Klebsiella pneumoniae necrotizing fasciitis associated with diabetes and liver cirrhosis

Klebsiella pneumoniae infections after liver transplantation: Drug resistance and distribution of pathogens, risk factors, and influence on outcomes

BACKGROUND

Liver transplantation (LT) is the only curative treatment for end-stage liver disease. However, LT recipients are susceptible to infection, which is the leading cause of early mortality after LT. Klebsiella pneumoniae infections (KPIs) in the bloodstream are common in LT recipients. We hypothesized that KPIs and carbapenem-resistant Klebsiella pneumoniae (CRKP) infections may affect the outcomes of LT recipients.

AIM

To assess KPI incidence, timing, distribution, drug resistance, and risk factors following LT and its association with outcomes.

METHODS

This retrospective study included 406 patients undergoing LT at The Third Xiangya Hospital of Central South University, a tertiary hospital, from January 2015 to January 2023. We investigated the risk factors for KPIs and assessed the impact of KPIs and CRKP infections on the prognosis of LT recipients using logistic regression analysis.

RESULTS

KPI incidence was 7.9% (n = 32), with lung/thoracic cavity the most frequent site of infection; the median time from LT to KPI onset was 7.5 d. Of 44 Klebsiella pneumoniae isolates, 43 (97.7%) and 34 (77.3%) were susceptible to polymyxin B or ceftazidime/avibactam and tigecycline, respectively; > 70% were resistant to piperacillin/ tazobactam, ceftazidime, cefepime, aztreonam, meropenem, and levofloxacin. Female sex [odds ratio (OR) = 2.827, 95% confidence interval (CI): 1.256-6.364; P = 0.012], pre-LT diabetes (OR = 2.794, 95%CI: 1.070-7.294; P = 0.036), day 1 post-LT alanine aminotransferase (ALT) levels ≥ 1500 U/L (OR = 3.645, 95%CI: 1.671-7.950; P = 0.001), and post-LT urethral catheter duration over 4 d (OR = 2.266, 95%CI: 1.016-5.054; P = 0.046) were risk factors for KPI. CRKP infections, but not KPIs, were risk factors for 6-month all-cause mortality post-LT.

CONCLUSION

KPIs occur frequently and rapidly after LT. Risk factors include female sex, pre-LT diabetes, increased post-LT ALT levels, and urethral catheter duration. CRKP infections, and not KPIs, affect mortality.

Atypical Presentation of Klebsiella pneumoniae Necrotizing Fasciitis of the Lower Extremities: Silent but Deadly: A Case Report

CASE

There has been an emerging trend of Klebsiella pneumoniae necrotizing fasciitis (KP-NF). We report a 50-year-old Chinese woman with rapidly progressive KP-NF, presenting atypically with innocuous skin symptoms. She had newly diagnosed diabetes mellitus. She had extensive subcutaneous crepitus in her lower limbs with subcutaneous gas on x-rays. Despite aggressive surgical debridement, she succumbed to septic shock and multiorgan failure.

CONCLUSION

KP-NF is an emerging clinical entity and is associated with a compromised host immunity and high mortality rates. Clinicians must be aware that not all may present with the typical fulminant features and should maintain a high index of suspicion.

Rotundic Acid Protects against Metabolic Disturbance and Improves Gut Microbiota in Type 2 Diabetes Rats

Rotundic acid (RA) is a major triterpene constituent in the barks of Ilex rotunda Thunb, which have been widely used to make herbal tea for health care in southern China. RA has a variety of bioactivities such as anti-inflammation and lipid-lowering effect. However, little is known about the effects and mechanisms of RA on metabolic disturbance in type 2 diabetes (T2D) and its effect on gut microbiota. A T2D rat model induced by high fat diet (HFD) feeding and low-dose streptozotocin (STZ) injection was employed and RA showed multipronged effects on T2D and its complications, including improving glucolipid metabolism, lowering blood pressure, protecting against cardiovascular and hepatorenal injuries, and alleviating oxidative stress and inflammation. Furthermore, 16s rRNA gene sequencing was carried out on an Illumina HiSeq 2500 platform and RA treatment could restore the gut microbial dysbiosis in T2D rats to a certain extent. RA treatment significantly enhanced the richness and diversity of gut microbiota. At the genus level, beneficial or commensal bacteria Prevotella, Ruminococcus, Leuconostoc and Streptococcus were significantly increased by RA treatment, while RA-treated rats had a lower abundance of opportunistic pathogen Klebsiella and Proteus. Spearman’s correlation analysis showed that the abundances of these bacteria were strongly correlated with various biochemical parameters, suggesting that the improvement of gut microbiota might help to prevent or attenuate T2D and its complication. In conclusion, our findings support RA as a nutraceutical agent or plant foods rich in this compound might be helpful for the alleviation of T2D and its complications through improving gut microbiota.

