1
|
Numan M, Mathew J, Hamad W, Abuhmaira M, Werah H, Khamkham A. Metastatic community acquired Klebsiella pneumonia infection, secondary to skin and soft tissue infection: A case report. IDCases 2024; 38:e02074. [PMID: 39309040 PMCID: PMC11415946 DOI: 10.1016/j.idcr.2024.e02074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 08/27/2024] [Accepted: 09/04/2024] [Indexed: 09/25/2024] Open
Abstract
Klebsiella pneumonia is known to cause hospital-acquired infections, primarily in immunocompromised patients. Recently, a distinct syndrome of community-acquired invasive Klebsiella pneumonia infection has been observed, mainly in the Southeast Asian population. This syndrome is associated with disseminated infection and the formation of multiple organ abscesses. Affected organs include the liver, the meninges, the brain, the eyes, and rarely the skin and soft tissue. Most of the affected patients suffer from diabetes mellitus. We present a case of invasive community-acquired Klebsiella pneumonia infection with the skin as the primary source. The patient was found to have multiple abscesses involving the skin, the liver, the right lung, and the brain. Cultures from the wound, the liver abscess, and the blood all revealed Klebsiella pneumonia. The liver abscess was drained, and the patient received a prolonged course of antibiotics based on the sensitivity. One month later, the patient achieved full recovery. Our report highlights the emerging syndrome of invasive community-acquired Klebsiella pneumonia infection and the need for timely diagnosis and treatment to achieve favorable outcomes.
Collapse
Affiliation(s)
- Mohammad Numan
- Department of Internal Medicine, Al-Khor Hospital, Hamad Medical Corporation,Doha, Qatar
- Internal Medicine, Collage of Medicine, University of Qatar, Doha, Qatar
| | - Joyal Mathew
- Department of Internal Medicine, Al-Khor Hospital, Hamad Medical Corporation,Doha, Qatar
- Internal Medicine, Collage of Medicine, University of Qatar, Doha, Qatar
| | - Wasfy Hamad
- Department of Internal Medicine, Al-Khor Hospital, Hamad Medical Corporation,Doha, Qatar
| | - Mohammad Abuhmaira
- Department of Internal Medicine, Al-Khor Hospital, Hamad Medical Corporation,Doha, Qatar
- Internal Medicine, Collage of Medicine, University of Qatar, Doha, Qatar
| | - Hassan Werah
- Department of Internal Medicine, Al-Khor Hospital, Hamad Medical Corporation,Doha, Qatar
| | - Almokhtar Khamkham
- Department of Internal Medicine, Al-Khor Hospital, Hamad Medical Corporation,Doha, Qatar
| |
Collapse
|
2
|
Zhao R, Jiang S, Ren S, Yang L, Han W, Guo Z, Gu J. A novel phage putative depolymerase, Depo16, has specific activity against K1 capsular-type Klebsiella pneumoniae. Appl Environ Microbiol 2024; 90:e0119723. [PMID: 38551353 PMCID: PMC11022553 DOI: 10.1128/aem.01197-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 03/10/2024] [Indexed: 04/18/2024] Open
Abstract
Klebsiella pneumoniae, especially hypervirulent K. pneumoniae (hvKP), is a common opportunistic pathogen that often causes hospital- and community-acquired infections. Capsular polysaccharide (CPS) is an important virulence factor of K. pneumoniae. Some phages encode depolymerases that can recognize and degrade bacterial polysaccharides. In this study, the lytic bacteriophage vB_KpnP_ZK1 (abbreviated as ZK1) was isolated using serotype K1 hvKP as the host. Although amino acid sequence BLAST analysis indicated that the tail fiber protein Depo16 of phage ZK1 showed no significant similarity to any reported phage depolymerases, it displayed enzymatic activities that are characteristic of phage depolymerases. After expression and purification, Depo16 could efficiently remove the capsular polysaccharide layer that surrounds the surface of serotype K1 K. pneumoniae. Although no bactericidal activity was detected, Depo16 makes serotype K1 K. pneumoniae sensitive to peritoneal macrophages (PMs). In addition, in a mouse bacteremia model of serotype K1 K. pneumoniae, 25 µg of Depo16 was effective in significantly prolonging survival. Depo16 treatment can reduce the bacterial load in blood and major tissues and alleviate tissue damage in mice. This indicates that the putative depolymerase Depo16 is a potential antibacterial agent against serotype K1 K. pneumoniae infections.IMPORTANCEKlebsiella pneumoniae often causes hospital-acquired infections and community-acquired infections. Capsular polysaccharide (CPS) is one of the crucial virulence factors of K. pneumoniae. K1 and K2 capsular-type K. pneumoniae strains are the most prevalent serotypes of hypervirulent K. pneumoniae (hvKP). In this study, a novel K. pneumoniae phage named vB_KpnP_ZK1 was isolated, and its putative depolymerase Depo16 showed low homology with other reported phage depolymerases. Depo16 can specifically degrade the K. pneumoniae K1 capsule making this serotype sensitive to peritoneal macrophages. More importantly, Depo16 showed a significant therapeutic effect in a mouse bacteremia model caused by serotype K1 K. pneumoniae. Thus, Depo16 is a potential antibacterial agent to combat serotype K1 K. pneumoniae infections.
Collapse
Affiliation(s)
- Rihong Zhao
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Key Laboratory for Zoonosis Research of the Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun, China
| | - Shanshan Jiang
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Key Laboratory for Zoonosis Research of the Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun, China
| | - Siyu Ren
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Key Laboratory for Zoonosis Research of the Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun, China
| | - Li Yang
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Key Laboratory for Zoonosis Research of the Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun, China
| | - Wenyu Han
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Key Laboratory for Zoonosis Research of the Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun, China
| | - Zhimin Guo
- Clinical Laboratory Department, Infectious Diseases and Pathogen Biology Center, First Hospital of Jilin University, Changchun, China
| | - Jingmin Gu
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Key Laboratory for Zoonosis Research of the Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun, China
- Jiangsu Co-Innovation Center for the Prevention and Control of Important Animal Infectious Diseases and Zoonoses, Yangzhou University, Yangzhou, China
| |
Collapse
|
3
|
Lee BH, Leong YH, Kwek Beng Kee E. Atypical Presentation of Klebsiella pneumoniae Necrotizing Fasciitis of the Lower Extremities: Silent but Deadly: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00082. [PMID: 37708317 DOI: 10.2106/jbjs.cc.23.00130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
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.
Collapse
Affiliation(s)
- Bing Howe Lee
- Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore
| | - Yen Hsin Leong
- Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore
| | | |
Collapse
|
4
|
Antimicrobial Resistance Pattern, Pathogenicity and Molecular Properties of Hypervirulent Klebsiella pneumonia (hvKp) among Hospital-Acquired Infections in the Intensive Care Unit (ICU). Microorganisms 2023; 11:microorganisms11030661. [PMID: 36985234 PMCID: PMC10052956 DOI: 10.3390/microorganisms11030661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/25/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Hypervirulent Klebsiella pneumoniae (hvKp) is a new emerging variant of K. pneumoniae that is increasingly reported worldwide. The variant hvKp is known to cause severe invasive community-acquired infections such as metastatic meningitis, pyogenic liver abscesses (PLA) and endophthalmitis, but its role in hospital-acquired infections (HAIs) is little known. The aim of this study was to evaluate the prevalence of hvKp among hospital-acquired (HA) K. pneumoniae infections in the intensive care unit (ICU) and to compare between hvKp and classical K. pneumoniae (cKP) regarding antimicrobial resistance pattern, virulence and molecular characteristics. The study was cross-sectional and included 120 ICU patients suffering from HA K. pneumoniae infections between January and September 2022. K. pneumoniae isolates were subjected to antimicrobial susceptibility testing and detection of extended-spectrum-β-lactamase (ESBL) production by the Phoenix 100 automated microbiology system, string test, biofilm formation, serum resistance assay, and detection of virulence-associated genes (rmpA, rmpA2, magA, iucA) and capsular serotype-specific genes (K1, K2, K5, K20, K57) by polymerase chain reaction (PCR). Of 120 K. pneumoniae isolates, 19 (15.8%) were hvKp. The hypermucoviscous phenotype was more significantly detected in the hvKp group than in the cKP group (100% vs. 7.9%, p ≤ 0.001). The rate of resistance to different antimicrobial agents was significantly higher in the cKP group than that in the hvKp group. Fifty-three strains were identified as ESBL-producing strains, which was more frequent in the cKP group than in the hvKp group (48/101 [47.5%] vs. 5/19 [26.3%], respectively, p ≤ 0.001). The hvKP isolates were highly associated with moderate and strong biofilm formation than cKP isolates (p = 0.018 and p = 0.043 respectively). Moreover, the hvKP isolates were highly associated with intermediate sensitivity and re sistance to serum in the serum resistance assay (p = 0.043 and p = 0.016 respectively). K1, K2, rmpA, rmpA2, magA and iucA genes were significantly associated with hvKp (p ≤ 0.001, 0.004, <0.001, <0.001, 0.037 and <0.001, respectively). However, K5, K20 and K57 were not associated with hvKp. The hvKp strains have emerged as a new threat to ICU patients because of their ability to cause more severe and life-threatening infections than cKP. The string test alone as a laboratory test for screening of hvKp has become insufficient. Recently, hvKp was defined as hypermucoviscous- and aerobactin-positive. It is important to improve the awareness towards the diagnosis and management of hvKp infections.
Collapse
|
5
|
Cao H, Liang S, Zhang C, Liu B, Fei Y. Molecular Profiling of a Multi-Strain Hypervirulent Klebsiella pneumoniae Infection Within a Single Patient. Infect Drug Resist 2023; 16:1367-1380. [PMID: 36937147 PMCID: PMC10017834 DOI: 10.2147/idr.s404202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/03/2023] [Indexed: 03/12/2023] Open
Abstract
Background The rising prevalence of infections caused by carbapenem-resistant and hypervirulent Klebsiella pneumoniae (CR-hvKP) has outpaced our understanding of their evolutionary diversity. By straining the antimicrobial options and constant horizontal gene transfer of various pathogenic elements, CR-hvKP poses a global health threat. Methods Six KP isolates (KP1~KP6) from urine, sputum and groin infection secretion of a single patient were characterized phenotypically and genotypically. The antimicrobial susceptibility, carbapenemase production, hypermucoviscosity, serum resistance, virulence factors, MLST and serotypes were profiled. Genomic variations were identified by whole-genome sequencing and the phylogenetic differentiation was analyzed by Enterobacterial repetitive intergenic consensus (ERIC)-PCR. Results All KP strains were multi-drug resistant. Four of them (KP1, KP3, KP5 and KP6) belonged to ST11-K64, with high genetic closeness (relatedness coefficient above 0.96), sharing most resistance and virulence genes. Compared with KP1, the later isolates KP3, KP5 and KP6 acquired bla KPC-1 and lost bla SHV-182 genes. KP2 and KP4 had the same clonal origin of ST35-K16 (relatedness coefficient 0.98), containing almost identical genes for resistance and virulence. They were non-mucoid and carried bla NDM-5 gene. Conclusion A co-infection with two types of CR-hvKP affiliated with different clades within a single patient amplified the treatment difficulties. In addition to source control and epidemiological surveillance, investigation of the in-host interactions between CR-hvKP variants may provide valuable treatment solutions.
