pneumoniae Blood Isolates From the Hospital Agency "Ospedale dei Colli," Naples, Italy. Front Microbiol. 2018;9:1463. [PMC free article: PMC6054975] [PubMed: 30061868]
- 6.
- Walter J, Haller S, Quinten C, Kärki T, Zacher B, Eckmanns T, Abu Sin M, Plachouras D, Kinross P, Suetens C., ECDC PPS study group. Healthcare-associated pneumonia in acute care hospitals in European Union/European Economic Area countries: an analysis of data from a point prevalence survey, 2011 to 2012. Euro Surveill. 2018 Aug;23(32) [PMC free article: PMC6092912] [PubMed: 30107871]
- 7.
- Para RA, Fomda BA, Jan RA, Shah S, Koul PA. Microbial etiology in hospitalized North Indian adults with community-acquired pneumonia. Lung India. 2018 Mar-Apr;35(2):108-115. [PMC free article: PMC5846258] [PubMed: 29487244]
- 8.
- Ergul AB, Cetin S, Altintop YA, Bozdemir SE, Ozcan A, Altug U, Samsa H, Torun YA. Evaluation of Microorganisms Causing Ventilator-Associated Pneumonia in a Pediatric Intensive Care Unit. Eurasian J Med. 2017 Jun;49(2):87-91. [PMC free article: PMC5469850] [PubMed: 28638248]
- 9.
- Liu C, Guo J. Characteristics of ventilator-associated pneumonia due to hypervirulent Klebsiella pneumoniae genotype in genetic background for the elderly in two tertiary hospitals in China. Antimicrob Resist Infect Control. 2018;7:95. [PMC free article: PMC6091109] [PubMed: 30128143]
- 10.
- Mitharwal SM, Yaddanapudi S, Bhardwaj N, Gautam V, Biswal M, Yaddanapudi L. Intensive care unit-acquired infections in a tertiary care hospital: An epidemiologic survey and influence on patient outcomes. Am J Infect Control. 2016 Jul 01;44(7):e113-7. [PubMed: 26944004]
- 11.
- Thakuria B, Singh P, Agrawal S, Asthana V. Profile of infective microorganisms causing ventilator-associated pneumonia: A clinical study from resource limited intensive care unit. J Anaesthesiol Clin Pharmacol. 2013 Jul;29(3):361-6. [PMC free article: PMC3788236] [PubMed: 24106362]
- 12.
- Claeys KC, Zasowski EJ, Trinh TD, Lagnf AM, Davis SL, Rybak MJ. Antimicrobial Stewardship Opportunities in Critically Ill Patients with Gram-Negative Lower Respiratory Tract Infections: A Multicenter Cross-Sectional Analysis. Infect Dis Ther. 2018 Mar;7(1):135-146. [PMC free article: PMC5840098] [PubMed: 29164489]
- 13.
- Luan Y, Sun Y, Duan S, Zhao P, Bao Z. Pathogenic bacterial profile and drug resistance analysis of community-acquired pneumonia in older outpatients with fever. J Int Med Res. 2018 Nov;46(11):4596-4604. [PMC free article: PMC6259400] [PubMed: 30027805]
- 14.
- Venkataraman R, Divatia JV, Ramakrishnan N, Chawla R, Amin P, Gopal P, Chaudhry D, Zirpe K, Abraham B. Multicenter Observational Study to Evaluate Epidemiology and Resistance Patterns of Common Intensive Care Unit-infections. Indian J Crit Care Med. 2018 Jan;22(1):20-26. [PMC free article: PMC5793017] [PubMed: 29422728]
Disclosure: John Ashurst declares no relevant financial relationships with ineligible companies.
Disclosure: Adam Dawson declares no relevant financial relationships with ineligible companies.
- STUDIES ON THE MECHANISM OF RECOVERY IN PNEUMONIA DUE TO FRIEDLANDER'S BACILLUS : I. THE PATHOGENESIS OF EXPERIMENTAL FRIEDLANDER'S BACILLUS PNEUMONIA.[J Exp Med. 1947]STUDIES ON THE MECHANISM OF RECOVERY IN PNEUMONIA DUE TO FRIEDLANDER'S BACILLUS : I. THE PATHOGENESIS OF EXPERIMENTAL FRIEDLANDER'S BACILLUS PNEUMONIA.Sale L, Wood WB. J Exp Med. 1947 Aug 31; 86(3):239-48.
- Brief report: community-acquired Friedlander's pneumonia and pulmonary metastatic Klebsiella pneumoniae infection caused by hypervirulent ST23 in the Netherlands.[Eur J Clin Microbiol Infect Di...]Brief report: community-acquired Friedlander's pneumonia and pulmonary metastatic Klebsiella pneumoniae infection caused by hypervirulent ST23 in the Netherlands.Fliss M, van den Berg CHSB, Kuijper E, Notermans DW, Hendrickx APA, Schoots MH, Bathoorn E. Eur J Clin Microbiol Infect Dis. 2022 Aug; 41(8):1133-1138. Epub 2022 Jul 5.
- [Serological varieties of Klebsiella pneumoniae in pneumonia].[Zh Mikrobiol Epidemiol Immunob...][Serological varieties of Klebsiella pneumoniae in pneumonia].Kiseleva BS, Solodova TL, Shliapnikov VN, Sageeva OF. Zh Mikrobiol Epidemiol Immunobiol. 1982 Sep; (9):34-42.
- Review Molecular basis of Klebsiella pneumoniae colonization in host.[Microb Pathog. 2023]Review Molecular basis of Klebsiella pneumoniae colonization in host.Chen Q, Wang M, Han M, Xu L, Zhang H. Microb Pathog. 2023 Apr; 177:106026. Epub 2023 Feb 10.
- Review The emerging problems of Klebsiella pneumoniae infections: carbapenem resistance and biofilm formation.[FEMS Microbiol Lett. 2016]Review The emerging problems of Klebsiella pneumoniae infections: carbapenem resistance and biofilm formation.Chung PY. FEMS Microbiol Lett. 2016 Oct; 363(20). Epub 2016 Sep 22.
- Klebsiella Pneumonia - StatPearlsKlebsiella Pneumonia - StatPearls
Your browsing activity is empty.
Activity recording is turned off.
See more...