A comparison of necrotising fasciitis in diabetics and non-diabetics

Aims

Diabetes mellitus is the most common co-morbidity associated with necrotising fasciitis. This study aims to compare the clinical presentation, investigations, Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score, microbiology and outcome of management of this condition in diabetic and non-diabetic patients.

Patients and Methods

The medical records of all patients with surgically proven necrotising fasciitis treated at our institution between 2005 and 2014 were reviewed. Diagnosis of necrotising fasciitis was made on findings of ‘dishwater’ fluid, presence of greyish necrotic deep fascia and lack of bleeding on muscle dissection found intra-operatively. Information on patients’ demographics, presenting symptoms, clinical signs, investigations, treatment and outcome were recorded and analysed.

Results

A total of 127 patients with surgically proven necrotising fasciitis were included in this study. In all, 78 (61.4%) were diabetic and 49 (38.6%) were non-diabetic. Diabetics tended to have polymicrobial infections (p = 0.03), renal impairment (p < 0.001), end-stage renal disease (p = 0.001) and multiple co-morbidities (p < 0.001). They presented atypically, with less tenderness (p = 0.042) and less hypotension (p = 0.034). This resulted in higher rates of misdiagnosis (p = 0.038) and a longer time to surgery (p = 0.05) leading to longer hospital stays (p = 0.043) and higher rates of amputation (p = 0.045). However, the rate of mortality is comparable (p = 0.525). A LRINEC score of > 8 appears to be more sensitive in diabetic patients (p < 0.001). However, the increased sensitivity in diabetic patients may be related to hyperglycemia and electrolyte abnormalities associated with renal impairment in these patients.

Conclusion

The LRINEC score must be used with caution in diagnosing necrotising fasciitis in diabetic patients. A high index of suspicion is key to the early diagnosis and subsequent management of these patients. Cite this article: Bone Joint J 2016;98-B:1563–8.

Bilateral Necrotizing Fasciitis of the Foot Associated with Group B Streptococcus

Necrotizing fasciitis (NF) is a severe bacterial infection involving fascia and subcutaneous tissue. It generally affects upper or lower extremities unilaterally, and there are few reports of bilateral-extremity NF. Here, we report a case of a 43-year-old male with type 1 diabetes who had NF on the left foot and subsequently developed NF on the other foot 1 week later. The patient survived with antimicrobial therapy and bilateral below-knee amputation. As group B streptococcus (GBS) was isolated by blood culture and culture of excised tissues of both feet, bilateral GBS NF of the foot was diagnosed. GBS is a rare causative pathogen in NF; however, there have been two case reports of bilateral GBS NF of an extremity in which NF appeared on the opposite extremity 1 week after the primary site infection, as in our case. GBS was isolated from cultures of blood and excised tissues of both extremities in both cases. Together, these observations suggest that GBS has a potential to cause secondary NF at remote sites by hematogenous dissemination with approximately 1 week delay and thereby lead to bilateral NF.

Monomicrobial Necrotizing Fasciitis Caused by Aeromonas hydrophila and Klebsiella pneumoniae

OBJECTIVE

To compare specific characteristics and clinical outcomes of monomicrobial necrotizing fasciitis caused by Aeromonashydrophila and Klebsiella pneumoniae.

MATERIAL AND METHODS

Cases of monomicrobial necrotizing fasciitis caused by A. hydrophila (n = 11) and K. pneumoniae (n = 7) over an 8-year period were retrospectively reviewed. Differences in mortality, patient characteristics, clinical presentations, and laboratory data were compared between the A. hydrophila and the K. pneumoniae groups.

RESULTS

The clinical signs and symptoms at the time of presentation did not differ significantly (p > 0.05) between the two groups. The A. hydrophila group had a significantly shorter interval between contact and admission (1.55 ± 0.52 vs. 5.14 ± 2.12 days, p < 0.001) and significant lower total white blood cell counts (10,245 ± 5,828 vs. 19,014 ± 11,370 cells/mm(3), p < 0.045) than the K. pneumoniae group in the emergency room. Hepatic dysfunction was associated with mortality in patients with A. hydrophila infection, while diabetes mellitus was associated with mortality in patients with K. pneumoniae infection. Overall, 5 (45.5%) patients in the A. hydrophila group and 3 (42.8%) in the K. pneumoniae group died.

CONCLUSION

The initial clinical course of A. hydrophila monomicrobial necrotizing fasciitis was characterized by more rapidly progressive disease than that of the K. pneumoniae infection. Patients with hepatic dysfunction and necrotizing fasciitis should be suspected of having A. hydrophila infection, and diabetic patients with necrotizing fasciitis should be suspected of having K. pneumoniae infection initially.