Collapse
Affiliation(s)
- Huijun Cao
- Centre for Clinical Laboratories, the Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, People’s Republic of China
| | - Shiwei Liang
- Centre for Clinical Laboratories, the Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, People’s Republic of China
- School of Clinical Laboratory Science, Guizhou Medical University, Guiyang, 550004, People’s Republic of China
| | - Chenchen Zhang
- School of Clinical Laboratory Science, Guizhou Medical University, Guiyang, 550004, People’s Republic of China
| | - Bao Liu
- Centre for Clinical Laboratories, the Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, People’s Republic of China
| | - Ying Fei
- Centre for Clinical Laboratories, the Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, People’s Republic of China
- Correspondence: Ying Fei, Email
| |
Collapse
|
6
|
Wu X, Zhan F, Zhang J, Chen S, Yang B. Identification of hypervirulent Klebsiella pneumoniae carrying terW gene by MacConkey-potassium tellurite medium in the general population. Front Public Health 2022; 10:946370. [PMID: 36091562 PMCID: PMC9448990 DOI: 10.3389/fpubh.2022.946370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/05/2022] [Indexed: 01/21/2023] Open
Abstract
Objectives To establish a MacConkey-potassium tellurium medium-based method for selectively culturing terW gene-positive Klebsiella pneumoniae (KP), to evaluate its performance and apply it to identifying particular clonal hypervirulent KP (hvKP) strains in epidemiological surveillance. Methods The virulence genes, rmpA, iutA, and terW, were detected by PCR. The minimum inhibitory concentration of potassium tellurite of hvKP (rmpA +/ iutA +) and classical KP (rmpA - and iutA -) was determined using the agar dilution method. The MacConkey medium containing 4 μg/ml potassium tellurite was prepared and the performance in detecting terW + KP was evaluated, including an agreement with PCR and positive/negative predictive value. Fecal samples from healthy volunteers in Fujian were collected and cultured in the medium, then positive strains were identified using MALDI-TOF MS, antimicrobial susceptibility was tested by Kirby-Bauer assays, and virulence genes and capsular serotype genes were tested by PCR. Results In KP isolated from clinical specimens (N = 198), the positive rate of terW was 37.9%, and the detection rate of terW in hvKP was significantly higher than that in classical KP (70.6% vs 13.3%). The potassium tellurite resistance levels of terW + (N = 75) and terW - (N = 55) KP were 8-128 μg/ml and <1-8 μg/ml, respectively, with significant differences. KP was selectively cultured on a MacConkey medium with 4 μg/ml potassium tellurite, and its agreement with PCR was good (Kappa=0.936), and the positive and negative percent agreement and positive and negative predictive values were 100% (75/75), 92.7% (51/55), 94.9% (75/79), and 100% (51/51), respectively. The prevalence of tellurite-resistant KP was 16.7% (86/516) in fecal samples from healthy volunteers, among which the positive rate of terW was 100% (86/86). The antimicrobial resistance characteristics of terW + KP showed no difference between healthy volunteers and inpatients. The most common capsular serotypes associated with high virulence were K1, K2, and K57. Conclusions The MacConkey medium containing 4 μg/ml potassium tellurite could easily select and culture terW + KP in fecal samples with high sensitivity and specificity, which is a practical method for the epidemic surveillance of hvKP in the general population.
Collapse
Affiliation(s)
- Xiufeng Wu
- Department of Laboratory Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Fuguo Zhan
- Department of Laboratory Medicine, Gene Diagnosis Research Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Key Laboratory of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,First Clinical College, Fujian Medical University, Fuzhou, China
| | - Jiawei Zhang
- Department of Laboratory Medicine, Gene Diagnosis Research Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Key Laboratory of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,First Clinical College, Fujian Medical University, Fuzhou, China
| | - Shanjian Chen
- Department of Laboratory Medicine, Gene Diagnosis Research Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Key Laboratory of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,First Clinical College, Fujian Medical University, Fuzhou, China
| | - Bin Yang
- Department of Laboratory Medicine, Gene Diagnosis Research Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Key Laboratory of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,First Clinical College, Fujian Medical University, Fuzhou, China,*Correspondence: Bin Yang
| |
Collapse
|
7
|
Lin TL, Yang FL, Ren CT, Pan YJ, Liao KS, Tu IF, Chang YP, Cheng YY, Wu CY, Wu SH, Wang JT. Development of Klebsiella pneumoniae Capsule Polysaccharide-Conjugated Vaccine Candidates Using Phage Depolymerases. Front Immunol 2022; 13:843183. [PMID: 35386691 PMCID: PMC8978995 DOI: 10.3389/fimmu.2022.843183] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 02/25/2022] [Indexed: 11/24/2022] Open
Abstract
Klebsiella pneumoniae is an important pathogen associated with nosocomial infection and has developed increasing resistance to antibiotics such as extended-spectrum β-lactams and carbapenem. In recent years, K. pneumoniae isolates have emerged as a major cause of global community-acquired infections such as pneumonia and pyogenic liver abscess. Although serotypes K1 and K2 have been identified as the predominant capsular types associated with invasive infections, no K. pneumoniae vaccine is commercially available, probably due to immunogenicity loss in the traditional depolymerization method to obtain capsule polysaccharide (CPS) for the preparation of conjugated vaccine. In this study, we successfully retained immunogenicity by using K1 (K1-ORF34) and K2 (K2-ORF16) CPS depolymerases that were identified from phages to cleave K1 and K2 CPSs into intact structural units of oligosaccharides with intact modifications. The obtained K1 and K2 oligosaccharides were separately conjugated with CRM197 carrier protein to generate CPS-conjugated vaccines. Immunization experiments of mice showed both K1 and K2 CPS-conjugated vaccines induced anti-CPS antibodies with 128-fold and 64-fold increases of bactericidal activities, respectively, compare to mice without vaccinations. Challenge tests indicated that K1 or K2 CPS-conjugated vaccine and divalent vaccine (a mixture of K1 and K2 CPS-conjugated vaccines) protected mice from subsequent infection of K. pneumoniae by the respective capsular type. Thus, we demonstrated K1 and K2 CPS-conjugated vaccines prepared by CPS depolymerases is a promising candidate for developing vaccines against human K. pneumoniae infections.
Collapse
Affiliation(s)
- Tzu-Lung Lin
- Department of Microbiology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Feng-Ling Yang
- Institute of Biological Chemistry, Academia Sinica, Taipei, Taiwan
| | - Chien-Tai Ren
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Yi-Jiun Pan
- Department of Microbiology, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Microbiology, School of Medicine, China Medical University, Taichung, Taiwan
| | | | - I-Fan Tu
- Institute of Biological Chemistry, Academia Sinica, Taipei, Taiwan
| | - Yu-Pei Chang
- Institute of Biological Chemistry, Academia Sinica, Taipei, Taiwan
| | - Yang-Yu Cheng
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Chung-Yi Wu
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Shih-Hsiung Wu
- Institute of Biological Chemistry, Academia Sinica, Taipei, Taiwan
| | - Jin-Town Wang
- Department of Microbiology, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
8
|
Tsai YH, Huang TY, Kuo LT, Chuang PY, Hsiao CT, Huang KC. Comparison of Surgical Outcomes and Predictors in Patients with Monomicrobial Necrotizing Fasciitis and Sepsis Caused by Vibrio vulnificus, Aeromonas hydrophila, and Aeromonas sobria. Surg Infect (Larchmt) 2022; 23:288-297. [PMID: 35180367 DOI: 10.1089/sur.2021.337] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Monomicrobial necrotizing fasciitis caused by Vibrio vulnificus, Aeromonas hydrophila, and Aeromonas sobria are often associated with high mortality rates. The purpose of this study was to compare the independent predictors related to outcomes between Vibrio vulnificus and Aeromonas species necrotizing fasciitis. Patients and Methods: Monomicrobial necrotizing fasciitis caused by Vibrio vulnificus (60 patients) and Aeromonas species (31 patients) over an 11-year period were reviewed retrospectively. Differences in mortality, patient characteristics, clinical presentations, and laboratory data were compared between the Vibrio vulnificus and Aeromonas species groups, and between the death and the survival subgroups of patients with Aeromonas species. Results: Six patients in the Vibrio vulnificus group (10%) and 11 in the Aeromonas species group (32.3%) died. Fifty-nine patents had bacteremia and 16 patients died (27.1%). Patients who had Vibrio vulnificus had a higher incidence of bacteremia. The patients who had Aeromonas species presenting with bacteremia were significantly associated with death. The death subgroup of patients with Aeromonas necrotizing fasciitis had a higher incidence of bacteremia, higher counts of banded leukocytes, lower platelet counts, lower total lymphocyte counts, and lower serum albumin level than the survival subgroup. Conclusions: Monomicrobial necrotizing fasciitis caused by Aeromonas species was characterized by more fulminating and higher mortality than that of Vibrio vulnificus, even after early fasciotomy and third-generation cephalosporin antibiotic therapy. Those risk factors, such as bacteremia, shock, lower platelet counts, lower albumin levels, and antibiotic resistance were associated with mortality, which should alert clinicians to pay more attention to and aggressively treat those patients with Aeromonas and Vibrio necrotizing fasciitis.
Collapse
Affiliation(s)
- Yao-Hung Tsai
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, Taiwan.,College of Medicine, Chang Gung University at Taoyuan, Taiwan
| | - Tsung-Yu Huang
- College of Medicine, Chang Gung University at Taoyuan, Taiwan.,Division of Infectious Diseases, Department of Internal Medicine, Chia-Yi Chang Gung Memorial Hospital, Taiwan
| | - Liang Tseng Kuo
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, Taiwan.,College of Medicine, Chang Gung University at Taoyuan, Taiwan
| | - Po-Yao Chuang
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, Taiwan.,College of Medicine, Chang Gung University at Taoyuan, Taiwan
| | - Cheng-Ting Hsiao
- College of Medicine, Chang Gung University at Taoyuan, Taiwan.,Department of Emergency Medicine, Chia-Yi Chang Gung Memorial Hospital, Taiwan
| | - Kuo-Chin Huang
- Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, Taiwan.,College of Medicine, Chang Gung University at Taoyuan, Taiwan
| |
Collapse
|
9
|
Stieferman AE, Mazi P, Burnham JP. Severe Skin and Soft-Tissue Infections. Semin Respir Crit Care Med 2022; 43:3-9. [PMID: 35172354 DOI: 10.1055/s-0041-1740974] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Skin and soft-tissue infections (SSTIs) are a common reason for hospital admission. Severe SSTIs, particularly necrotizing infections, often require intensive care. Source control (often with surgical debridement) and broad-spectrum antimicrobials are paramount for minimizing significant morbidity and mortality. Rapid diagnostic tests may help in selection and de-escalation of antimicrobials for SSTIs. Besides early source control and early effective antimicrobial therapy, other patient-level factors such as comorbidities and immune status play a role in clinical outcomes. Intravenous immunoglobulin continues to be studied for severe SSTI, though recruitment in trials continues to be an issue. Severe SSTIs are complex to manage, due in part to regional variation in predominant pathogens and antimicrobial resistance patterns, as well as variations in host immune responses. This review includes descriptions of source control, antimicrobial therapies, intravenous immunoglobulin, and hyperbaric oxygen therapy, as well as host factors in severe SSTIs.
Collapse
Affiliation(s)
- Addison E Stieferman
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Patrick Mazi
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
10
|
Hung S, Chiu C, Huang C, Lin C, Yeh J, Yang H, Huang Y. Impact of wound microbiology on limb preservation in patients with diabetic foot infection. J Diabetes Investig 2022; 13:336-343. [PMID: 34418309 PMCID: PMC8847138 DOI: 10.1111/jdi.13649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 07/26/2021] [Accepted: 08/18/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS/INTRODUCTION To investigate the association between specific bacterial pathogens and treatment outcome in patients with limb-threatening diabetic foot infection (LT-DFI). MATERIALS AND METHODS Consecutive patients treated for LT-DFI in a major diabetic foot center in Taiwan were analyzed between the years 2014 and 2017. Patients with positive wound culture results at first aid were enrolled. Clinical factors, laboratory data, and wound culture results were compared. Lower-extremity amputations and in-hospital mortality were defined as a poor outcome. RESULTS Among the 558 patients, 272 (48.7%) patients had lower extremity amputation and 22 (3.9%) patients had in-hospital mortality. Gram-negative bacterial (GNB) infection was the independent factor following factors adjustment. When all the 31 microorganisms were analyzed, only E. coli (adjusted odds ratio [aOR], 3.01; 95% CI, 1.60-5.65), Proteus spp. (aOR, 2.99; 95% CI, 1.69-5.29), and Pseudomonas aeruginosa (aOR, 2.00; 95% CI 1.20-3.32) were associated with poor outcome. The analysis of specific GNB species in association with major- or minor- amputation have been reported. No specific pathogen was associated with cause of death in patients with mortality within 30 days. The antimicrobial-resistant strains were not associated with a poor treatment outcome. CONCLUSIONS The presence of GNB was associated with limb amputations. This study provides insight into more timely and appropriate management of the diabetic foot infection.
