What is the best treatment for a patient with Klebsiella (Klebs) positive urosepsis and hyperchloremic metabolic acidosis?

From the Guidelines

For Klebsiella-positive urosepsis with hyperchloremic metabolic acidosis, I recommend immediate treatment with broad-spectrum antibiotics, such as intravenous meropenem 1g every 8 hours, as it is a carbapenem recommended for targeted therapy in patients with bloodstream infections and severe infections due to 3GCephRE 1.

Treatment Approach

• Start with broad-spectrum antibiotics while awaiting culture sensitivity results, as recommended by the Surviving Sepsis Campaign guidelines 1.
• Once sensitivity results are available, narrow therapy to the most appropriate antibiotic, considering the susceptibility pattern of the isolate.
• Address the metabolic acidosis with intravenous fluid resuscitation using balanced crystalloids like Lactated Ringer's solution at 20-30 ml/kg in the first hour, followed by maintenance fluids based on clinical response, as recommended by the KDIGO guidelines 1.
• Monitor serum electrolytes, renal function, and acid-base status every 4-6 hours initially.
• If severe acidosis persists (pH < 7.2), consider sodium bicarbonate administration (50-100 mEq in 1L of D5W over 4-6 hours).
• Ensure adequate source control with urinary catheterization to relieve any obstruction and consider urological consultation if indicated.

Rationale

• Klebsiella infections often produce extended-spectrum beta-lactamases, necessitating broad initial coverage.
• The hyperchloremic acidosis typically results from renal tubular dysfunction during sepsis and improves with appropriate fluid resuscitation and infection control.
• The use of meropenem is supported by the ESCMID guidelines, which recommend carbapenems as targeted therapy for patients with bloodstream infections and severe infections due to 3GCephRE 1.
• The use of balanced crystalloids, such as Lactated Ringer's solution, is recommended to avoid hyperchloremic metabolic acidosis, which can be induced by normal saline 1.

From the FDA Drug Label

Sodium Bicarbonate Injection, USP is indicated in the treatment of metabolic acidosis which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest and severe primary lactic acidosis Treatment of metabolic acidosis should, if possible, be superimposed on measures designed to control the basic cause of the acidosis Vigorous bicarbonate therapy is required in any form of metabolic acidosis where a rapid increase in plasma total CO2 content is crucial - e. g., cardiac arrest, circulatory insufficiency due to shock or severe dehydration, and in severe primary lactic acidosis or severe diabetic acidosis.

The best treatment for Klebs +ve urosepsis with hyperchloremic metabolic acidosis includes:

• Sodium bicarbonate (IV) therapy to minimize risks inherent to the acidosis itself 2
• Addressing the underlying cause of the acidosis, such as treating the sepsis and urosepsis
• Vigorous bicarbonate therapy may be required in severe cases of metabolic acidosis, such as those accompanied by shock or severe dehydration 2
• Monitoring and adjusting treatment as necessary to control the acidosis and underlying condition.

From the Research

Treatment of Klebsiella-positive Urosepsis

• The treatment of urosepsis, including Klebsiella-positive cases, should involve empirical antibiotic therapy initiated within the first hour after diagnosis 3, 4, 5.
• The choice of antibiotics should consider local resistance patterns and the expected pathogen spectrum, with broad-spectrum beta-lactam antibiotics being a common choice 3, 4, 5.
• In cases of suspected or confirmed ESBL-producing bacteria, such as Klebsiella, carbapenems or cephalosporin/beta-lactamase inhibitor combinations may be used as monotherapy 3.

Management of Hyperchloremic Metabolic Acidosis

• Hyperchloremic metabolic acidosis can be caused by renal or extrarenal factors, and its management depends on the underlying cause 6, 7.
• In cases of renal origin, treatment may involve addressing the underlying defect in renal acidification, such as with bicarbonate supplementation or treatment of underlying conditions like renal tubular acidosis (RTA) 6, 7.
• It is essential to assess urinary ammonium excretion and calculate the urine anion gap or osmolal gap to distinguish between renal and extrarenal causes of metabolic acidosis 6.

Additional Considerations

• Urosepsis treatment should also involve supportive therapy, such as stabilizing and maintaining blood pressure, and control or elimination of complicating factors like urinary tract obstruction or abscess formation 3, 4, 5.
• Interdisciplinary collaboration between urologists, intensive care specialists, and microbiologists is crucial for optimal management of urosepsis 4.
• Regular monitoring of antibiotic resistance patterns and adjustment of empiric treatment accordingly is vital to ensure effective treatment of urosepsis 3, 4, 5.