Necrotizing fasciitis caused by hypermucoviscous Klebsiella pneumoniae in a Filipino female in North America

Necrotizing fasciitis caused by Klebsiella pneumoniae has been described in Southeast Asia, but has only recently begun to emerge in North America. The hypermucoviscous strain of K. pneumoniae is a particularly virulent strain known to cause devastatingly invasive infections, including necrotizing fasciitis. Here we present the first known case of necrotizing fasciitis caused by hypermucoviscous K. pneumoniae in North America.

Recent trend of necrotizing fasciitis in Taiwan: focus on monomicrobial Klebsiella pneumoniae necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening soft-tissue infection that is traditionally caused by group A Streptococcus (GAS) or mixed aerobic/anaerobic bacteria. Monomicrobial Klebsiella pneumoniae NF (KP-NF) has been reported since 1996 but has not yet been systematically studied.

METHODS

We retrospectively studied consecutive NF cases treated at a university hospital in Taiwan during 1997-2010 and investigated the clinical characteristics and outcomes associated with monomicrobial KP-NF, using monomicrobial GAS-NF as a reference. We also analyzed the virulence gene profiles of the isolated K. pneumoniae strains.

RESULTS

Of 134 NF cases, 88 were monomicrobial, of which the most common pathogens were GAS (n = 16) and K. pneumoniae (n = 15). Monomicrobial KP-NF entailed a moderate risk of limb loss (20% vs 25%; P = 1.000) and high mortality (47% vs 19%; P = .135), and it was more likely to involve bacteremia (80% vs 31%; P = .011), concomitant distant abscesses (27% vs 0%; P = .043), and underlying immunocompromising conditions (100% vs 63%; P = .018), compared with GAS-NF. The isolated K. pneumoniae strains (n = 10) were of capsular polysaccharides genotype K1 (n = 4), K54/K20/K5 (n = 4), K2 (n = 1), and K16 (n = 1). All strains carried rmpA, iucABCDiutA, and iroA. Genotype K1 strains had a significantly higher risk of concomitant distant abscesses, compared with non-K1 strains (75% vs 0%; P = .033).

CONCLUSIONS

K. pneumoniae has become a common pathogen of monomicrobial NF in Taiwan. Physicians treating patients with monomicrobial KP-NF should be aware of the risk of concomitant distant abscesses, particularly in cases caused by genotype K1.

Klebsiella pneumoniae Causing Necrotizing Fasciitis in a Patient with Thalassaemia Major

We present a case of Klebsiella pneumoniae necrotizing fasciitis in a patient with thalassaemia major. Klebsiella sp. is known to cause severe infections in patients with thalassaemia, with high mortality rates.

Do neutrophils play a role in establishing liver abscesses and distant metastases caused by Klebsiella pneumoniae?

Serotype K1 Klebsiella pneumoniae is a major cause of liver abscesses and endophthalmitis. This study was designed to identify the role of neutrophils in the development of distant metastatic complications that were caused by serotype K1 K. pneumoniae. An in vitro cellular model was used to assess serum resistance and neutrophil-mediated killing. BALB/c mice were injected with neutrophils containing phagocytosed K. pneumoniae. Serotype K1 K. pneumoniae was significantly more resistant to serum killing, neutrophil-mediated phagocytosis and intra-cellular killing than non-K1 isolates (p<0.01). Electron microscopic examination had similar findings as in the bioassay findings. Intraperitoneal injection of neutrophils containing phagocytosed serotype K1 K. pneumoniae led to abscess formation in multiple sites including the subcutaneous tissue, lung, and liver, whereas no abscess formation was observed in mice injected with non-K1 isolates. The resistance of serotype K1 K. pneumoniae to complement- and neutrophil-mediated intracellular killing results in the dissemination of K. pneumoniae via the bloodstream. Escape from neutrophil intracellular killing may contribute to the dissemination and establishment of distant metastases. Thus, neutrophils play a role as a vehicle for helping K. pneumoniae and contributing to the establishment of liver abscess and distant metastatic complications.

Postirradiation Klebsiella pneumoniae-associated necrotizing fasciitis in the western hemisphere: a rare but life-threatening clinical entity

Necrotizing fasciitis (NF) caused by Klebsiella spp. is a unique entity, particularly, in Asia, where virulent strains of Klebsiella predominate. It is now clear that Klebsiella spp. are capable of causing NF either isolated or in the context of disseminated disease. We present a unique case of NF caused by Klebsiella pneumoniae in the Western hemisphere after radiotherapy in a hospitalized patient with significant comorbidities. Physicians should be aware of nosocomially acquired K. pneumoniae fasciitis after radiotherapy in the setting of chronic comorbidities, such as diabetes and malignancy. Early diagnosis, surgical intervention, and appropriate empirical antibiotics are essential for a favorable outcome in such rare but life-threatening cases of NF.

