Klebsiella pneumoniae

by



OVERVIEW

由肺炎克雷伯菌感染所致的肺部炎症性病变
有寒战、高热，咳砖红色胶冻样痰，严重者出现呼吸困难、全身衰竭
肺炎克雷伯菌感染所致
有抗感染治疗、呼吸支持技术等综合治疗措施

Definition.

Inflammation of the terminal airways, alveoli, and interstitium caused by Klebsiella pneumoniae (KP) infection is called Klebsiella pneumoniae pneumonia, and is commonly associated with hospital-acquired pneumonia.

Classification

The main classification is of Klebsiella pneumoniae.

Classification is based on genotypes

经典肺炎克雷伯菌（cKP）

Mainly found in hospitals or long-term care facilities, commonly in older populations with underlying disease and compromised immunity.

高毒力肺炎克雷伯菌（hvKP）

It is more likely to cause disease in healthy and young people.

Classification according to drug resistance

Classified as carbapenem-sensitive Klebsiella pneumoniae (CSKP) and carbapenem-resistant Klebsiella pneumoniae (CRKP), the latter can be further classified into carbapenem-resistant high-virulence Klebsiella pneumoniae (CR⁃hvKP) and carbapenem-resistant non-high-virulence Klebsiella pneumoniae (CR-non-hvKP).

Morbidity

Klebsiella pneumoniae is an important pathogen of hospital-acquired infections and is becoming one of the major drug-resistant strains.2021 National CHINET drug resistance surveillance data showed that Klebsiella pneumoniae ranked as the 2nd most common clinical pathogen and the 1st most common respiratory pathogen.2021 National CHINET drug resistance surveillance data showed that Klebsiella pneumoniae ranked as the 2nd most common clinical pathogen and the 1st most common respiratory pathogen.

The case fatality rate of Klebsiella pneumoniae pneumonia is high, ranging from 20% to 70% in the literature. According to statistics, the case fatality rate of Klebsiella pneumoniae bacteremia combined with pneumonia can be more than 50%.

Causes

Causes

Klebsiella pneumoniae is a common conditionally pathogenic bacteria, often colonized in the upper respiratory tract and intestinal tract, when the body’s immunity is lowered, it can invade the lungs and cause Klebsiella pneumonia, or invasive operations invade the body and cause infection.

Risk factors

Host-related factors

  • Age ≥ 60 years.
  • Chronic lung disease.
  • Immunocompromised state (e.g., malnutrition, diabetes, alcoholism, malignancy).
  • Severe illness (e.g., impaired consciousness, shock, etc.).

    • Medical-related factors

  • Environmental factors (e.g. contaminated air or water supply system in the hospital room, prolonged hospitalization, cross-infection, etc.).
  • Drug factors (e.g. long-term antibiotic treatment, acid-suppressing drugs and H2 receptor antagonist drugs, etc.).
  • Invasive procedures (e.g., surgery of the head, chest, and abdomen, intracranial pressure monitoring, etc.).
  • Presence of a route of bacterial entry (e.g., tracheal intubation, nasogastric tubes, intravenous tubes, etc.).

    • Symptoms

    Typical symptoms of Klebsiella pneumoniae are chills, high fever, and coughing up brick-red jelly-like sputum. However, symptoms are often atypical due to severe underlying disease, depressed immune status, and interference with therapeutic measures (drugs, mechanical ventilation, etc.).

    Main symptoms

    Fever

  • Fever is often preceded by chills and chills; it is usually high, and the axillary temperature usually reaches 38℃ or above.
  • A few weaker people do not have obvious fever, or even no fever.

    • Cough and sputum

  • The cough may be paroxysmal and irritating; in severe cases, the cough is severe and persistent, which may affect sleep.
  • Infection with Klebsiella pneumoniae will cause alveolar hemorrhage, and blood and purulent secretions will fuse together to form jelly-like sputum, which is a typical symptom.

    • Shortness of breath

  • It is characterized by increased respiratory rate and labored breathing.
  • In severe cases, there are symptoms of hypoxia such as dyspnea and cyanosis.

    • Chest pain

    It can be caused by severe coughing or combined with pleurisy, mostly related to respiratory movement, and chest pain is obvious when taking deep breaths.

    Gastrointestinal symptoms

    Diarrhea, vomiting, loss of appetite and other symptoms may occur.

    Complications

    Parapneumonic pleural effusion

  • It can be caused by localized inflammation in the lungs that irritates the pleura and causes exudation, leading to pleural effusion.
  • It can also be seen in severe infections when bacteria enter the pleural cavity to produce purulent exudate, commonly known as pyothorax, with symptoms such as high fever and dyspnea, and in severe cases, thoracentesis is required to drain the chest.