Collapse
Affiliation(s)
- Shih‐Yuan Hung
- Division of Endocrinology and MetabolismDepartment of Internal MedicineChang Gung Memorial HospitalTaoyuan CityTaiwan
| | - Cheng‐Hsun Chiu
- Division of Pediatric Infectious DiseasesDepartment of PediatricsChang Gung Memorial HospitalTaoyuan CityTaiwan
| | - Chung‐Huei Huang
- Division of Endocrinology and MetabolismDepartment of Internal MedicineChang Gung Memorial HospitalTaoyuan CityTaiwan
| | - Cheng‐Wei Lin
- Division of Endocrinology and MetabolismDepartment of Internal MedicineChang Gung Memorial HospitalTaoyuan CityTaiwan
| | - Jiun‐Ting Yeh
- Division of Trauma Plastic SurgeryDepartment of Plastic and Reconstructive SurgeryChang Gung Memorial HospitalChang Gung UniversityTaoyuan CityTaiwan
| | - Hui‐Mei Yang
- Division of Endocrinology and MetabolismDepartment of Internal MedicineChang Gung Memorial HospitalTaoyuan CityTaiwan
| | - Yu‐Yao Huang
- Division of Endocrinology and MetabolismDepartment of Internal MedicineChang Gung Memorial HospitalTaoyuan CityTaiwan
- College of MedicineChang Gung UniversityTaoyuan CityTaiwan
- Department of Medical Nutrition TherapyChang Gung Memorial HospitalTaoyuan CityTaiwan
| |
Collapse
|
11
|
Himeno D, Matsuura Y, Maruo A, Ohtori S. A novel treatment strategy using continuous local antibiotic perfusion: A case series study of a refractory infection caused by hypervirulent Klebsiella pneumoniae. J Orthop Sci 2022; 27:272-280. [PMID: 33353777 DOI: 10.1016/j.jos.2020.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Conventional topical antimicrobial therapy cannot maintain a constant local concentration, resulting in uncontrolled infection and complications. We propose continuous local antibiotic perfusion (CLAP), which can maintain a constant appropriate local antibiotic concentration for a long time with less invasiveness and complications. CLAP is clearly different from traditional treatment because it uses negative pressure to direct the continuously infused antibiotic solution to the center of infection and excrete it outside the body. This study aimed to demonstrate the effectiveness of CLAP by presenting cases in which even refractory bone and soft-tissue infections caused by the hypervirulent Klebsiella pneumoniae (hvKp) could be cured without significant tissue loss and dysfunction. METHODS This study is a case series in which four patients with limb infection due to hvKp were treated by CLAP. hvKp was defined by a positive string test. The therapy included intra-soft-tissue antibiotic perfusion and intramedullary antibiotic perfusion. Gentamicin (60 mg/50 cc) was infused continuously through dual-lumen tubes and bone marrow needles at low-flow rates (2 mL/h). Negative pressure was used to collect the antimicrobial solution and eliminate the dead space. RESULTS The infection was controlled in all four patients after a mean period of 44.3 days. The mean maximum blood concentration of gentamicin was 1.6 μg/dL, and no cases of renal dysfunction or ototoxicity occurred. After CLAP, wound closure was required in two patients and iliac bone grafting was required in one patient. As sequelae, there were one case of osteoarthritis and one case of higher brain dysfunction due to hypoxia. CONCLUSIONS Our results suggest that intractable hvKp infections can be controlled by CLAP. CLAP may give us the option to directly control local infections with less systemic complications. Therefore, it is considered a valuable treatment for further basic and clinical research, and this research report may be a first step.
Collapse
Affiliation(s)
- Daisuke Himeno
- Department of Orthopedic Surgery, School of Medicine, Chiba University, Chuo-ku Inohana 1-8-1, Chiba, 260-8670, Japan.
| | - Yusuke Matsuura
- Department of Orthopedic Surgery, School of Medicine, Chiba University, Chuo-ku Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Akihiro Maruo
- Department of Orthopedic Surgery, Steel Memorial Hirohata Hospital, Yumesaki-cho 3-1, Hirohata-ku, Himeji, Hyogo, 671-1122, Japan
| | - Seiji Ohtori
- Department of Orthopedic Surgery, School of Medicine, Chiba University, Chuo-ku Inohana 1-8-1, Chiba, 260-8670, Japan
| |
Collapse
|
12
|
Ding Z, Li Z, Tang M, Zeng Z, Song M, Yang K, Ding Y, Wang Z, Liu J. The molecular characteristics, clinical manifestations, 44 and risk factors of hypervirulent Klebsiella pneumoniae infections in a large teaching hospital in southwest China. Microb Pathog 2021; 162:105152. [PMID: 34742892 DOI: 10.1016/j.micpath.2021.105152] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 05/06/2021] [Accepted: 08/17/2021] [Indexed: 01/23/2023]
Abstract
Hypervirulent Klebsiella pneumoniae (hvKp) has been globally disseminated recently, especially in Asia. The purpose of this study was to identify the molecular characteristics, clinical manifestations, and clinical risk factors of hvKp infections among patients in a large teaching hospital. A retrospective study was conducted in 123 patients infected with K. pneumoniae at the Affiliated Hospital of Southwest Medical University (Luzhou, China) from October 2016 to November 2018. An isolate that positive for both PCR amplification of aerobactin gene and Galleria mellonella infection model was defined as hvKp. Overall, 43.1% (53/123) of K. pneumoniae isolates were hvKp. String tests were performed on all isolates, and MLSTs of all hvKp were conducted. The K1 ST23 isolates were the dominant clone of hvKp (35.8%). Univariate analysis revealed the following risk factors for hvKp: hepatic abscess (OR = 41.818 [95% CI, 5.379-335.086]), bacteremia (OR = 19.94 [95% CI, 5.565-71.446]), metastatic spread (OR = 19.938 [95% CI, 6.344-62.654]), CRP (OR = 1.008 [95% CI, 1.001-1.015]), nitroimidazole treatment (OR = 7.907 [95% CI, 1.652-37.843]), diabetes (OR = 3.067 [95% CI, 1.38-6.817]), and admission to positive culture interval (OR = 3.636 [95% CI, 1.524-8.678]). Moreover, Multivariate analysis implicated hepatic abscess (OR = 74.332 [95% CI, 3.121-1769.588]), bacteremia (OR = 28.388 [95% CI, 3.039-264.200]), and metastatic spread (OR = 19.391 [95% CI, 3.633-103.498]) as independent risk factors for hvKp infections. Thirteen of twenty-one tested antibiotics were founded resistance to non-hvKp, which is significantly greater than hvKp. Importantly, the ESBL-hvKp and MDR-hvKp were responsible for 7.5% and 15.1% in the hvKp group, respectively.
Collapse
Affiliation(s)
- Zixuan Ding
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, PR China
| | - Zhaoyinqian Li
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, PR China
| | - Min Tang
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, PR China
| | - Zhangrui Zeng
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, PR China
| | - Min Song
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, PR China
| | - Kui Yang
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, PR China
| | - Yinhuan Ding
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, PR China
| | - Zhibin Wang
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, PR China
| | - Jinbo Liu
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, PR China.
| |
Collapse
|
13
|
Naamany E, Shiber S, Duskin-Bitan H, Yahav D, Bishara J, Sagy I, Granat N, Drescher M. Polymicrobial and monomicrobial necrotizing soft tissue infections: comparison of clinical, laboratory, radiological, and pathological hallmarks and prognosis. A retrospective analysis. Trauma Surg Acute Care Open 2021; 6:e000745. [PMID: 34693024 PMCID: PMC8499350 DOI: 10.1136/tsaco-2021-000745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 09/14/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Necrotizing soft tissue infection (NSTI) is a life-threatening infection associated with high morbidity and mortality. Treatment consists of surgery and antibiotics. Many studies have addressed NSTI and its subtypes, but few have reviewed the clinical, radiological, and pathological differences between the polymicrobial and monomicrobial diseases. The objective of our study was to evaluate the clinical, radiological, and pathological features of patients with polymicrobial (NSTI I) and monomicrobial (NSTI II) infections and their association with outcome. METHODS The cohort consisted of patients hospitalized with NSTI at a tertiary medical center in 2002-2019. The medical charts were reviewed for clinical, radiological, and pathological features. Findings were compared between patients in whom blood/tissue bacterial cultures yielded one or more than one pathological isolate. The primary clinical outcome measure of the study was all-cause mortality at 90 days. Secondary outcomes were duration of hospitalization, intensive care unit (ICU) admission, score on the LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis), and need for vasopressor treatment. RESULTS A total of 81 patients met the inclusion criteria: 54 (66.6%) with monomicrobial NSTI and 27 (33.3%) with polymicrobial NSTI. There were no significant between-group differences in in-hospital and 90-day mortality. On multivariate analysis, the monomicrobial disease group had a significantly higher 90-day mortality rate in addition to higher rates of in-hospital mortality, ICU admission, and vasopressor use than the polymicrobial disease group. CONCLUSION Our study is the first to compare the clinical, radiological, and pathological differences between the two most common types of NSTI. The results demonstrate better prognosis for polymicrobial NSTI, with minimal ICU stay, lower mortality, and lower use of vasopressors. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
Collapse
Affiliation(s)
- Eviatar Naamany
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shachaf Shiber
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Emergency Medicine, Rabin Medical Center, Petah Tikva, Israel
| | - Hadar Duskin-Bitan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Endocrinology, Rabin Medical Center, Petah Tikva, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Disease, Rabin Medical Center, Petah Tikva, Israel
| | - Jihad Bishara
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Disease, Rabin Medical Center, Petah Tikva, Israel
| | - Iftach Sagy
- Rheumatology, Soroka Medical Center, Beer Sheva, Israel
- Rheumatology, Rabin Medical Center, Petah Tikva, Israel
| | - Nadav Granat
- Emergency Medicine, Rabin Medical Center, Petah Tikva, Israel
| | - Michael Drescher
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Emergency Medicine, Rabin Medical Center, Petah Tikva, Israel
| |
Collapse
|
14
|
Hailemariam M, Alemayehu T, Tadesse B, Nigussie N, Agegnehu A, Habtemariam T, Ali M, Mitiku E, Azerefegne E. Major bacterial isolate and antibiotic resistance from routine clinical samples in Southern Ethiopia. Sci Rep 2021; 11:19710. [PMID: 34611232 PMCID: PMC8492677 DOI: 10.1038/s41598-021-99272-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/13/2021] [Indexed: 02/08/2023] Open
Abstract
Currently, antibiotic-resistant bacterial infections are a challenge for the health care system. Although physicians demand timely drug resistance data to guide empirical treatment, local data is rather scarce. Hence, this study performed a retrospective analysis of microbiological findings at the Hawassa public hospital. Secondary data were retrieved to assess the prevalence and level of drug resistance for the most common bacterial isolates from clinical samples processed at Hawassa University Comprehensive Specialized Hospital. Out of 1085 clinical samples processed in the microbiology laboratory, the prevalence of bacterial infection was 32.6%. Bacterial bloodstream infection was higher in children than in adults (OR, 4; 95% CI 1.8-14.6; p = 0.005). E. coli and K. pneumoniae were the commonest bacterial isolate both in children (36.8%, 26.3%) and in adults (33.3%, 26.7%) from the urine sample while, the leading bacteria identified from the CSF sample was P. aeruginosa, 37% in children and 43% in adult. In this study, all identified bacterial isolates were multi-drug resistant (MDR) ranging from 50 to 91%. The highest proportion of MDR was S. aureus 91.1 followed by K. pneumoniae 87.6%. Since the nationwide investigation of bacterial isolate, and drug resistance is rare in Ethiopia, a report from such type of local surveillance is highly useful to guide empirical therapy by providing awareness on the level resistance of isolates.
