Klebsiella Infections Treatment & Management

http://emedicine.medscape.com/article/219907-treatment

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Klebsiella Infections Treatment & Management

Author: Obiamiwe Umeh, MBBS; Chief Editor: Burke A Cunha, MD more... Updated: May 29, 2013

Medical Care
Antibiotic selection Klebsiella organisms are resistant to multiple antibiotics. This is thought to be a plasmid-mediated property. Length of hospital stay and performance of invasive procedures are risk factors for acquisition of these strains. Treatment depends on the organ system involved. In general, initial therapy of patients with possible bacteremia is empirical. The choice of a specific antimicrobial agent depends on local susceptibility patterns. Once bacteremia is confirmed, treatment may be modified. Agents with high intrinsic activity against K pneumoniae should be selected for severely ill patients. Examples of such agents include third-generation cephalosporins (eg, cefotaxime, ceftriaxone), carbapenems (eg, imipenem/cilastatin), aminoglycosides (eg, gentamicin, amikacin), and quinolones. These agents may be used as monotherapy or combination therapy. Some experts recommend using a combination of an aminoglycoside and a third-generation cephalosporin as treatment for nonESBLproducing isolates. Others disagree and recommend monotherapy. Aztreonam may be used in patients who are allergic to beta-lactam antibiotics. Quinolones are also effective treatment options for susceptible isolates in patients with either carbapenem allergy or major beta-lactam allergy. Other antibiotics used to treat susceptible isolates include ampicillin/sulbactam, piperacillin/tazobactam, ticarcillin/clavulanate, ceftazidime, cefepime, levofloxacin, norfloxacin, gaitfloxacin, moxifloxacin, meropenem, and ertapenem. Treatment of Klebsiella pneumonia has discrepant results. For patients with severe infections, a clinically prudent approach is the use of an initial short course (48-72 h) of combination therapy with an aminoglycoside, followed by a switch to an extended-spectrum cephalosporin when susceptibility is confirmed and ESBL production is excluded. The carbapenems are preferred for ESBL-producing strains. Carbapenem resistance has been reported in patients with Klebsiella pneumonia. This is most notably due to the Kpneumoniae carbapenemase beta-lactamase. Community-acquired pneumonia The mortality rate may be 50%, regardless of treatment. Effective treatment for this rare condition consists of empirical coverage for gram-negative organisms, aggressive ventilation, and supportive care. Other measures include clinical and radiologic surveillance for surgically treatable entities such as pulmonary gangrene, lung abscess, and empyema. Third-generation cephalosporins or quinolones provide coverage for community-acquired K pneumoniae infection. In one study, combination therapy with aminoglycosides was shown to be superior; this benefit was not observed in other studies. Macrolides have no useful activity against K pneumoniae. Antibiotic therapy should be implemented for at least 14 days. Nosocomial K pneumoniae pneumonia
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Klebsiella Infections Treatment & Management

http://emedicine.medscape.com/article/219907-treatment

Choose antibiotics with high intrinsic activity. A regimen that includes imipenem, third-generation cephalosporins, quinolones, or aminoglycosides may be used alone or in combination. Always confirm susceptibility. Treatment should last at least 14 days. If response is slow, chest tomography scans may be useful in helping exclude entities that are treatable with debridement or drainage. In patients who rapidly respond to intravenous therapy, switching to an oral quinolone is regarded as safe so long as the isolate is susceptible. K pneumoniae UTI Uncomplicated cases caused by susceptible strains may be treated with most oral agents except ampicillin. Monotherapy is effective, and therapy for 3 days is sufficient. Complicated cases may be treated with oral quinolones or with intravenous aminoglycosides, imipenem, aztreonam, third-generation cephalosporins, or piperacillin/tazobactam. Duration of treatment is usually 14-21 days. Intravenous agents are used until the fever resolves. Other measures may include correction of an anatomical abnormality or removal of a urinary catheter. Other K pneumoniae infections Combination therapy with a beta-lactam antibiotic and an aminoglycoside is considered the standard for empiric treatment of cholangitis. Few comparative data exist to establish this as the optimal therapy. Ciprofloxacin monotherapy is as effective as combination therapy for acute suppurative cholangitis. Antimicrobials are administered for at least 10 days. Biliary decompression may be required. Klebsiella meningitis in adults is rare. Nosocomial disease complicates shunts in children. Thirdgeneration cephalosporins are the drugs of choice because of superior central nervous system penetration. Reports indicate success with cefotaxime, and meropenem is a useful alternative. Adjunctive measures include removal of infected shunts. The suggested duration of treatment is 3 weeks because higher relapse rates have been noted in patients treated with shorter courses of therapy. Klebsiella endophthalmitis and endocarditis are rare. Therapy for endophthalmitis may be intravitreal, intravenous, or both. Clinical experience is greatest with intravenous ceftazidime and aminoglycosides; however, intravenous therapy alone results in very poor drug levels at the site of infection. Endocarditis has been treated with a combination of an intravenous aminoglycoside and a beta-lactam antibiotic. Few data exist to guide treatment duration; however, 6 weeks of antibiotic therapy is considered reasonable. Infection with other Klebsiella species Antibiotic susceptibility and treatment guidelines for K oxytoca infection are virtually identical to those for K pneumoniae. In one study of very ill patients, K oxytoca bacteremia had a 21% mortality rate at 14 days. Rhinoscleroma is treated with combination antimicrobial therapy for 6-8 weeks. Therapeutic choices include aminoglycosides, tetracycline, sulfonamides, rifampin, and quinolones. Ozena may be treated with a 3-month course of ciprofloxacin. Intravenous aminoglycosides and trimethoprim/sulfamethoxazole are also useful in the treatment of these conditions. Susceptibility testing is usually required.

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. Specialty Editor Board 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

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David Hall Shepp, MD is a member of the following medical societies: Infectious Diseases Society of America Disclosure: Gilead Sciences Salary Management position Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment 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, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi Disclosure: Merck Grant/research funds Other 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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