    • Acute lung injury and acute respiratory distress syndrome

    Acute lung injury is the damage of alveolar capillaries caused by lung inflammation, and the serious case is called acute respiratory distress syndrome, which is characterized by extreme dyspnea, cyanosis of lips and mouth, and increased heart rate, and requires mechanical ventilation and other treatments.

    Septicemia, septic shock

    Septicemia is a systemic inflammatory reaction syndrome caused by bacterial infection. In severe cases, shock manifestations such as cold extremities, confusion, low blood pressure, etc. can occur, which is called septic shock, and requires active anti-infective, rehydration and other treatments.

    Consultation

    Department of Medicine

    Respiratory Medicine

    If you have cough, purulent or bloody sputum, or chest pain, it is recommended that you consult a doctor promptly.

    Emergency Department

    In case of emergencies such as difficulty in breathing, unconsciousness, agitation, high fever, wet and cold limbs, etc., it is recommended to go to the Emergency Department immediately.

    Preparation for medical treatment

    Preparation for medical consultation: registration, preparation of documents, common problems

    Tips for seeking medical treatment

    Chest X-ray or chest CT is often needed. It is recommended to wear loose-fitting clothes, and those who are pregnant or planning to become pregnant should inform the doctor in time.

    Preparation Checklist

    症状清单

    Pay special attention to the time of onset of symptoms and special manifestations.

  • Is there a fever? What is the highest temperature?
  • Is there a cough? What kind of cough? How long has the cough lasted?
  • Is there phlegm? What color is the phlegm?
  • Is there chest pain? What makes it worse or relieves it?
  • How long have these symptoms been present? Are they combined with other symptoms?
    • 病史清单
  • Is there diabetes, chronic obstructive pulmonary disease, etc.?
  • Are there any long-term use of medications such as glucocorticoids and immunosuppressants?
  • Is there any smoking or alcohol consumption?
  • Is there any history of surgery or trauma?
    • 检查清单

    Test results in the last six months, which can be brought to the doctor’s office

  • Laboratory tests: blood test, C-reactive protein, calcitonin, sputum smear and culture, etc.
  • Imaging tests: chest X-ray, chest CT, chest ultrasound, etc.
    • 用药清单

    Medication in the last 3 months, if there is a box or package, you can bring it with you to the doctor.

  • Antibiotics: piperacillin tazobactam, meropenem, etc.
  • Cough and phlegm medicines: Ambroxol, Acetylcysteine, etc.
  • Antipyretic and analgesic drugs: ibuprofen, acetaminophen, etc.

    • Diagnosis

    The diagnosis of Klebsiella pneumonia is based on the history, symptoms, signs, laboratory and imaging examinations and other relevant information to clinically diagnose pneumonia, and further pathogenetic examination to find Klebsiella pneumoniae to confirm the diagnosis.

    Diagnosis is based on

    Medical history

  • Long-term use of hormones and immunosuppressive drugs or immunodeficiency diseases.
  • Surgery or mechanical ventilation.
  • Prolonged hospitalization or ICU stay
  • Presence of severe malnutrition or chronic lung disease.
  • Have been in close contact with a person diagnosed or suspected of having pneumonia.

    • Clinical manifestations

    症状

    Symptoms such as chills, high fever, cough and coughing up brick-red sputum may be accompanied by other symptoms such as chest pain, loss of appetite and depression.

    体征
  • Observation of respiration may reveal increased respiratory rate, labored breathing, and cyanosis of the lips and mouth in severe cases.
  • Palpation of the chest may reveal increased voice tremor; if there is pleural effusion, the voice tremor will be weakened.
  • Chest percussion, turbid sounds can be found, indicating the presence of pulmonary solid changes or pleural effusion.
  • On chest auscultation, phlegm sounds and wet rales may be heard.
    • 实验室检查
  • Blood counts may show elevated white blood cell and neutrophil ratios.
  • C-reactive protein, interleukin-6, and calcitonin may be elevated, and their values are often positively correlated with the severity of the disease.
  • Arterial blood gas analysis may show decreased partial pressure of oxygen, oxygen saturation, and oxygenation index, and acid-base imbalance.
    • 病原学检查

    Pathogen isolation and culture are commonly used in the clinic and are more reliable tests for definitive diagnosis, but the culture cycle is long, usually taking 3 to 5 days or longer.

    The diagnosis of Klebsiella pneumoniae pneumonia can be established by positive blood, pleural fluid or bronchoalveolar lavage culture results without other primary lesions.