Collapse
Affiliation(s)
- Mengistu Hailemariam
- grid.192268.60000 0000 8953 2273School of Medical Laboratory Science, Hawassa University College of Medicine and Health Sciences, P.O. Box 1560, Hawassa, Ethiopia
| | - Tsegaye Alemayehu
- grid.192268.60000 0000 8953 2273School of Medical Laboratory Science, Hawassa University College of Medicine and Health Sciences, P.O. Box 1560, Hawassa, Ethiopia
| | - Bereket Tadesse
- grid.192268.60000 0000 8953 2273Hawassa University Comprehensive and Specialized Hospital, Hawassa, Ethiopia
| | - Netsanete Nigussie
- grid.192268.60000 0000 8953 2273Hawassa University Comprehensive and Specialized Hospital, Hawassa, Ethiopia
| | - Asnakech Agegnehu
- grid.192268.60000 0000 8953 2273Hawassa University Comprehensive and Specialized Hospital, Hawassa, Ethiopia
| | - Techilo Habtemariam
- grid.192268.60000 0000 8953 2273Hawassa University Comprehensive and Specialized Hospital, Hawassa, Ethiopia
| | - Mulubrhan Ali
- grid.192268.60000 0000 8953 2273School of Medical Laboratory Science, Hawassa University College of Medicine and Health Sciences, P.O. Box 1560, Hawassa, Ethiopia
| | - Enkosilassie Mitiku
- grid.192268.60000 0000 8953 2273Hawassa University Comprehensive and Specialized Hospital, Hawassa, Ethiopia
| | - Elshaday Azerefegne
- grid.192268.60000 0000 8953 2273Hawassa University Comprehensive and Specialized Hospital, Hawassa, Ethiopia
| |
Collapse
|
15
|
Dhanasekara CS, Marschke B, Morris E, Kahathuduwa CN, Dissanaike S. Global patterns of necrotizing soft tissue infections: A systematic review and meta-analysis. Surgery 2021; 170:1718-1726. [PMID: 34362585 DOI: 10.1016/j.surg.2021.06.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/29/2021] [Accepted: 06/21/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Frequency, microbiology, and outcomes of necrotizing soft tissue infections vary based on locoregional and environmental factors; however, there has been no global survey of these patterns. We performed a systematic review/meta-analysis on published reports of necrotizing soft tissue infections from across the globe. METHODS Peer-reviewed empirical studies examining rates of polymicrobial and monomicrobial necrotizing soft tissue infections with microbial isolation and overall mortality rate were extracted along with geographic location using PubMed, Scopus, ProQuest, and Web of Science. Random-effects meta-analyses and sensitivity analyses were performed, adjusting for publication bias. Meta-regression analyses examined moderator effects of risk factors. RESULTS One hundred and five studies (8,718 total patients) were included. Pooled prevalence of polymicrobial and monomicrobial infections were 53% and 37.9%, respectively. Truncal necrotizing soft tissue infections were commonly polymicrobial (P < .001), whereas monomicrobial infections prevailed in extremities (P = .008). Global prevalence of monomicrobial necrotizing soft tissue infections was observed to increase by 1.1% annually (P = .003). Staphylococcus aureus was the most common organism globally and in North America, Asia, the Middle East, and Africa, followed by Streptococcus pyogenes and Escherichia coli. Methicillin-resistant S. aureus accounted for 16% of necrotizing soft tissue infections globally. Overall mortality was 23.1%, observed to decline globally over the last decade (P = .020). No regional differences were noted for mortality. CONCLUSION Although polymicrobial infections remain predominant worldwide, the incidence of monomicrobial infections is increasing. The observed decline in necrotizing soft tissue infection-related mortality is encouraging and may reflect advances in management, despite major variations in available healthcare resources globally.
Collapse
Affiliation(s)
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX
| | - Chanaka N Kahathuduwa
- Department of Psychiatry, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; Department of Laboratory Sciences and Primary Care, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX.
| |
Collapse
|
16
|
Genome sequencing and comparative genome analysis of 6 hypervirulent Klebsiella pneumoniae strains isolated in China. Arch Microbiol 2021; 203:3125-3133. [PMID: 33811489 PMCID: PMC8019302 DOI: 10.1007/s00203-021-02263-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 02/17/2021] [Accepted: 02/24/2021] [Indexed: 11/23/2022]
Abstract
Hypervirulent Klebsiella pneumoniae (hvKP) has been increasingly reported over the past three decades and causes severe infections. To increase our understanding of hvKP at the genome level, genome sequencing and comparative genome analysis were performed on 6 hvKPs. The whole genome DNA from 6 hvKPs with different capsular serotypes isolated in China was extracted. The genome sequencing and assembly results showed the genome size of the six hvKPs and GC content. Comparative analyses of the genomes revealed the gene homology and genome rearrangement in the 6 hvKPs compared with Klebsiella pneumonia NTUH-K2044. The phylogenetic tree based on full-genome SNPs of the 7 hvKPs showed that NTUH-K2044 formed a single clade, showing distant evolutionary distances with the other six strains, and the non-K1 hvKP strains had a relatively closer phylogenetic relationship. BLAST comparison analysis found that some selected virulence genes had different degrees of deletion in the non-K1 hvKPs. SNP-based virulence gene mutation analysis showed that some virulence genes had different degrees of SNP mutations. The whole-genome sequencing and comparative genome analysis of six hvKP strains with NTUH-K2044 provide us with a basic understanding of the genome composition, genetic polymorphism, evolution and virulence genes of hvKP and a basis for further research on these genes and the pathogenesis of hvKP.
Collapse
|
17
|
Xie M, Dong N, Chen K, Yang X, Ye L, Chan EWC, Zhang R, Chen S. A hybrid plasmid formed by recombination of a virulence plasmid and a resistance plasmid in Klebsiella pneumoniae. J Glob Antimicrob Resist 2020; 23:466-470. [PMID: 33212284 DOI: 10.1016/j.jgar.2020.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/29/2020] [Accepted: 10/22/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE The emergence of multidrug-resistant (MDR) and hypervirulent Klebsiella pneumoniae (hvKP) facilitates simultaneous dissemination of virulence and resistance in a single event, which poses serious threat to public health. METHODS This study characterized the multidrug-resistant and moderately virulent ST11 K64 K. pneumoniae strain HB25-1 from a clinical case with microbiological and genomic approaches. Plasmids from strain HB25-1 were subjected to whole plasmid sequencing using both the Illumina NextSeq 500 sequencing platform and Nanopore MinION sequencer platforms. Klebsiella pneumoniae HB25-1 was subjected to a conjugation experiment and Galleria mellonella infection model to evaluate the transmission and virulence potential. RESULTS We report the emergence of an ST11, serotype K64 K. pneumoniae isolate, which is resistant to third-generation cephalosporin and exhibited a moderate level of virulence. WGS revealed that this strain harboured a plasmid, pHB25-1, which carried multidrug resistance genes (blaDHA-1, qnrB4, dfrA12, aadA2, sul1, aac(3)-lld, blaTEM-1, mph(E)) and virulence-encoding genes (the regulator of mucoid phenotype A gene rmpA2 and the aerobactin gene cluster iutAiucABCD). Genomic analysis indicated that pHB25-1 was formed through co-integration of structural regions located in two different plasmids, enabling it to encode both resistance and virulent phenotypes. CONCLUSION Findings in this study provide evidence of active plasmid evolution in K. pneumoniae and suggest that surveillance of multidrug-resistant and hypervirulent K. pneumoniae is urgently needed.
Collapse
Affiliation(s)
- Miaomiao Xie
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong
| | - Ning Dong
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong
| | - Kaichao Chen
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong
| | - Xuemei Yang
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong
| | - Lianwei Ye
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong
| | - Edward Wai-Chi Chan
- State Key Lab of Chemical Biology and Drug Discovery, Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Rong Zhang
- Department of Clinical Laboratory, Second Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang, Hangzhou, China.
| | - Sheng Chen
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon, Hong Kong; State Key Lab of Chemical Biology and Drug Discovery, Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong.
| |
Collapse
|
18
|
Animal Model To Study Klebsiella pneumoniae Gastrointestinal Colonization and Host-to-Host Transmission. Infect Immun 2020; 88:IAI.00071-20. [PMID: 32839189 PMCID: PMC7573435 DOI: 10.1128/iai.00071-20] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 08/17/2020] [Indexed: 02/07/2023] Open
Abstract
An important yet poorly understood facet of the life cycle of a successful pathogen is host-to-host transmission. Hospital-acquired infections (HAI) resulting from the transmission of drug-resistant pathogens affect hundreds of millions of patients worldwide. Klebsiella pneumoniae, a Gram-negative bacterium, is notorious for causing HAI, with many of these infections difficult to treat, as K. pneumoniae has become multidrug resistant. Epidemiological studies suggest that K. pneumoniae host-to-host transmission requires close contact and generally occurs through the fecal-oral route. An important yet poorly understood facet of the life cycle of a successful pathogen is host-to-host transmission. Hospital-acquired infections (HAI) resulting from the transmission of drug-resistant pathogens affect hundreds of millions of patients worldwide. Klebsiella pneumoniae, a Gram-negative bacterium, is notorious for causing HAI, with many of these infections difficult to treat, as K. pneumoniae has become multidrug resistant. Epidemiological studies suggest that K. pneumoniae host-to-host transmission requires close contact and generally occurs through the fecal-oral route. Here, we describe a murine model that can be utilized to study mucosal (oropharynx and gastrointestinal [GI]) colonization, shedding within feces, and transmission of K. pneumoniae through the fecal-oral route. Using an oral route of inoculation, and fecal shedding as a marker for GI colonization, we showed that K. pneumoniae can asymptomatically colonize the GI tract in immunocompetent mice and modifies the host GI microbiota. Colonization density within the GI tract and levels of shedding in the feces differed among the clinical isolates tested. A hypervirulent K. pneumoniae isolate was able to translocate from the GI tract and cause hepatic infection that mimicked the route of human infection. Expression of the capsule was required for colonization and, in turn, robust shedding. Furthermore, K. pneumoniae carrier mice were able to transmit to uninfected cohabitating mice. Lastly, treatment with antibiotics led to changes in the host microbiota and development of a transient supershedder phenotype, which enhanced transmission efficiency. Thus, this model can be used to determine the contribution of host and bacterial factors toward K. pneumoniae dissemination.
Collapse
|
19
|
Kubota Y, Ishioka H, Harada S, Suzuki M, Shiotsuka J, Lefor AK, Sanui M. Septic shock with emphysematous cholecystitis and disseminated infection caused by hypervirulent Klebsiella pneumoniae capsular genotype K2-ST65 in a Japanese man with diabetes mellitus: A case report. J Infect Chemother 2020; 27:350-353. [PMID: 33008737 DOI: 10.1016/j.jiac.2020.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/26/2020] [Accepted: 09/12/2020] [Indexed: 11/17/2022]
Abstract
Hypervirulent Klebsiella pneumoniae capsular genotypes K1 and K2 are common pathogens responsible for community-acquired liver abscesses and invasive infections especially in East Asia. We report a Japanese man with diabetes mellitus who rapidly developed emphysematous cholecystitis and fulminant disseminated infection with life-threatening multiple organ-system failure due to K. pneumoniae K2 strains belonging to sequence type 65. In East Asia, clinicians should be aware of fulminant infections caused by hypervirulent K2 strains in patients with community-acquired K. pneumoniae infections. Further epidemiological studies are warranted to elucidate the clinical features associated with the virulence K. pneumoniae K2 strains.
Collapse
Affiliation(s)
- Yoshifumi Kubota
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Haruhiko Ishioka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan.
| | - Sohei Harada
- Department of Infection Control and Prevention, University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Suzuki
- Department of Microbiology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Junji Shiotsuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | | | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| |
Collapse
|
20
|
Albasha AM, Osman EH, Abd-Alhalim S, Alshaib EF, Al-Hassan L, Altayb HN. Detection of several carbapenems resistant and virulence genes in classical and hyper-virulent strains of Klebsiella pneumoniae isolated from hospitalized neonates and adults in Khartoum. BMC Res Notes 2020; 13:312. [PMID: 32611369 PMCID: PMC7328261 DOI: 10.1186/s13104-020-05157-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/25/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Klebsiella pneumoniae (K. pneumoniae) involves both community-acquired and nosocomial infections. It is responsible for a wide variety of infections, including infections of the urinary tract, pneumonia, bacteremia, meningitis, wound infection and purulent abscesses. We constructed this study to detect several carbapenems resistant and virulence genes in classical and hyper-virulent strains of K. pneumoniae isolated from hospitalized neonates and adults in Khartoum state. RESULTS Seventy percent of the isolates were resistant to ceftazidime, 18(30%) to ciprofloxacin, 23(38.3%) to chloramphenicol, 24(40%) to gentamicin and 8% to imipenem, 35% were multidrug-resistant, and 7% extensively drug-resistant, all blood isolates (n = 14) were resistant to ceftazidime. entB was the most predominant virulence gene (93.3%), followed by mrkD (78.3%), kfu (60%), K2 (51.7%), magA (18.3%) and rmpA (5%). blaOXA-48 was the most predominant carbapenem-resistant gene (68.3%), followed by blaNDM (10%), blaKPC (8.3%), and blaIMP (3.3%). Eight hyper-virulent strains were positive for blaOXA-48 and two for blaNDM genes.
