What is the management for Carbapenem-resistant Klebsiella pneumoniae (CR-KP) isolated from a rectal swab?

From the Guidelines

When a resistant Klebsiella pneumoniae is isolated from a rectal swab, the primary action should be to implement contact precautions to prevent transmission to other patients, as this represents colonization rather than active infection. The patient should be placed in a single room if possible, and healthcare workers should use gloves and gowns when providing care, as recommended by the guidelines for the diagnosis, treatment, prevention and control of infections caused by carbapenem-resistant gram-negative bacilli 1. Hand hygiene is crucial before and after patient contact. No antibiotic treatment is typically needed for colonization alone, as antibiotics would not eliminate the carrier state and might increase resistance. However, the patient should be monitored for signs of active infection such as fever or organ-specific symptoms. If infection develops, antibiotic therapy should be guided by susceptibility testing, potentially including combinations of carbapenems, polymyxins (colistin), tigecycline, or newer agents like ceftazidime-avibactam depending on the resistance pattern, as recommended by the diagnosis and management of infections caused by multidrug-resistant bacteria guideline 1. The colonization status should be documented in the patient's medical record to inform future care decisions, and infection prevention teams should be notified to monitor for potential outbreaks. This approach balances preventing transmission while avoiding unnecessary antibiotic use that could worsen antimicrobial resistance. Some key considerations for the management of patients with resistant Klebsiella pneumoniae colonization include:

• Implementing bundle interventions including contact isolation of patients with CRGNB infections or colonization in hospital settings, as recommended by the guidelines for the diagnosis, treatment, prevention and control of infections caused by carbapenem-resistant gram-negative bacilli 1
• Using single room or cohorting isolation for patients with CRGNB infections or colonization, with priority given to those with fecal or urinary incontinence, using invasive devices, or having continuous wound secretion
• Ensuring nursing staff designated to care for patients with CRGNB infections or colonization do not participate in caring for other patients
• Documenting the colonization status in the patient's medical record and notifying infection prevention teams to monitor for potential outbreaks. It is also important to consider the role of active screening for CRE carriage in hospital settings, particularly for patients with hematologic malignancy, as recommended by the guidelines for the diagnosis, treatment, prevention and control of infections caused by carbapenem-resistant gram-negative bacilli 1. Active CRE screening can help reduce the incidence of CRE infection and mortality, and should be performed in patients with a history of CRE colonization or infection, those sharing hospital wards with other patients who have CRE colonization or infection, and those expected for ICU admission. Overall, a comprehensive approach to managing resistant Klebsiella pneumoniae colonization should include contact precautions, active screening, and careful consideration of antibiotic use to balance the prevention of transmission with the risk of worsening antimicrobial resistance.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of Colistimethate for Injection, USP and other antibacterial drugs, Colistimethate for Injection, USP should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy.

The presence of resistant Klebsiella pneumoniae in a rectal swab indicates that the bacteria are not susceptible to the antibiotic.

• The isolation of resistant bacteria from a rectal swab does not necessarily indicate an infection that requires treatment.
• No treatment is indicated based on the information provided, as the rectal swab is likely a colonization rather than an infection. 2

From the Research

Resistant Klebsiella Pneumoniae Isolation

When resistant Klebsiella pneumoniae is isolated from a rectal swab, several steps can be taken to control the spread and manage the infection:

• Immediate intervention through patient isolation to prevent person-to-person transmission 3
• Enhanced environmental cleaning of the ward environment to reduce the risk of spread 3
• Adaptation of empirical antibiotic prescribing to take account of identified resistances 3
• Consideration of combination therapy with antibiotics such as colistin and fosfomycin, which has shown synergistic effects against carbapenem-resistant Klebsiella pneumoniae 4, 5

Antibiotic Treatment Options

The choice of antibiotic treatment depends on the susceptibility profile of the isolated strain and the site of infection:

• Colistin and fosfomycin may represent an important treatment option for KPC-producing K. pneumoniae otherwise resistant to traditional antibiotics 4
• Other treatment options include tigecycline, gentamicin, and ceftazidime/avibactam, although their use may be limited by pharmacokinetics/pharmacodynamics properties and side effects 6
• Novel antimicrobial options, such as plazomicin and cefiderocol, may also be considered 6

Screening and Detection

Rectal screening for Klebsiella pneumoniae carbapenemases can be performed using real-time PCR or culture on selective agar plates:

• Real-time PCR has been shown to have higher sensitivity and faster turnaround time compared to culture 7
• The use of selective agar plates, such as CHROMagar ESBL and VACC plates, can also be effective for detecting KPC-colonized patients 7