    However, positive sputum culture results should be evaluated, and if the smear shows sputum from the lower respiratory tract with predominance of gram-negative bacilli, and the culture shows predominant organisms or pure cultures, the diagnosis of Klebsiella pneumonia can be essentially established.

    Drug susceptibility testing can also be performed on the basis of culture, which helps the physician adjust the drug regimen.

    影像学

    Typical imaging changes include solid changes in the lobes or segments of the lungs, honeycomb lung abscesses, and interlobar drop.

    Differential Diagnosis

    Pneumonia due to other pathogens

    Similarities: both can cause fever, cough, sputum and other symptoms, chest imaging common pulmonary inflammation and exudation.

    Differences: Pneumonia caused by different pathogens have their own characteristics, but it is usually difficult to distinguish them based on history, physical signs and imaging. Pathogenetic examination is of great value in identifying pneumonia caused by different pathogenic bacteria.

    Pulmonary embolism

    Similarities: symptoms such as cough, shortness of breath, chest pain, etc. Pulmonary infiltrates and pleural effusion can be seen on chest imaging.

    Differences: pulmonary embolism often has a history of deep phlebitis, varicose veins, trauma, surgery, braking, etc.; elevated blood D-dimer, T-wave changes, ST-segment drop on ECG, wedge-shaped infiltration shadow on X-ray, pleural effusion, etc.

    Lung tumor

    Similarity: there are symptoms such as cough, fever, cough and sputum.

    Differences: Lung tumors often have a history of long-term smoking, chest pain, hemoptysis, enlarged peripheral lymph nodes, sputum and histopathological examination can find tumor cells, which can make a clear diagnosis.

    Treatment

    Treatment aim: control infection as soon as possible, improve ventilation function, protect important organ function and prevent complications.

    Treatment principle: comprehensive treatment mainly based on medication, early removal and drainage of primary lesions, and selection of sensitive antibiotic treatment.

    General treatment

    Oxygen therapy

  • If the patient has irritability, cyanosis and other hypoxic manifestations, or arterial oxygen partial pressure is less than 60mmHg, oxygen needs to be inhaled.
  • Low-flow oxygen is the mainstay, and it is appropriate to maintain the patient’s blood oxygen to more than 90%.
  • Patients with severe respiratory failure can be treated with mechanical ventilation.

    • Airway management

  • Remove oral and nasal secretions in time, and suction sputum when necessary to keep the airway open and improve ventilation.
  • Nebulized inhalation can be given to humidify the airway and promote sputum elimination.
  • Tracheal intubation is feasible when necessary to facilitate the removal of sputum.

    • Maintaining water-electrolyte balance and nutritional support

  • Appropriate intravenous rehydration to maintain water electrolyte balance.
  • Pay attention to nutritional supplementation to ensure that the patient’s daily intake of sufficient calories, and at the same time should ensure balanced nutrition.
  • Patients who have difficulty in eating can be given parenteral nutritional support.

    • Drug treatment

    Symptomatic supportive treatment

  • Antipyretic drugs, such as acetaminophen and ibuprofen, can be used for those with fever.
  • For cough and phlegm, coughing and expectorant drugs can be used, such as strong loquat lozenges, compound licorice oral solution, aminobromine, etc. However, it should be noted that too much cough suppressant may lead to sputum is not easy to cough out but aggravate the condition.

    • Anti-infection treatment

    Anti-infection treatment is a key part of the treatment of Klebsiella pneumoniae, including empirical treatment and anti-pathogen treatment. Sensitive antibiotics should be used according to the doctor’s instructions or according to the results of drug sensitivity. In recent years, the infection rate and drug resistance rate of Klebsiella pneumoniae have shown an upward trend, and the associated infections have a prolonged course, which poses a serious threat to the clinical anti-infective treatment, and should be highly valued.

  • Successive Klebsiella pneumoniae pneumonia can be treated with semi-synthetic penicillins (e.g. piperacillin tazobactam), or cephalosporins (e.g. cefoperazone sulbactam, ceftriaxone, etc.).
  • Carbapenem antibiotics (e.g., meropenem, imipenem cilastatin, etc.) are available for highly virulent severe cases.
  • Carbapenem-resistant Klebsiella pneumoniae-induced pneumonia, often choose the more sensitive polymyxin (such as polymyxin E, polymyxin B ) and glycylcycline antibiotics (minocycline, tigecycline) and so on.

    • Interventional therapy

    There is no specific interventional therapy for Klebsiella pneumoniae pneumonia. For patients with severe pneumonia, bronchoscopy and bronchoalveolar lavage (BAL) can be routinely performed to remove substances retained in the airways and alveoli, relieve airway obstruction, improve respiratory function, and control the infection.