Collapse
Affiliation(s)
- Aalaa Mahgoub Albasha
- Department of Microbiology, College of Medical Laboratory Science, Sudan University of Science and Technology, Khartoum, Sudan.
| | - Esraa Hassan Osman
- Department of Microbiology, College of Medical Laboratory Science, Sudan University of Science and Technology, Khartoum, Sudan
| | - Saga Abd-Alhalim
- Department of Microbiology, College of Medical Laboratory Science, Sudan University of Science and Technology, Khartoum, Sudan
| | - Elianz F Alshaib
- Department of Microbiology, College of Medical Laboratory Science, Sudan University of Science and Technology, Khartoum, Sudan
| | - Leena Al-Hassan
- Department of Global Health and Infection, Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, UK
| | - Hisham N Altayb
- Biochemistry Department, Faculty of Sciences, King Abdulaziz University, Jeddah, 21452, Saudi Arabia
| |
Collapse
|
21
|
De Oliveira DMP, Forde BM, Kidd TJ, Harris PNA, Schembri MA, Beatson SA, Paterson DL, Walker MJ. Antimicrobial Resistance in ESKAPE Pathogens. Clin Microbiol Rev 2020; 23:788-99. [PMID: 32404435 DOI: 10.1111/imb.12124] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023] Open
Abstract
Antimicrobial-resistant ESKAPE ( Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) pathogens represent a global threat to human health. The acquisition of antimicrobial resistance genes by ESKAPE pathogens has reduced the treatment options for serious infections, increased the burden of disease, and increased death rates due to treatment failure and requires a coordinated global response for antimicrobial resistance surveillance. This looming health threat has restimulated interest in the development of new antimicrobial therapies, has demanded the need for better patient care, and has facilitated heightened governance over stewardship practices.
Collapse
Affiliation(s)
- David M P De Oliveira
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| | - Brian M Forde
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| | - Timothy J Kidd
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| | - Patrick N A Harris
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
- UQ Centre for Clinical Research, The University of Queensland, QLD, Australia
| | - Mark A Schembri
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| | - Scott A Beatson
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| | - David L Paterson
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
- UQ Centre for Clinical Research, The University of Queensland, QLD, Australia
| | - Mark J Walker
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| |
Collapse
|
22
|
De Oliveira DMP, Forde BM, Kidd TJ, Harris PNA, Schembri MA, Beatson SA, Paterson DL, Walker MJ. Antimicrobial Resistance in ESKAPE Pathogens. Clin Microbiol Rev 2020; 33:e00181-19. [PMID: 32404435 PMCID: PMC7227449 DOI: 10.1128/cmr.00181-19] [Citation(s) in RCA: 877] [Impact Index Per Article: 219.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Antimicrobial-resistant ESKAPE ( Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) pathogens represent a global threat to human health. The acquisition of antimicrobial resistance genes by ESKAPE pathogens has reduced the treatment options for serious infections, increased the burden of disease, and increased death rates due to treatment failure and requires a coordinated global response for antimicrobial resistance surveillance. This looming health threat has restimulated interest in the development of new antimicrobial therapies, has demanded the need for better patient care, and has facilitated heightened governance over stewardship practices.
Collapse
Affiliation(s)
- David M P De Oliveira
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| | - Brian M Forde
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| | - Timothy J Kidd
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| | - Patrick N A Harris
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
- UQ Centre for Clinical Research, The University of Queensland, QLD, Australia
| | - Mark A Schembri
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| | - Scott A Beatson
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| | - David L Paterson
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
- UQ Centre for Clinical Research, The University of Queensland, QLD, Australia
| | - Mark J Walker
- School of Chemistry and Molecular Biosciences, The University of Queensland, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, QLD, Australia
| |
Collapse
|
23
|
Muchuweti D, Muguti E, Mungazi SG. Spontaneous closure of an extensive postdebridement perineal wound in a newly diagnosed diabetic patient presenting with necrotizing fasciitis. Clin Case Rep 2020; 8:1044-1047. [PMID: 32577261 PMCID: PMC7303866 DOI: 10.1002/ccr3.2805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/28/2020] [Accepted: 02/26/2020] [Indexed: 12/19/2022] Open
Abstract
Diabetes mellitus may present for the first time with necrotizing fasciitis. Early treatment of septic shock and immediate surgical debridement reduces mortality. A diverting loop colostomy prevents soiling of extensive postdebridement wound. Local wound care together with good glycemic and infection control leads to spontaneous wound closure.
Collapse
Affiliation(s)
- David Muchuweti
- Department of SurgeryCollege of Health SciencesUniversity of ZimbabweHarareZimbabwe
| | - Edwin Muguti
- Department of SurgeryCollege of SciencesUniversity of ZimbabweHarareZimbabwe
| | | |
Collapse
|
24
|
Kim HS, Chang YJ, Chung CH. Klebsiella pneumoniae necrotizing fasciitis on the upper lip in a patient with uncontrolled diabetes. Arch Craniofac Surg 2020; 21:127-131. [PMID: 32380815 PMCID: PMC7206462 DOI: 10.7181/acfs.2019.00696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/31/2020] [Indexed: 01/04/2023] Open
Abstract
A 60-year-old woman with a history of diabetes mellitus and chronic renal failure was admitted to the hospital with severe pain in the upper lip, which began 4 days prior to admission, accompanied by a bullous lesion and suspected cellulitis in the upper lip. Immediately after admission, as the patient´s general condition worsened, tests revealed a non-ST elevated myocardial infarction, septic embolism of the lung, as well as septic shock. Her upper lip suddenly presented a gangrenous and necrotic change, which the tissue and blood culture confirmed to be a Klebsiella pneumoniae infection. After a quick response, the patient’s general condition improved. Subsequently, serial debridement was performed to effectively clear away the purulent discharge. While under general anesthesia, the process confirmed full-layer necrosis of the upper lip including the orbicularis oris muscle. Almost half of the entire upper lip sustained a full-layer skin and soft tissue defect, with scar contracture. Six months later, to correct the drooling and lip sealing following the defects, a scar release and an Abbe flap coverage were performed considering both functional and aesthetic aspects. The follow-up revealed a favorable corrective result of the upper lip drooling, and the patient was satisfied from a functional perspective.
Collapse
Affiliation(s)
- Hyeong Seop Kim
- Department of Plastic and Reconstructive Surgery, Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Yong Joon Chang
- Department of Plastic and Reconstructive Surgery, Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Chul Hoon Chung
- Department of Plastic and Reconstructive Surgery, Kangdong Sacred Heart Hospital, Seoul, Korea
| |
Collapse
|
25
|
Bruun T, Rath E, Oppegaard O, Skrede S. Beta-Hemolytic Streptococci and Necrotizing Soft Tissue Infections. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1294:73-86. [PMID: 33079364 DOI: 10.1007/978-3-030-57616-5_6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
β-hemolytic streptococci are major causes of necrotizing soft tissue infections (NSTIs), Streptococcus pyogenes (group A streptococcus; GAS) in particular. NSTIs caused by Streptococcus dysgalactiae (SD) have also been reported. In the INFECT cohort of 409 NSTIs patients, more than a third of the cases were caused by GAS (31%) or SD (7%). Risk factors of streptococcal NSTIs compared to streptococcal cellulitis have previously been largely unknown. The INFECT study confirmed blunt trauma as an important risk factor. In addition, absence of pre-existing skin lesions and a lower BMI were associated with NSTIs. The study also confirmed that septic shock is more frequent in GAS cases than in other types of NSTIs. Septic shock was also among several predictors of mortality. The role of intravenous immunoglobulin (IVIG) in streptococcal NSTIs has been unclear. In the INFECT cohort, IVIG treatment was associated with increased survival. As in other studies, a significant microbial diversity was observed, but with predominance of a few emm types. Overall, the INFECT study gives a comprehensive and contemporary picture of the clinical characteristics and the microbes involved in streptococcal NSTIs. The reported severity of disease underscores the need for new efforts aimed at identifying novel diagnostic measures and improved treatment.
Collapse
Affiliation(s)
- Trond Bruun
- Department of Clinical Science, University of Bergen, Bergen, Norway.
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
26
|
Liu TJ, Tai HC, Chien KL, Cheng NC. Predisposing factors of necrotizing fasciitis with comparison to cellulitis in Taiwan: A nationwide population-based case–control study. J Formos Med Assoc 2020; 119:18-25. [DOI: 10.1016/j.jfma.2019.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 11/29/2022] Open
|
27
|
Clinical and Molecular Characteristics of Klebsiella pneumoniae Isolates Causing Bloodstream Infections in Japan: Occurrence of Hypervirulent Infections in Health Care. J Clin Microbiol 2019; 57:JCM.01206-19. [PMID: 31434721 DOI: 10.1128/jcm.01206-19] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/16/2019] [Indexed: 01/02/2023] Open
Abstract
Although hypervirulent Klebsiella pneumoniae (hvKp) has been associated with severe community-acquired infections that occur among relatively healthy individuals, information about hvKp infections in health care settings remains limited. Here, we systematically analyzed the clinical and molecular characteristics of K. pneumoniae isolates causing bloodstream infections in a cross-sectional study. Clinical characteristics of K. pneumoniae bloodstream infections from hospitals across Japan were analyzed by a review of the medical records. Whole-genome sequencing of the causative isolates was performed. Bacterial species were confirmed and hvKp were identified using whole-genome sequencing data. Clinical characteristics of hvKp infections were compared with those of non-hvKp infections by bivariate analyses. Of 140 cases of K. pneumoniae bloodstream infections, 26 cases (18.6%) were caused by various clones of hvKp defined by the carriage of cardinal virulence genes. Molecular identification revealed that 24 (17.1%) and 14 (10%) cases were caused by Klebsiella variicola and Klebsiella quasipneumoniae, respectively. Patients with hvKp infections had higher proportions of diabetes mellitus (risk ratio [RR], 1.75; 95% confidence interval [CI], 1.05 to 2.94), and their infections had significantly higher propensity to involve pneumonia (RR, 5.85; 95% CI, 1.39 to 24.6), liver abscess (RR, 5.85; 95% CI, 1.39 to 24.6), and disseminated infections (RR, 6.58; 95% CI, 1.16 to 37.4) than infections by other isolates. More than one-half of hvKp infections were health care associated or hospital acquired, and a probable event of health care-associated transmission of hvKp was documented. hvKp isolates, which are significantly associated with severe and disseminated infections, are frequently involved in health care-associated and hospital-acquired infections in Japan.
Collapse
|
28
|
Abstract
Klebsiella pneumoniae is considered a nosocomial pathogen, usually infecting immunocompromised patients. However, a pathotype of K. pneumoniae, termed hypervirulent K. pneumoniae (hvKp), has emerged and is spreading throughout the community, causing severe, often fatal, disease in healthy individuals. Moreover, reports on multidrug-resistant hvKp isolates are increasing in frequency. It is imperative that strategies to combat hvKp begin immediately to prevent further dissemination of this new class of “superbugs.” Here, we show that bioconjugate vaccines targeting the capsule of hvKp can provide immunity and protection against extremely lethal hvKp strains. Further, we demonstrate that bioconjugation is a promising technology for rapid development of efficacious vaccines against emerging bacterial threats. Hypervirulent Klebsiella pneumoniae (hvKp) is globally disseminating as a community-acquired pathogen causing life-threatening infections in healthy individuals. The fact that a dose as little as 50 bacteria is lethal to mice illustrates the dramatic increase of virulence associated with hvKp strains compared with classical K. pneumoniae (cKp) strains, which require lethal doses greater than 107 bacteria. Until recently, these virulent strains were mostly antibiotic-susceptible. However, multidrug-resistant (MDR) hvKp strains have been emerging, spawning a new generation of hypervirulent “superbugs.” The mechanisms of hypervirulence are not fully defined, but overproduction of capsular polysaccharide significantly impedes host clearance, resulting in increased pathogenicity of hvKp strains. While there are more than 80 serotypes of K. pneumoniae, the K1 and K2 serotypes cause the vast majority of hypervirulent infections. Therefore, a glycoconjugate vaccine targeting these 2 serotypes could significantly reduce hvKp infection. Conventionally, glycoconjugate vaccines are manufactured using intricate chemical methodologies to covalently attach purified polysaccharides to carrier proteins, which is widely considered to be technically challenging. Here we report on the recombinant production and analytical characterization of bioconjugate vaccines, enzymatically produced in glycoengineered Escherichia coli cells, against the 2 predominant hypervirulent K. pneumoniae serotypes, K1 and K2. The K. pneumoniae bioconjugates are immunogenic and efficacious, protecting mice against lethal infection from 2 hvKp strains, NTUH K-2044 and ATCC 43816. This preclinical study constitutes a key step toward preventing further global dissemination of hypervirulent MDR hvKp strains.
