Treating Patients Who Have Klebsiella pneumoniae Pneumonia

Abstract

We read with interest the article on bacteremic Klebsiella pneumoniae pneumonia in alcoholics, published recently (CHEST 1995; 107:214-17). We have a relatively high prevalence of infection with K pneumoniae among patients with community-acquired pneumonia admitted to our hospital, particularly among severely ill patients needing admission to our ICU.1Feldman C Kallenbach JM Levy H et al.Community-acquired pneumonia of diverse aetiology: prognostic features in patients admitted to an intensive care unit and a “severity of illness” score.Intensive Care Med. 1989; 15: 302-307Crossref PubMed Scopus (84) Google Scholar, 2Feldman C Kallenbach JM Levy H et al.Comparison of bacteraemic community-acquired pneumonia due to S pneumoniae and K pneumoniae in an intensive care unit.Respiration. 1991; 58: 265-270Crossref PubMed Scopus (39) Google Scholar The authors state that the combination antibiotic therapy with an aminoglycoside and β-lactam antibiotic could not alter the rapidly fatal outcome of their patients. If we, however, analyze their data, it becomes apparent that most of their patients died rapidly, often within hours, and possibly before antibiotic therapy had had a chance to act. Only two of their patients survived more than 26 h; and therefore, it is likely that their patients were in the “terminal” stage of their illness, unlikely to be influenced by therapy directed against the causative agent. We conducted a study among 47 patients with various clinical entities associated with K pneumoniae bacteremia admitted to our hospital in Johannesburg, South Africa. This.3Feldman C Smith C Levy H et al.Klebsiella pneumoniae bacteraemis at an urban general hospital.J Infect. 1990; 20: 21-31Abstract Full Text PDF PubMed Scopus (38) Google Scholar in origin. Of 28 patients surviving more than 48 h of antibiotic therapy, the outcome was significantly better in patients receiving a combination of “appropriate” (agents to which the organism was susceptible) β-lactam and aminoglycoside therapy than in any of the other treatment groups (p=0.007). While this study may have, by its design, preselected less severely ill patients who survived at least 48 h, there was a significant difference in mortality between the group treated with appropriate antibiotic combination agents (zero mortality) and any of the other treatment groups (mortality of 33.3% or more). While we agree that alternative forms of therapy in Gram-negative pneumonia, such as the use of immunotherapy, need to be investigated further, we believe that early antibiotic therapy with combination aminoglycoside and β-lactam agents is essential in the initial empiric management of infections suspected as being the result of K pneumoniae, as has also been suggested in other studies from South Africa.4Hammond JMJ Potgieter PD Linton DM et al.Intensive care management of community-acquired Klebsiella pneumoniae.Respir Med. 1990; 84: 11-16Abstract Full Text PDF PubMed Scopus (20) Google Scholar