    Prognosis

    Cure

    Some patients can be cured, but some drug-resistant Klebsiella pneumoniae infections can lead to long-term bacterial colonization and persistent infections that are difficult to cure.

    Prognostic factors

    Related to the bacterial type of Klebsiella pneumoniae and the patient’s own physical condition, comorbidities and underlying diseases.

    Carbapenem-resistant Klebsiella pneumoniae infections have a mortality rate of up to 50%.

    Hazards.

    Most of them do not leave permanent damage, and the structure and function can be restored to normal, but a small number of them can cause necrotic lesions in the lung tissue, forming cavities or fibrosis.

    Daily

    Daily management

  • It is contagious. Wear a good mask and try to avoid close contact with young children, the elderly, pregnant women and immunocompromised people.
  • Quit smoking and drinking to prevent aggravation of lung damage and adverse effects of alcohol on antibiotics.
  • Regular work and rest, avoid exertion, late night, balanced nutrition, sufficient water and protein, energy.

    • Disease monitoring

  • If the patient has received surgical treatment such as thoracocentesis and closed chest drainage, ensure that the wound and dressings are clean and dry after the operation, and observe whether the drainage tube is open, and whether there is any change in the amount and nature of the drainage material.
  • Pay attention to the change of the patient’s condition. If there is persistent high fever, dyspnea, cyanosis, depression, wet and cold extremities, etc., consult the doctor immediately.

    • Follow-up examination

  • About 1 week after discharge, review the routine blood test, C-reactive protein, calcitoninogen and other infection indexes, and biochemical and coagulation indexes if necessary, according to the test results, adjust the drug treatment program and course of treatment according to the doctor’s instructions.
  • About 1 month after discharge from the hospital, repeat chest X-ray/chest CT to observe the absorption of inflammation and healing of the lungs.

    • Prevention

    The vaccine is still in the clinical research stage, therefore, strictly speaking, there is no specific means to prevent Klebsiella pneumoniae pneumonia, but you can reduce the possibility of infection by the following methods.

  • Maintain indoor air circulation, avoid going to places where people gather, and wear a good mask.
  • Pay attention to hand hygiene and wash your hands frequently before and after meals.
  • Quit smoking and drinking, have balanced nutrition, and strengthen outdoor exercise to improve body resistance.
    • 参考文献
    [1]
    葛均波，徐永健，王辰. 内科学[M].9版. 北京：人民卫生出版社，2018.
    [2]
    陈 娜，张峰波，周鹏鹏，等． 耐碳青霉烯类肺炎克雷伯菌的耐药性和同源性分析[J].中国临床药理学杂志，2020，36(6)：595-598.
    [3]
    郑茂，邹玉，刘晓，等．耐碳青霉烯类高毒力肺炎克雷伯菌的研究进展[J].中国感染与化疗杂志，2021，21(1)：105-110.
    [4]
    雷静, 周维肖, 雷珂, 等. 重症监护病房耐碳青霉烯类高毒力肺炎克雷伯菌分子及临床特征分析[J]. 中华预防医学杂志，2022，56(1): 63-68.
    [5]
    瞿介明，施毅.中国成人医院获得性肺炎与呼吸机相关性肺炎诊断和治疗指南(2018年版)的更新与解读，中华结核和呼吸杂志，2018，41（4）：244-246.
    [6]
    瞿介明，曹彬.中国成人社区获得性肺炎诊断和治疗指南（2016版）[J].中华结核和呼吸杂志，2016，39（4）：253-279.
    [7]
    胡付品, 2021年CHIENT中国细菌耐药监测网[DB/OL]. http://www.chinets.com/Document/Index#（2022-2-11）[2022-9-14]
    [8]
    陈倩倩, 宋缘缘, 唐洪影, 等．生物膜阳性肺炎克雷伯菌血流感染及预后危险因素分析[J] ．中华临床感染病杂志，2020，13（2）：119-124.
    [9]
    刘又宁，王辰，康健等.呼吸内科学[M].北京：人民军医出版社，2015.
    [10]
    https://www.uptodate.com/contents/zh-Hans/clinical-features-diagnosis-and-treatment-of-klebsiella-pneumoniae-infection
    [11]
    Wu PF, Chuang C, Su CF, et al. High minimum inhibitory concentration of imipenem as a predictor of fatal outcome in patients with carbapenem non-susceptible Klebsiella pneumoniae[J]. Sci Rep. 2016 Sep 2;6:32665.