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW To review the salient features of the management of severe skin and soft tissue infections (SSTIs), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis. RECENT FINDINGS For severe SSTIs, intensive care, source control, and broad-spectrum antimicrobials are required for the initial phase of illness. There is an increasing focus on the utility of rapid diagnostic tests to help in selection and de-escalation of antimicrobials for SSTIs. In addition, clinical prediction scores have shown promise in helping predict patients who do not require antimicrobials directed against methicillin-resistant Staphylococcus aureus. Immune status has been shown to be important in clinical outcomes of some, but not all types of SSTIs. The debate for benefits of intravenous immunoglobulin continues to be waged in the recent literature. SUMMARY Severe SSTIs are common and their management complex due to regional variation in predominant pathogens and antimicrobial resistance patterns, as well variations in host immune responses. Unique aspects of care for severe SSTIs are discussed including the role of surgical consultation and source control. The unique features of SSTIs in immunocompromised hosts are also described.
Collapse
|
30
|
Guo K, Gong W, Zheng T, Hong Z, Wu X, Ren H, Wang G, Gu G, Nthumba P, Ren J, Li J. Clinical parameters and outcomes of necrotizing soft tissue infections secondary to gastrointestinal fistulas. BMC Infect Dis 2019; 19:597. [PMID: 31288746 PMCID: PMC6617561 DOI: 10.1186/s12879-019-4248-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 07/01/2019] [Indexed: 12/14/2022] Open
Abstract
Background Necrotizing soft tissue infections (NSTIs) is severe surgical infections which can occur following trauma or abdominal surgery. NSTIs secondary to gastrointestinal (GI) fistula is a rare but severe complication. Methods A retrospective cohort study was performed on all subjects presenting with GI fistulas associated NSTIs were included. Clinical characteristics, microbiological profile, operations performed, and outcomes of patients were analyzed. Results Between 2014 and 2017, 39 patients were finally enrolled. The mean age were 46.9 years and male were the dominant. For the etiology of fistula, 25 (64.1%) of the patients was due to trauma. Overall, in-hospital death occurred in 15 (38.5%) patients. Microbiologic findings were obtained from 31 patients and Klebsiella pneumoniae was the most common species (41.0%). Eight patients were treated with an open abdomen; negative pressure wound therapy was used in 33 patients and only 2 patients received hyperbaric oxygen therapy. Younger age and delayed abdominal wall reconstruction repair were more common in trauma than in non-trauma. Non-survivors had higher APACHE II score, less source control< 48 h and lower platelet count on admission than survivors. Multiple organ dysfunction syndrome, multidrug-resistant organisms and source control failure were the main cause of in-hospital mortality. Conclusions Trauma is the main cause of GI fistulas associated NSTIs. Sepsis continues to be the most important factor related to mortality. Our data may assist providing enlightenment for quality improvement in these special populations.
Collapse
Affiliation(s)
- Kun Guo
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Wenbin Gong
- Department of General Surgery, School of Medicine, Southeast University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Tao Zheng
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Zhiwu Hong
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Xiuwen Wu
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Huajian Ren
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Gefei Wang
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Guosheng Gu
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | | | - Jianan Ren
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China.
| | - Jieshou Li
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| |
Collapse
|
31
|
Kudo M, Matono T, Morita M, Izumiya H, Ohnishi M, Hasegawa J, Izumi M, Yoshino M, Arai K, Imura H. Molecular analysis of virulence factors of hypermucoviscous Klebsiella pneumoniae in a diabetes patient with multifocal intramuscular and musculoskeletal abscesses. J Infect Chemother 2019; 26:110-114. [PMID: 31266705 DOI: 10.1016/j.jiac.2019.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/18/2019] [Accepted: 06/04/2019] [Indexed: 11/26/2022]
Abstract
Unusual community-acquired invasive Klebsiella pneumoniae infection has been reported worldwide, particularly in Asia. Recently, several virulence-associated genes of the isolates have been investigated. We report a case of multifocal intramuscular and musculoskeletal abscesses caused by K. pneumoniae in a 61-year-old male diabetes patient. A string test of the K. pneumoniae isolate, which was recovered from abscesses obtained by surgical debridement and drainage, was positive. We used whole-genome sequencing to analyze the virulence-associated gene profile of the isolate. The isolate belonged to the K2 genotype with sequence type 375. The isolate harbored rmpA and rmpA2, which induce serum resistance (hypermucoviscosity). The isolate also carried siderophores, i.e., aerobactin and salmochelin, which are associated with enhanced bacterial growth. The isolate did not harbor K1-unique virulence factors, such as colibactin, microcin, and yersiniabactin. Our K2 strain harbored a combination of virulence plasmid-associated genes-rmpA/A2 and siderophores (aerobactin and salmochelin). Hence, we advocate that essential molecular virulence factors of isolates that cannot be identified by a string test and capsular serotyping alone may exist.
Collapse
Affiliation(s)
- Masataka Kudo
- Department of General Internal Medicine, Iizuka Hospital, 3-83 Yoshio-machi, Iizuka, Fukuoka, 820-8505, Japan
| | - Takashi Matono
- Department of Infectious Diseases, Iizuka Hospital, 3-83 Yoshio-machi, Iizuka, Fukuoka, 820-8505, Japan.
| | - Masatomo Morita
- Department of Bacteriology I, National Institute of Infectious Diseases, 1-23-1 Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan
| | - Hidemasa Izumiya
- Department of Bacteriology I, National Institute of Infectious Diseases, 1-23-1 Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan
| | - Makoto Ohnishi
- Department of Bacteriology I, National Institute of Infectious Diseases, 1-23-1 Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan
| | - Junichi Hasegawa
- Department of General Internal Medicine, Iizuka Hospital, 3-83 Yoshio-machi, Iizuka, Fukuoka, 820-8505, Japan
| | - Migiwa Izumi
- Department of General Internal Medicine, Iizuka Hospital, 3-83 Yoshio-machi, Iizuka, Fukuoka, 820-8505, Japan
| | - Mai Yoshino
- Department of General Internal Medicine, Iizuka Hospital, 3-83 Yoshio-machi, Iizuka, Fukuoka, 820-8505, Japan
| | - Ken Arai
- Department of Orthopedics, Iizuka Hospital, 3-83 Yoshio-machi, Iizuka, Fukuoka, 820-8505, Japan
| | - Hiroshi Imura
- Department of General Internal Medicine, Iizuka Hospital, 3-83 Yoshio-machi, Iizuka, Fukuoka, 820-8505, Japan
| |
Collapse
|
32
|
Abstract
Hypervirulent K. pneumoniae (hvKp) is an evolving pathotype that is more virulent than classical K. pneumoniae (cKp). hvKp usually infects individuals from the community, who are often healthy. Infections are more common in the Asian Pacific Rim but are occurring globally. hvKp infection frequently presents at multiple sites or subsequently metastatically spreads, often requiring source control. hvKp has an increased ability to cause central nervous system infection and endophthalmitis, which require rapid recognition and site-specific treatment. The genetic factors that confer hvKp's hypervirulent phenotype are present on a large virulence plasmid and perhaps integrative conjugal elements. Increased capsule production and aerobactin production are established hvKp-specific virulence factors. Similar to cKp, hvKp strains are becoming increasingly resistant to antimicrobials via acquisition of mobile elements carrying resistance determinants, and new hvKp strains emerge when extensively drug-resistant cKp strains acquire hvKp-specific virulence determinants, resulting in nosocomial infection. Presently, clinical laboratories are unable to differentiate cKp from hvKp, but recently, several biomarkers and quantitative siderophore production have been shown to accurately predict hvKp strains, which could lead to the development of a diagnostic test for use by clinical laboratories for optimal patient care and for use in epidemiologic surveillance and research studies.
Collapse
Affiliation(s)
- Thomas A Russo
- Department of Medicine, University at Buffalo-State University of New York, Buffalo, New York, USA
- Department of Microbiology and Immunology, University at Buffalo-State University of New York, Buffalo, New York, USA
- The Witebsky Center for Microbial Pathogenesis, University at Buffalo-State University of New York, Buffalo, New York, USA
- The Veterans Administration Western New York Healthcare System, Buffalo, New York, USA
| | - Candace M Marr
- Department of Medicine, University at Buffalo-State University of New York, Buffalo, New York, USA
- Erie County Medical Center, Buffalo, New York, USA
| |
Collapse
|
33
|
Community-acquired liver abscess caused by capsular genotype K2-ST375 hypervirulent Klebsiella pneumoniae isolates. IDCases 2019; 17:e00577. [PMID: 31293894 PMCID: PMC6595073 DOI: 10.1016/j.idcr.2019.e00577] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/12/2019] [Accepted: 06/12/2019] [Indexed: 11/24/2022] Open
Abstract
Hypervirulent Klebsiella pneumoniae has been associated with community-acquired liver abscesses in relatively healthy subjects since the 1990s, occasionally accompanied by disseminated disease. While isolates of capsular genotype K1 belonging to sequence type (ST) 23 have been the most prominent causative pathogen of this syndrome, other virulent clones have been implicated sporadically in recent years. A 68-year-old woman with diabetes in Okinawa, Japan suffered from a K. pneumoniae liver abscess, which recurred after a prolonged antibacterial treatment. The clinical course was further complicated with multiple sites of dissemination. Another 45-year-old woman living in Okinawa without underlying conditions was also diagnosed with a community-acquired K. pneumoniae liver abscess, which was cured with antibacterial treatment alone. Both of the causative isolates carried rmpA and aerobactin genes, and were confirmed as capsular genotype K2 and ST375. K. pneumoniae K2-ST375 is a hypervirulent clone of epidemiological significance causing severe community-acquired infections in relatively healthy subjects. More information about clinical characteristics and molecular epidemiology of hypervirulent K. pneumoniae clones other than K1-ST23 should be accumulated.
Collapse
|
34
|
Abstract
PURPOSE OF REVIEW Two pathotypes of Klebsiella pneumoniae cause human infections, classical (cKp) and hypervirulent (hvKp) K. pneumoniae. The present understanding of genetic elements, the need for an accurate test to identify hvKp, the clinical implications of infection, the knowledge gap on how and why hvKp colonization transitions to infection, and potential infection prevention and control issues for hvKp are discussed. RECENT FINDINGS Infections because of hvKp are increasingly recognized worldwide. Its ability to cause organ and life-threatening disease in healthy individuals from the community merits concern, which has been magnified by increasing descriptions of multiply drug-resistant (MDR) and extensively drug-resistant (XDR) strains. Increased capsule and siderophore production by hvKp relative to cKp are critical virulence traits. Asians are most commonly infected, but whether this is mediated by a genetic susceptibility, or increased exposure and colonization is unknown. Specific studies about the epidemiology and transmission of hvKp are lacking, but precautions are appropriate for MDR/XDR strains and perhaps all infected/colonized individuals. SUMMARY hvKp is evolving into an increasingly concerning pathogen, in part because of the development of XDR strains. An accurate test to identify hvKp is needed for optimal clinical care, epidemiological, and research studies. An improved understanding of how infection develops, if a genetic susceptibility exists, and appropriate infection prevention and control measures also are needed.
