What is the effective treatment for Klebsiella infections?

Treatment of Klebsiella Infections

For Klebsiella infections, carbapenems (meropenem, imipenem/cilastatin, or doripenem) are the first-line treatment options for serious infections, while ceftazidime/avibactam or meropenem/vaborbactam should be used for KPC-producing carbapenem-resistant Klebsiella. 1

First-Line Treatment Options

For Susceptible Klebsiella

• Carbapenems:
  • Meropenem 1g IV every 8 hours 1
  • Imipenem/Cilastatin 1g IV every 8 hours 1, 2
  • Doripenem 500mg IV every 8 hours 1

For Carbapenem-Resistant Klebsiella (CRE)

• First-line options:
  • Ceftazidime/avibactam 1
  • Meropenem/vaborbactam 1

Alternative Treatment Options

Carbapenem-Sparing Regimens

• Ceftolozane/Tazobactam 1.5g IV every 8 hours + Metronidazole 500mg IV every 6 hours 1
• Piperacillin/Tazobactam 4.5g IV every 6 hours 1
• Third-generation cephalosporins (if susceptible) 1, 3

For Multidrug-Resistant Klebsiella

• Imipenem/relebactam 1
• Cefiderocol 1
• Tigecycline (for complicated skin and skin structure infections, complicated intra-abdominal infections) 4
• Combination therapy with polymyxins (colistin or polymyxin B) plus another active agent 1, 5
• Double carbapenem therapy may be considered as salvage therapy in highly resistant cases 5

Treatment Duration

• Uncomplicated infections: 5-7 days 1
• Complicated infections: 7-14 days 1, 4, 2
• Severe infections with bacteremia: 10-14 days 1

Infection Control Measures for CRE

For carbapenem-resistant Klebsiella, the CDC and HICPAC recommend an aggressive infection control strategy:

• Manage all patients with CRE using contact precautions 6
• Implement Clinical and Laboratory Standards Institute (CLSI) guidelines for detection of carbapenemase production 6
• In non-endemic areas, review microbiology records for the preceding 6-12 months to identify previously unrecognized CRE 6
• Perform active surveillance cultures of patients with epidemiologic links to persons from whom CRE have been recovered 6

Special Considerations

Site-Specific Treatment

1. Respiratory Infections:

   • Carbapenems are preferred for Klebsiella pneumonia 6, 2
   • Third- and fourth-generation cephalosporins or quinolones are alternatives 3

2. Urinary Tract Infections:

   • Imipenem/cilastatin is indicated for both complicated and uncomplicated UTIs caused by Klebsiella 2
   • For recurrent UTIs with multidrug-resistant Klebsiella, fecal microbiota transplantation may be considered in refractory cases 7

3. Intra-abdominal Infections:

   • Tigecycline is indicated for complicated intra-abdominal infections caused by Klebsiella pneumoniae 4
   • Imipenem/cilastatin is also effective for intra-abdominal infections 2

Antimicrobial Stewardship

• De-escalate broad-spectrum antibiotics once susceptibility results are available 1
• Source control (drainage of abscesses, removal of infected catheters) is essential 1
• For catheter-associated infections, catheter removal is recommended 6

Pitfalls and Caveats

1. Resistance Detection: Some Klebsiella strains with carbapenemase may show MICs in the susceptible range, requiring modified Hodge test for detection 6

2. Treatment Failure: Failure to adequately treat resistant organisms has been associated with increased mortality 6

3. Empiric Therapy: For healthcare-associated infections, complex multidrug regimens may be necessary due to the higher likelihood of resistant organisms 6

4. Immunocompromised Patients: More aggressive therapy may be needed in neutropenic patients with Klebsiella infections 6

By following these evidence-based treatment recommendations and infection control measures, clinicians can effectively manage Klebsiella infections while minimizing the risk of treatment failure and further resistance development.