Monomicrobial necrotizing fasciitis in a white male caused by hypermucoviscous Klebsiella pneumoniae

We report a case of monomicrobial necrotizing fasciitis caused by hypermucoviscous Klebsiella pneumoniae in an immunocompromised white male after travel to China. The K. pneumoniae isolate belonged to the K2 serotype, and carried the virulence factors RmpA and aerobactin. To the best of our knowledge this is the first report of necrotizing fasciitis caused by hypermucoviscous K. pneumoniae resembling the highly virulent K. pneumoniae isolates associated with liver abscess syndrome in Asia.

Klebsiella pneumoniae necrotizing fasciitis and septic arthritis: an appearance in the Western hemisphere

BACKGROUND

Necrotizing fasciitis caused by Klebsiella pneumoniae is rare, with 11 documented cases in the literature, all occurring in Asia and the Middle East. These reports have become more frequent in recent years in association with the emergence of the highly virulent K1 capsular serotype of Klebsiella. We report a case of Klebsiella necrotizing fasciitis and con-current septic arthritis in the Western hemisphere.

METHODS

Case report and review of the literature.

RESULTS

Our patient, a 50-year-old Cambodian man with advanced hepatitis B-associated cirrhosis, who had last visited an endemic area six months prior to presentation, was hospitalized after several days of left knee and thigh pain. He was hypotensive, tachycardic, and bacteremic with K. pneumoniae. A computed tomography scan showed gas in the tissues of the thigh and left knee joint. Despite aggressive surgical debridement and antibiotic therapy, the patient died on day three. Serotyping of blood, wound, and synovial cultures revealed K1-type K. pneumoniae.

CONCLUSIONS

Although K. pneumoniae is common, monomicrobial necrotizing fasciitis and septic arthritis caused by this pathogen has not been reported previously outside Asia, where it is rare. The appearance of this infection in the Western hemisphere may reflect geographic spread of the aggressive K1 phenotype. Physicians treating patients with symptoms and signs of necrotizing fasciitis or septic arthritis, particularly in the setting of underlying chronic illness or recent travel to Asia, should consider K. pneumoniae as a potential cause and treat accordingly.

Cryptogenic invasive Klebsiella pneumoniae liver abscess syndrome

BACKGROUND

Klebsiella pneumoniae-associated liver abscesses have distinct clinical and epidemiologic features.

METHODS

We report the unusual case of an American patient with a K. pneumoniae-associated liver abscess and septic spread to other organs. We additionally present a comprehensive review of K. pneumoniae-associated liver abscess syndromes in adults.

RESULTS

We identified three distinct K. pneumoniae liver abscess syndromes: the polymicrobial liver abscess, the monomicrobial cryptogenic noninvasive liver abscess, and the monomicrobial cryptogenic invasive K. pneumoniae-associated liver abscess (CIKPLA) syndromes, with distinct clinical, epidemiologic and outcome features. CIKPLA syndrome typically affects diabetic patients, mainly in Southeast Asia, and is complicated by septic spread to other organs.

CONCLUSIONS

The community-acquired, monomicrobial, K. pneumoniae-associated liver abscess syndromes that typically occur in the USA are mainly noninvasive and affect Asian or Hispanic persons. However, this report provides an alert that CIKPLA syndrome can occur in North America, and physicians need to be aware of it.

Four cases of necrotizing fasciitis caused by Klebsiella species

Presented here are four cases of necrotizing fasciitis caused by Klebsiella spp. that were treated at one hospital over a 2-year period. Klebsiella necrotizing fasciitis can occur via direct inoculation, local trauma or, more commonly, hematogenous spread from other septic foci. Early, aggressive, surgical debridement and appropriate antimicrobial treatment are the cornerstones of treatment for this condition. Necrotizing fasciitis due to Klebsiella spp. is unique in that it is commonly associated with multiple septic foci. While liver abscesses and endogenous endophthalmitis are better-known associations of disseminated Klebsiella infection, necrotizing fasciitis is increasingly recognized as one of the manifestations of this syndrome. When treating Klebsiella necrotizing fasciitis, awareness of the potential for multiorgan involvement should prompt a thorough search for associated foci of infection.

Infections in cirrhosis

Infection is a well-described complication of cirrhosis and is a major cause of death in this population. This article examines the types of infections related with cirrhosis, such as bacteremia, urinary tract infections, meningitis, and others.