Collapse
|
35
|
Rahim G, Gupta N, Maheshwari P, Singh M. Monomicrobial Klebsiella pneumoniae necrotizing fasciitis: an emerging life-threatening entity. Clin Microbiol Infect 2019; 25:316-323. [DOI: 10.1016/j.cmi.2018.05.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/05/2018] [Accepted: 05/12/2018] [Indexed: 10/16/2022]
|
36
|
Liu C, Guo J. Hypervirulent Klebsiella pneumoniae (hypermucoviscous and aerobactin positive) infection over 6 years in the elderly in China: antimicrobial resistance patterns, molecular epidemiology and risk factor. Ann Clin Microbiol Antimicrob 2019; 18:4. [PMID: 30665418 PMCID: PMC6341648 DOI: 10.1186/s12941-018-0302-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 12/31/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The definition of hypervirulent Klebsiella pneumoniae (hvKp), traditionally regarded as hypermucoviscosity, is controversial. However, data based on both phenotype (hypermucoviscous) and genetic (aerobactin) criteria are limited. METHODS A retrospective study was conducted in 175 geriatric patients between January 2008 and January 2014. The clinical and molecular data, including antimicrobial susceptibility testing, extended-spectrum-β-lactamase (ESBL) production, virulence gene, and multilocus sequence typing of the hvKp-group (hypermucoviscosity and aerobactin positive) were compared with those of classic K. pneumoniae (cKp) isolates. RESULTS Of 175 Kp isolates, 45.7% were hvKp. In pathogenicity, K1, K2, magA, rmpA, and rmpA2 genes were strongly associated with hvKp (P < 0.01). In the hvKp group, invasive infections (P < 0.000), liver abscess (P = 0.008), abdominal infection (P = 0.002) and septic shock (P = 0.035) are significantly higher than cKp group. Patients with better nutritional status were frequently infected with hvKp. However, host inflammatory reaction is most severe in hvKp group. Patients with diabetes (odds ratio [OR] = 2.548) and digestive diseases (OR = 2.196) are more likely to be infected with hvKp. Importantly, the detection of hvKp isolates increased from January 2008 to January 2010, January 2010 to January 2012, and January 2010 to January 2014 (12, 30, and 48 isolates, respectively). Overall, 16.3% of hvKp isolates produced ESBLs and 20.0% were MDR-hvKp. Multivariate analysis implied that infection occurred in the ICU (OR = 5.826) and patients with indwelling stomach tubes (OR = 6.461) are independent risk factors for ESBL-hvKp infection. CONCLUSIONS HvKp, especially ESBL-hvKp and MDR-hvKp, is emerging in the elderly. It is essential to enhance clinical awareness and management of hvKp infections.
Collapse
Affiliation(s)
- Chao Liu
- Department of Respiratory Medicine, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jun Guo
- Department of Respiratory Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Changping District, Beijing, 102218, China. .,Department of Geriatric Respiratory Medicine, Chinese PLA General Hospital, Beijing, China.
| |
Collapse
|
37
|
Park SY, Yu SN, Lee EJ, Kim T, Jeon MH, Choo EJ, Park S, Chae JW, In Bang H, Kim TH. Monomicrobial gram-negative necrotizing fasciitis: An uncommon but fatal syndrome. Diagn Microbiol Infect Dis 2019; 94:183-187. [PMID: 30713116 DOI: 10.1016/j.diagmicrobio.2018.12.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 12/17/2018] [Accepted: 12/26/2018] [Indexed: 12/20/2022]
Abstract
This study aimed to characterize patients with monomicrobial gram-negative necrotizing fasciitis in three university hospitals in Korea. In this study, of the 115 patients with community-acquired necrotizing fasciitis, 67 (58%) had monomicrobial infections: 31 (27%) in the gram-negative group and 36 (31%) in the gram-positive group. The majority of patients in the gram-negative group were infected with Escherichia coli followed by Klebsiella pneumoniae and Vibrio vulnificus. More patients in the gram-negative group showed liver cirrhosis than those in the gram-positive group (39% vs. 14%, P = 0.02). In a multivariable logistic regression analysis, liver cirrhosis (adjusted odds ratio [aOR], 13.7; 95% confidence interval [CI], 2.9-67.0), treatment with antibiotics without surgery (aOR, 10.2; 95% CI, 2.1-48.3), and lower level of albumin (aOR 4.9; 95% CI, 1.6-14.9) were associated with 30-day mortality. Our findings suggest that gram-negative necrotizing fasciitis is more often associated with liver cirrhosis and has poorer outcomes than gram-positive necrotizing fasciitis.
Collapse
Affiliation(s)
- Se Yoon Park
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Shi Nae Yu
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Eun Jung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Tark Kim
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Min Hyok Jeon
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Eun Ju Choo
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Joon Won Chae
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Hae In Bang
- Department of Laboratory Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Tae Hyong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
38
|
Park BC, Lim HR, Shin MH. Endogenous Endophthalmitis by Hypervirulent Klebsiella Pneumoniae Invasive Syndrome. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2019. [DOI: 10.3341/jkos.2019.60.12.1334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Beom Chan Park
- Department of Ophthalmology, Chosun University College of Medicine, Gwangju, Korea
| | - Hwa Rang Lim
- Department of Ophthalmology, Chosun University College of Medicine, Gwangju, Korea
| | - Min Ho Shin
- Department of Ophthalmology, Chosun University College of Medicine, Gwangju, Korea
| |
Collapse
|
39
|
Teles AR, Montgomery S, Thomas KC. Necrotizing Fasciitis Involving Spine: Unusual Medical Emergency for Spine Surgeon. World Neurosurg 2018; 121:124-126. [PMID: 30321674 DOI: 10.1016/j.wneu.2018.10.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Necrotizing fasciitis (NF) is a surgical diagnosis characterized by a rapidly progressive soft tissue infection, widespread tissue necrosis, and associated systemic illness. Friability of the superficial fascia, dishwater-gray exudate, and absence of pus are surgical characteristics of this diagnosis. Due to rapid progression of the infection, early recognition and aggressive surgical debridement are crucial to reduce mortality. Despite being commonly seen by general, plastic, and orthopedic surgeons, NF is an extremely rare spine surgery emergency. Our objective is to report on a case of NF involving the spine and highlight this unusual surgical emergency for the spine surgeon. CASE DESCRIPTION We present a rare case of a 61-year-old woman who presented to the emergency department in septic shock. She had a 1-week history of increasing back pain before presenting to us. Computed tomography revealed extensive soft tissue emphysema with involvement of the L3 vertebral body and spina canal. She underwent emergency surgical debridement. Despite maximal medical and surgical therapies, the patient died secondary to multisystem organ failure within 36 hours of initial presentation. CONCLUSIONS To the best of our knowledge, the literature presents only 1 previous case reported involving the spine. Necrotizing fasciitis is an unusual surgical spine surgery emergency. Spine surgeons should be aware of this diagnosis in order to provide timely aggressive surgical debridement.
Collapse
Affiliation(s)
- Alisson R Teles
- McGill Scoliosis & Spine Group, McGill University, Montreal, Quebec.
| | - Spencer Montgomery
- Department of Surgery, Section of Orthopedic Surgery, University of Calgary, Alberta, Canada
| | - Kenneth C Thomas
- Department of Surgery, Section of Orthopedic Surgery, University of Calgary, Alberta, Canada
| |
Collapse
|
40
|
Hypervirulent Klebsiella pneumoniae: a Call for Consensus Definition and International Collaboration. J Clin Microbiol 2018; 56:JCM.00959-18. [PMID: 29950337 DOI: 10.1128/jcm.00959-18] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Hypervirulent Klebsiella pneumoniae strains have higher potential to cause more severe and disseminated infections than classic K. pneumoniae strains. While initially reported from East Asian countries, cases have now been identified worldwide, sometimes in conjunction with extensive drug resistance. In this issue of the Journal of Clinical Microbiology, T. A. Russo et al. (J Clin Microbiol 56:e00776-18, 2018, https://doi.org/10.1128/JCM.00776-18) validated the diagnostic accuracy of biomarkers that differentiate hypervirulent K. pneumoniae strains from classic strains. This represents a major step forward in building a consensus definition and designing international studies aimed at elucidating the global epidemiology, clinical features, and outcome of this important pathogen.
Collapse
|
41
|
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. [PMID: 30128143 PMCID: PMC6091109 DOI: 10.1186/s13756-018-0371-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/26/2018] [Indexed: 12/31/2022] Open
Abstract
Background Aerobactin is a critical factor for the hypervirulent Klebsiella pneumoniae (hvKp), but data for the aerobactin-positive genotype of hvKp in elderly persons with ventilator-associated pneumonia (VAP) is limited. The purpose of this study is to understand the risk factors and characteristics of the hvKp genotype for elderly patients with VAP. Methods A retrospective study of 73 elderly patients with Kp was conducted from November 2008 to December 2017 in two tertiary hospitals. The clinical and microbiological data, including inflammatory reaction, nutritional status, antimicrobial susceptibility testing, string test, extended-spectrum-β-lactamase (ESBL) production, virulence-associated gene (capsular serotype-specific gene and rmpA/A2,magA,aerobaction) and multilocus sequence typing, of the hvKp group defined as aerobactin positive were compared with those of classic Kp strains. Results Of 73 Kp isolates, 46.6% were hvKp. ST23 is highly prevalent in two hospitals but is not highly associated with hvKp in different hospitals. Additionally, ST23, ST37 and ST2906 are more likely to induce lethal VAP. Most hvKp strains are sensitive to common antibiotics, but the number of multidrug-resistant (MDR) hvKp is increasing. Importantly, 38.2% of hvKp isolates produced ESBLs. Hypermucoviscosity and virulence-associated genes (K1,magA and rmpA/A2) were highly clustered in the hvKp group (P < 0.001). Cancer (P = 0.004), digestive disease (P = 0.038) and surgery (P = 0.023) within 1 month are strongly associated with the VAP-hvKp group. The incidence of septic shock (P = 0.016) and Sequential Organ Failure Assessment (SOFA) scores (P < 0.001) are significantly higher in the hvKp group. Multivariate analysis indicated that cancer (odds ratio [OR] = 5.365) is an independent risk factor for VAP-hvKp infection. Conclusions The morbidity for elderly patients with VAP due to hvKp is high. MDR-HvKp is emerging, which is a great challenge for clinical practice.
Collapse
Affiliation(s)
- Chao Liu
- 1Department of Respiratory Medicine, Peking Union Medical College, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Jun Guo
- 2Department of Respiratory Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China.,3Department of Geriatric Respiratory Medicine, Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
42
|
Xu M, Fu Y, Kong H, Chen X, Chen Y, Li L, Yang Q. Bloodstream infections caused by Klebsiella pneumoniae: prevalence of bla KPC, virulence factors and their impacts on clinical outcome. BMC Infect Dis 2018; 18:358. [PMID: 30064360 PMCID: PMC6069789 DOI: 10.1186/s12879-018-3263-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 07/20/2018] [Indexed: 12/03/2022] Open
Abstract
Background Klebsiella pneumoniae bloodstream infections (BSIs) occur with significant prevalence and high mortality worldwide. Antimicrobial resistance and virulence are two main factors participating in the pathogenicity of K. pneumoniae. Here we investigated the prevalence of blaKPC and virulence factors in K. pneumoniae isolated from patients with BSIs and their association with clinical outcome. Methods The clinical data of 285 K. pneumoniae BSI cases diagnosed from January 2013 to December 2015 in a Chinese university hospital were retrospectively evaluated. The “string test” was performed to identify hypermucoviscous K. pneumoniae (HMKP). blaKPC, rmpA, magA and serotype-specific genes were detected by PCR amplification. Finally, a Cox proportional hazards model was employed to determine the predictors of 14-day mortality. Results Of these isolates, the prevalence of blaKPC and rmpA were 33.3% (95/285) and 31.6% (90/285) respectively. 69 isolates (24.2%, 69/285) were HMKP. rmpA was strongly associated with HM phenotype. The KPC-producing KP and HMKP were almost non-overlapping and only three HMKP isolates harbored blaKPC. K1 (28, 40.6%) and K2 (22, 31.9%) were the most common serotypes in HMKP. 44.9% of HMKP BSIs had origin of biliary tract infection or liver abscess. The 14-day mortality was 100% in blaKPC+/HM+ subgroup (3/3), followed by blaKPC+/HM− (39/92, 42.4%), blaKPC−/HM+ (5/66, 7.6%) and blaKPC−/HM− (7/124, 5.6%). The 14-day cumulative survival was significantly different between blaKPC+ and blaKPC− subgroup (Log-rank p < 0.001) but almost equal between blaKPC−/HM+ and blaKPC−/HM− subgroup (Log-rank p = 0.578) under the condition of comparable illness severity between blaKPC−/HM+ and blaKPC−/HM− subgroup. Independent risk factors for 14-day mortality were Pitt bacteremia score (HR 1.24, CI 95% 1.13–1.36, p < 0.001), Charlson comorbidity index (HR 1.24, CI 95% 1.09–1.41, p = 0.001), septic shock (HR 2.61, CI 95% 1.28–5.35, p = 0.009) and blaKPC (HR 2.20, CI 95% 1.06–4.54, p = 0.034). Conclusions Most of HMKP were antibiotic-susceptible and people infected received appropriate antimicrobial therapy, which may explain the favorable outcome of HMKP BSIs. The KPC-producing HMKP BSIs were scarce but life-threatening. blaKPC was valuable in predicting 14-day mortality. Electronic supplementary material The online version of this article (10.1186/s12879-018-3263-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Min Xu
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Center of Clinical Laboratory, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yiqi Fu
- Department of Respiratory Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Haishen Kong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiao Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yu Chen
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Center of Clinical Laboratory, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Qing Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.
