1. Case Study Pathogenic Bacteriology Case #13 Team Members: Jae Kim, Roubina Tatavosian, James Muro

2. Case Summary
The patient is a 40 year-old male with multisystem failure secondary to bilaterial pneumonia.
Complained to physician three days before transfer to a hospital via helicopter of fevers, malaise, and vague respiratory symptoms.
He was given amantadine for suspected influenza.
The patients condition became progressively worse, with shortness of breath a fever to C, and he was admitted to an outside hospital 24 h prior to transfer.

3. Key Information Pointing to Diagnosis
A laboratory examination revealed liver and renal functions.
Therapy with Timentin and trimethoprim-sulfamethoxazole was begun.
On admission, he underwent a bronchoscopic examination which revealed mildly inflamed airways containing thin, watery secretions.

4. The Diagnosis for Case #13
A Gram stain of bronchial washings was obtained.
Bronchial washings is a procedure in which isotonic saline is instilled through a bronchioscope and fluid containing cells, microorganisms, or other material from the upper airways --- trachea, bronchi, bronchioles, is aspirated into a trap; the material is then centralized to concentrate the cells, stained, and examined by microscopy or cultured if infection is suspected.

5. Diagnosis for Case #13
The genus Klebsiella belongs to the tribe Klebsiellae, a member of the family Enterobacteriaceae.
Klebsiella pneumonia is a Gram-negative, non-motile, encapsulated, lactose fermenting, facultative anaerobic, rod shaped bacterium found in the normal flora of the mouth, skin, and intestines.
It is the most important member of the Klebsiella genus of Enterobacteriaceae; it is closely related to K. oxytoca from which it is distinguished by being indole negative.

6. Klebsiella pneumoniae
Scientific classification
Kingdom: Bacteria
Phylum: Protobacteria
Class: Gamma Proteobacteria
Order: Enterobacteriales
Family: Enterobacteriaceae
Genus: Klebsiella
Species: K. pneumoniae
Binomial Names: Klebsiella pneumoniae

7. Classification, Gram Stain Results, and Microscopic Appearance of Klebsiella pneumoniae
K. Pneumoniae is a community-acquired bacterial pneumoniae but S. pneumoniae is the most common cause of bacterial pneumoniae.

8. Diseases and Pathogenesis of Disease Caused by Klebsiella pneumoniae
K. pneumoniae has been a recognized pulmonary pathogen since its discovery more than 100 years ago.
A striking clinical finding concerning a new manifestation of community-acquired K. pneumoniae infections has been documented.
An unusual presentation of K. pneumoniae infection, primary bacteremic liver abscess, has been described by numerous investigators in Asia.
A third striking clinical observation is the preponderance of K. pneumoniae as a community-acquired bacterial meningitis in adults in Taiwan, even in the absence of liver abscess or other sites of infection..

9. Diagnosis/Isolation/Identification/of Klebsiella pneumoniae
NF of GI tract, but potential pathogen in other areas
TSI A/A+gas
LIA K/K
Urea +
Citrate +
MR-, VP+
Motility –
Has both O and K antigens
EMB – blue colonies on black agar

10. Therapy, Prevention and Prognosis of Patient Infected with Klebsiella pneumoniae
Virulence factors
Capsule
Adesions
Iron capturing ability
Clinical Significance
--Causes pneumoniae, mostly in immunocompromised hosts
--Permanent lung damage is a frequent occurrence (rare in other types of bacteria pneumonia)
--A major cause of nosocomial infections as septicemia and meningitis

11. Therapy, Prevention and Prognosis of Patient Infected with K
Therapy, Prevention and Prognosis of Patient Infected with K. pneumoniae
Antibiotic Selection
Cephalosporins
Carbapenems
Aminoglycosides
Quinolones
Trimethoprim/sulfamethoxazole

12. Deterrence/Prevention
Follow hospital protocol for infection control to limit spread of infection and resistance
Proper hand washing is crucial for prevent transmission from patient to patient via medical personnel
Contaminated nebulizers are a major source of hospital-acquired infection; this source has been eliminated through the use of disposable devices

13. Primary Research Article
Struve, Carson, et al, 2008, Characterization of Klebsiella pneumoniae Type 1 Fimbriae by Detection of Phase Variation during Colonization and Infection and Impact on Virulence, Infection and Immunity, vol:
Experimental setup used bacterial strains and mouse models.
What did they find:
They found that most clinical isolates
produce vast amounts of capsular
polysaccharide covering the bacterial
surface. The capsule protects the
bacteria against opsonization and phagocytosis,
and the significance of the capsule in K. pneumoniae virulence
has been demonstrated in several studies
This article relates and supports my case that K. pneumoniae is the second most common agent of gram-negative sepsis as epidemiological studies have revealed that the first step of K. pneumoniae infections is the colonization of the patient’s gastrointestinal tract.

14. Take Home Message
K. pneumoniae typically affects middle-aged and older men with debilitating diseases such as alcoholism, diabetes, or chronic bronchopulmonary disease
Typical symptoms include pneumonia, bacteremia, thrombophlebitis, urinary tract infection, cholecystitis, diarrhea, upper respiratory tract infections, wound infections, osteomyelitis, and meningitis
Diagnostics tests include McKonkey agar, Indole, Eosin-methylene Blue Agar, PCR.
Therapy is based on a third generation cephalosporins and aminoglycosides
Prognosis for K. pneumoniae has a 50% mortality rate, even with adequate therapy. The prognosis is worse in patients with alcoholism and bacteremia

15. Take Home Message
Preventive strategies and early diagnosis and treatment help to reduce morbidity.
Transmission is via air droplets.
The threat is serious in hospitals and for individuals that are diabetic and alcoholics.

16. References
Mahon, Connie R., and et al. (2007). Textbook of Diagnostic Microbiology (3rd ed.). Missouri: Saunders ElSevier, Inc.
Patterson, David L., and et al. (2002). Community-Acquired Klebsiella pneumoniae Bacteremia: Global Difference in Clinical Patterns. CDC, 8, 1-15.
Struve, Carsten, Bojer, M., & Krogfelt, K. (2008). Characterization of Klebsiella pneumoniae Type I Fimbriae by Detection of Phase Variation during Colonization and Infection and Impact on Virulence. Infection and Immunity, 76,
Umeh, Oblaamiwe. (2006). Klebsiella Infections: Treatment & Medication [Electronic version]. eMedicine 7(5), Retrieved March 10, 2009, from