Can Klebsiella pneumoniae bloodstream infections be treated with oral (PO) antibiotics?

From the Guidelines

Klebsiella pneumoniae bloodstream infections can be treated with oral (PO) antibiotics, such as ciprofloxacin 500-750mg twice daily, in select cases where the organism is susceptible and the patient is clinically stable, but this approach should be used cautiously and typically only after initial intravenous (IV) therapy. The decision to use oral antibiotics should be based on antimicrobial susceptibility testing, as K. pneumoniae has increasing resistance patterns worldwide 1. According to the British Thoracic Society guideline, oral ciprofloxacin 500 mg or 750 mg BD can be used to treat coliforms, including Klebsiella, for 14 days 1. However, it is essential to note that oral therapy is not appropriate for critically ill patients, those with severe sepsis, endocarditis, or infections with highly resistant strains like carbapenem-resistant K. pneumoniae 1.

Key Considerations

• The patient should have clinically improved and be hemodynamically stable before transitioning to oral therapy
• The organism should be susceptible to the chosen oral antibiotic
• Blood cultures should be repeated to confirm clearance of bacteremia before transitioning to oral therapy
• The total treatment duration typically ranges from 7-14 days depending on the source of infection, clinical response, and presence of complications

Suitable Oral Options

• Fluoroquinolones (ciprofloxacin 500-750mg twice daily or levofloxacin 750mg daily)
• Trimethoprim-sulfamethoxazole (TMP-SMX) (1-2 double-strength tablets twice daily)
• Amoxicillin-clavulanate (875/125mg twice daily)

Recent Guidelines

The Italian Society of Infection and Tropical Diseases recommends the use of novel β-lactam agents, such as ceftazidime/avibactam and meropenem/vaborbactam, as first-line treatment options for infections caused by KPC-producing carbapenem-resistant Enterobacterales (CRE) 1. However, these guidelines are focused on CRE infections, and the use of oral antibiotics for K. pneumoniae bloodstream infections should be individualized based on the patient's clinical condition and the organism's susceptibility pattern.

From the FDA Drug Label

1. 1 Nosocomial Pneumonia Levofloxacin tablets are indicated for the treatment of nosocomial pneumonia due to methicillin-susceptible Staphylococcus aureus, Pseudomonas aeruginosa, Serratia marcescens, Escherichia coli, Klebsiella pneumoniae, Haemophilus influenzae, or Streptococcus pneumoniae.

2. 9 Complicated Urinary Tract Infections: 5 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of complicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis

Adult Patients: Urinary Tract Infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, Providencia rettgeri, Morganella morganii, Citrobacter diversus, Citrobacter freundii, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus epidermidis, Staphylococcus saprophyticus, or Enterococcus faecalis

Lower Respiratory Tract Infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Proteus mirabilis, Pseudomonas aeruginosa, Haemophilus influenzae, Haemophilus parainfluenzae, or penicillin-susceptible Streptococcus pneumoniae.

Klebsiella pneumoniae bloodstream infections are not explicitly mentioned in the provided drug labels as an indication for treatment with oral antibiotics.

• The labels mention Klebsiella pneumoniae as a cause of various infections, including nosocomial pneumonia, complicated urinary tract infections, and lower respiratory tract infections.
• However, bloodstream infections are not specifically listed as an indication for treatment with levofloxacin or ciprofloxacin. Therefore, based on the provided information, it is unclear if Klebsiella pneumoniae bloodstream infections can be treated with oral antibiotics 2 3.

From the Research

Treatment of Klebsiella pneumoniae Bloodstream Infections

• The treatment of Klebsiella pneumoniae bloodstream infections, particularly those caused by carbapenem-resistant strains, is a complex issue due to the limited availability of effective antibiotics 4, 5.
• Studies have investigated the use of various antibiotic regimens, including combination therapies, to treat these infections 6, 7, 8.
• The use of oral antibiotics for the treatment of Klebsiella pneumoniae bloodstream infections is not well-established, and most studies have focused on intravenous antibiotic therapies 4, 5, 6, 7, 8.

Antibiotic Regimens

• Combination therapies, such as meropenem plus vaborbactam, meropenem plus colistin, and carbapenem plus carbapenem, have shown promise in treating carbapenem-resistant Klebsiella pneumoniae infections 5.
• The use of ceftazidime-avibactam-containing regimens has been associated with reduced risk of composite endpoint (30-day mortality or nephrotoxicity) compared to colistin-containing regimens 4.
• Imipenem-tigecycline and meropenem-colistin combinations have also shown synergy against clinical isolates of carbapenem-resistant Klebsiella pneumoniae 7.

Treatment Outcomes

• The overall mortality rate for patients with carbapenemase-producing Klebsiella pneumoniae infections has been reported to be around 32.2% 8.
• Pooled clinical and microbiological success rates have been reported to be around 67.6% and 74.9%, respectively 8.
• Combination therapy has been shown to be associated with lower mortality rates compared to monotherapy 8.