| |
Collapse
|
43
|
Liu C, Shi J, Guo J. High prevalence of hypervirulent Klebsiella pneumoniae infection in the genetic background of elderly patients in two teaching hospitals in China. Infect Drug Resist 2018; 11:1031-1041. [PMID: 30104891 PMCID: PMC6074765 DOI: 10.2147/idr.s161075] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Purpose Aerobactin is a critical factor for hypervirulent Klebsiella pneumoniae (hvKp) in genetic backgrounds, but data based on the genotype for the elderly is limited. Materials and methods A retrospective study was conducted on elderly patients from June 2008 to July 2017 in 2 teaching hospitals. The clinical and microbiological data, including antimicrobial susceptibility testing, string test, extended-spectrum β-lactamase (ESBL) production, virulence gene, and multilocus sequence typing, of the hvKp group defined as aerobactin positive were compared with those of classic K. pneumoniae isolates. Results A total of 45.7% of 202 K. pneumoniae isolates were hvKp.ST23, which were predominant in 2 hospitals, but they were not highly associated with hvKp in different hospitals. Hypermucoviscosity, K1, K2, magA, and rmpA/A2 genes were highly related to hvKp (P=0.000). With regard to the host, invasive infections (P=0.000), liver abscess (P=0.000), abdominal infection (P=0.000), pneumonia (P=0.037), and septic shock (P=0.045) were significantly higher in the elderly with hvKp. In the hvKp group, patients with better nutritional status were associated with a more severe sequential organ failure assessment score and a more serious inflammation reaction. Patients with diabetes (odds ratio [OR]=2.566) are more likely to be infected with hvKp. Previous hvKp is associated with hypermucoviscosity (OR=15.249) are often paralleled with hvKp. Importantly, 26% of hvKp isolates produced ESBLs, and most of them showed a carbapenems-resistant (CR) phenotype. Multivariate analysis implied that patients with a history of surgery within the last 1 month (OR=15.999) is an independent risk factor for CR-hvKp infection. Conclusion The prevalence of hvKP is high in the elderly. ESBL-hvKp, especially CR-hvKp, is emerging, which is a sign that clinical awareness and infection monitoring needs to improve.
Collapse
Affiliation(s)
- Chao Liu
- Department of Respiratory Medicine, Peking Union Medical College, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Jiaojiao Shi
- Department of Respiratory Medicine, Peking University Third Hospital, Peking University, Beijing, China
| | - Jun Guo
- Department of Respiratory Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China, .,Department of Geriatric Respiratory Medicine, Chinese PLA General Hospital, Beijing, China,
| |
Collapse
|
44
|
Comparative Prevalence of blaCTX-M-15 Gene with Virulence Genes and Serotypes in Klebsiella pneumoniae. Jundishapur J Microbiol 2018. [DOI: 10.5812/jjm.61285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
45
|
Bonne SL, Kadri SS. Evaluation and Management of Necrotizing Soft Tissue Infections. Infect Dis Clin North Am 2018; 31:497-511. [PMID: 28779832 DOI: 10.1016/j.idc.2017.05.011] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite advances in antibiotic and surgical management and supportive care for necrotizing soft tissue infections, morbidity and mortality remain substantial. Although there are clinical practice guidelines in place, there still remains much variability in choice and duration of antibiotic therapy, time to initial surgical debridement, and use of adjuvant medical therapies. This article offers an overview of necrotizing soft tissue infections with a focus on current diagnostic and treatment modalities.
Collapse
Affiliation(s)
- Stephanie L Bonne
- Division of Trauma and Critical Care, Department of Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07101, USA
| | - Sameer S Kadri
- Clinical Epidemiology Section, Department of Critical Care Medicine, National Institutes of Health Clinical Center, 10 Center Drive 10/2C145, Bethesda, MD 20892, USA.
| |
Collapse
|
46
|
Are there any reasons to change our behavior in necrotizing fasciitis with the advent of new antibiotics? Curr Opin Infect Dis 2018; 30:172-179. [PMID: 28134677 DOI: 10.1097/qco.0000000000000359] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW The treatment of necrotizing fasciitis requires a multifaceted approach, consisting of surgical source control with immediate surgical debridement along with life support, clinical monitoring, and antimicrobial therapy. Many drugs are now available for the treatment of this life-threatening infectious disease, and the purpose of this review is to provide the reader with an updated overview of the newest therapeutic options. RECENT FINDINGS Because most necrotizing soft tissue infections are polymicrobial, broad-spectrum coverage is advisable. Acceptable monotherapy regimens include piperacillin-tazobactam or a carbapenem. However, drugs such as ceftolozane-tazobactam, ceftazidime-avibactam in association with an antianaerobic agent (metronidazole or clindamycin) are currently available as valuable alternatives. The new cephalosporins active against methicillin-resistant Staphylococcus aureus (MRSA), ceftaroline, and ceftobiprole share similar antibacterial activity against Gram-positive cocci, and they might be considered as an alternative to nonbetalactam anti-MRSA agents for necrotizing fasciitis management. Two new long-acting lypoglycopeptides - oritavancin and dalbavancin - share the indications for acute bacterial skin and skin structure infections and had similar activity against Gram-positive cocci including MRSA and streptococci. SUMMARY Carbapenem-sparing agents are particularly suitable for antimicrobial stewardship strategy. The new long-acting lypoglycopeptides are very effective in treating necrotizing fasciitis and are uttermost attractive for patients requiring short hospital stays and early discharge.
Collapse
|
47
|
Lee CR, Lee JH, Park KS, Jeon JH, Kim YB, Cha CJ, Jeong BC, Lee SH. Antimicrobial Resistance of Hypervirulent Klebsiella pneumoniae: Epidemiology, Hypervirulence-Associated Determinants, and Resistance Mechanisms. Front Cell Infect Microbiol 2017; 7:483. [PMID: 29209595 PMCID: PMC5702448 DOI: 10.3389/fcimb.2017.00483] [Citation(s) in RCA: 283] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/09/2017] [Indexed: 01/09/2023] Open
Abstract
Klebsiella pneumoniae is one of the most clinically relevant species in immunocompromised individuals responsible for community-acquired and nosocomial infections, including pneumonias, urinary tract infections, bacteremias, and liver abscesses. Since the mid-1980s, hypervirulent K. pneumoniae, generally associated with the hypermucoviscosity phenotype, has emerged as a clinically significant pathogen responsible for serious disseminated infections, such as pyogenic liver abscesses, osteomyelitis, and endophthalmitis, in a generally younger and healthier population. Hypervirulent K. pneumoniae infections were primarily found in East Asia and now are increasingly being reported worldwide. Although most hypervirulent K. pneumoniae isolates are antibiotic-susceptible, some isolates with combined virulence and resistance, such as the carbapenem-resistant hypervirulent K. pneumoniae isolates, are increasingly being detected. The combination of multidrug resistance and enhanced virulence has the potential to cause the next clinical crisis. To better understand the basic biology of hypervirulent K. pneumoniae, this review will provide a summarization and discussion focused on epidemiology, hypervirulence-associated factors, and antibiotic resistance mechanisms of such hypervirulent strains. Epidemiological analysis of recent clinical isolates in China warns the global dissemination of hypervirulent K. pneumoniae strains with extensive antibiotic resistance in the near future. Therefore, an immediate response to recognize the global dissemination of this hypervirulent strain with resistance determinants is an urgent priority.
Collapse
Affiliation(s)
- Chang-Ro Lee
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, Yongin, South Korea
| | - Jung Hun Lee
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, Yongin, South Korea
| | - Kwang Seung Park
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, Yongin, South Korea
| | - Jeong Ho Jeon
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, Yongin, South Korea
| | - Young Bae Kim
- Biotechnology Program, North Shore Community College, Danvers, MA, United States
| | - Chang-Jun Cha
- Department of Systems Biotechnology, College of Biotechnology and Natural Resources, Chung-Ang University, Anseong, South Korea
| | - Byeong Chul Jeong
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, Yongin, South Korea
| | - Sang Hee Lee
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, Yongin, South Korea
| |
Collapse
|
48
|
A Case of Rituximab-Induced Necrotizing Fasciitis and a Review of the Literature. Case Rep Hematol 2017; 2017:6971027. [PMID: 29082050 PMCID: PMC5634570 DOI: 10.1155/2017/6971027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 08/22/2017] [Indexed: 11/25/2022] Open
Abstract
Necrotizing fasciitis is a fulminant soft tissue infection characterized by rapid progression and high mortality. Rituximab is a generally well-tolerated immunosuppresive medication used for B-cell malignancies and some rheumatological disorders. We report a case of a 69-year-old male with chronic lymphocytic leukemia who suffered necrotizing fasciitis of his left lower extremity secondary to Clostridium septicum 7 weeks after treatment with rituximab. Despite immediate intravenous antimicrobial therapy and emergent fasciotomy with extensive debridement, his hospital course was complicated by septic shock and he required an above-the-knee amputation. Physicians need to be aware of the possibility of necrotizing fasciitis in patients presenting with skin infections after rituximab therapy.
Collapse
|
49
|
Virulence Characteristics of Carbapenem-Resistant Klebsiella pneumoniae Strains from Patients with Necrotizing Skin and Soft Tissue Infections. Sci Rep 2017; 7:13533. [PMID: 29051525 PMCID: PMC5648777 DOI: 10.1038/s41598-017-13524-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/22/2017] [Indexed: 12/18/2022] Open
Abstract
Two types of Klebsiella pneumoniae (KP) strains are currently emerging: hypervirulent (hvKP) strains and carbapenem-resistant (CR-KP) strains. To date, these two strain types rarely overlap. Recent reports, however, suggest that CR-KP strains are increasing in virulence. hvKP strains frequently present as highly invasive infections, such as necrotizing skin and soft tissue infections (NSSTI). To examine whether CR-KP strains with features of hvKP were present in our U.S. hospital, we retrospectively identified four cases of CR-KP NSSTI diagnosed between January 2012 and January 2016. Whole-genome sequencing was used to perform multilocus sequence typing, capsular typing, and identification of virulence and antimicrobial resistance genes. Additionally, the virulence of each isolate was determined in vitro and using murine pneumonia and subcutaneous infection models. We identified one CR-KP isolate that possessed features of hypervirulent KP, including a hypermucoviscous phenotype, K2 capsule, and resistance to phagocytosis. Of the four CR-KP isolates, two had no evidence of enhanced pathogenicity in either mouse model, demonstrating that low-virulence strains can cause NSSTI in immunosuppressed patients. The remaining two isolates exhibited low virulence in the pneumonia model but high virulence in the subcutaneous infection model, suggesting that the virulence attributes of these isolates are adapted to causing NSSTI.
Collapse
|
50
|
Metabolite Transporter PEG344 Is Required for Full Virulence of Hypervirulent Klebsiella pneumoniae Strain hvKP1 after Pulmonary but Not Subcutaneous Challenge. Infect Immun 2017; 85:IAI.00093-17. [PMID: 28717029 DOI: 10.1128/iai.00093-17] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 07/07/2017] [Indexed: 01/02/2023] Open
Abstract
Hypervirulent Klebsiella pneumoniae (hvKP) is an emerging pathotype that is capable of causing tissue-invasive and organ- and life-threatening infections in healthy individuals from the community. Knowledge on the virulence factors specific to hvKP is limited. In this report, we describe a new factor (PEG344) that increases the virulence of hvKP strain hvKP1. peg-344 is present on the hvKP1 virulence plasmid, is broadly prevalent among hvKP strains, and has increased RNA abundance when grown in human ascites. An isogenic derivative of hvKP1 (hvKP1Δpeg-344) was constructed and compared with its wild-type parent strain in in vitro, ex vivo, and infection model studies. Both survival and competition experiments with outbred CD1 mice demonstrated that PEG344 was required for full virulence after pulmonary challenge but, interestingly, not after subcutaneous challenge. In silico analysis suggested that PEG344 serves as an inner membrane transporter. Compared to hvKP1, a small but significant decrease in the growth/survival of hvKP1Δpeg-344 was observed in human ascites, but resistance to the bactericidal activity of complement was similar. These data suggested that PEG344 may transport an unidentified growth factor present in ascites. The data presented are important since they expand our limited knowledge base on virulence factors unique to hvKP, which is needed to lay the groundwork for translational approaches to prevent or treat these devastating infections.
Collapse
|