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					         Journal Reading

      Community-Acquired Klebsiella
      pneumoniae Bacteremia: Global
      Differences in Clinical Patterns
        Emerging infectious disease. Vol 8, No. 2, february 2002



本檔僅供內部教學使用        R2 黃鈴富 / VS 余文良
檔案內所使用之照片之版權仍屬於原期刊
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Introduction
 Recognized       pulmonary pathogen
   1920s~1960s   : important CAB factor
   > 1960s : decline in north America

 KP   liver abscess
  >   900 patients : taiwan
        No hepatobiliary disease
        70 % DM patients

 Community       acquired bacterial menigitis
   Liver abscess or other sites of infection
   isn’t necessary
Method
 From  January 1, 1996, to December 31,
  1997. 12 hospitals.
 >16 years of age with positive blood
  cultures for K. pneumoniae
 Antimicrobial agents and other therapeutic
  management
   Designed  by patient's physician, not the
    investigators
 Method
 CAB : positive B/C within 48 hours of admission
 Pitt bacteremia score
       Mental status, vital signs, need for MV, and recent
        cardiac arrest
   Type of infection
       Pneumonia, UTI, meningitis, wound infection, soft
        tissue infection, intraabdominal infection, and primary
        bloodstream infection
   Distinctive sites of K. pneumoniae bacteremia
       Liver abscess, meningitis, or endophthalmitis
Method
 Liver   abscesses
   Blood cultures grew K. P
   Intrahepatic abscess by echo or CT

 Meningitis
   CSF    cultures grew K. P
 Endophthalmitis
   Blood cultures grew K. P
   Decreased visual acuity, pain, hypyon, or
    severe anterior uveitis
Result
 202/455   (44.4%) : K. P CAB cases
   96 (68%) of 142 in Taiwan
   25 (43%) of 68 in the United States

   28 (39%) of 71 in Australia

   40 (34%) of 116 in South Africa

   6 (22%) of 27 in Europe

   7 (17%) of 41 in Argentina

 Taiwan   VS. other countries
   68%   vs.36%, p=0.0001
Critically ill defined as Pitt
bacteremia score >4
NS = not significant at p >0.20
pneumonia and liver abscess (2)
liver abscess and meningitis (1)
pneumonia and endophthalmitis (1)
pneumonia and meningitis (1)
NS = not significant at p >0.20
 Result
 Pneumonia        : the most common infection
   57    (28%) of 202 cases
        53 (93%) of 57 cases in Taiwan & South Africa
 Prior   antibiotic use (>24 hours) (p=0.0003)
   21    (10%) of 202 patients
      4 (4%) of 96 patients in taiwan
      2 (5%) of 40 patients in South Africa

      15 (23%) of 66 in the other countries

   Oxyimino-containing       cephalosporin : 4
        South Africa (2), Argentina(1), Taiwan(1)
Result
 ESBL
  78 (30.8%) of 253 hospital-acquired strains
  7 (3.5%) of 202 community-acquired strains
    Africa (3), Turkey (2), the United States (1), and
     Australia (1)
    6 of 7 had recent hospital exposure

    Oxyimino-containing cephalosporin used : nil
Result
 Ciprofloxacin   resistant K.P.
   25 B/C were ciprofloxacin resistant
   7 (28%) of 25 were community acquired
      All had serious underlying disease
      None had received a quinolone in the 14 days

       before hospital admission
      5 of 7 were from Taiwan
liver cirrhosis, acute cholangitis, and liver
abscess were excluded from the analysis of
liver function tests
NS = not significant at p >0.20
Result
   Community-acquired K.P. pneumonia
       Univariate analysis
            Alcoholism ( + ) : ( - ) = 18% : 4% (p=0.007)
                  All was come from South Africa or Taiwan
            HIV infection ( + ) : ( - ) = 10% : 1% (p=0.002)
       Multivariate analysis
            Residing in Africa (p=0.0001)
            Taiwan (p=0.0046)
            Alcoholism (p=0.04)
            HIV infection was not an independent factor (p=0.23)
       Mortality : 54% in Taiwan and 56% in South Africa
Critically ill defined as Pitt bacteremia score >4
NS = not significant at p >0.20
    Result
   Distinctive K. pneumoniae bacteremia syndrome
       Definition : Liver abscess, endophthalmitis, meningitis
       22 of 25 (88%) case were from Taiwan
            Liver abscess : 16
                  Diabetes mellitus : 14
            Meningitis : 4
            Liver abscess and meningitis : 1
            Endophthalmitis : 1
       3 of 25 (12%) case were from the other countries
            Liver abscess : 1 from Belgium
            Meningitis : 2 from South Africa
Result
   Distinctive K. pneumoniae bacteremia syndrome
       Univariate analysis for K.P. liver abscess
            Residing in Taiwan : 88% (p=0.0001)
            Diabetes mellitus 60% (p=0.001)
            Gender, age, previous antibiotic use, presence of underlying
             liver disease : NS
       Multivariate analysis for K.P. liver abscess
            Residence in Taiwan (p=0.0034)
            Diabetes mellitus (p=0.0058)
            Renal failure (p=0.0178)
 Discussion
 Community-acquired                 K.P. Pneumonia
   Africa     and Asia > other countries
        In this study = 53 : 4
             Taiwan : 28 (29%)
             South Africa : 25 (62%)
   Common          in alcoholics : 18%
        Limited access to health care related ???
             Reduced access to antibiotics?
        The study of aborigines from northern Australia
             35% alcoholics, suboptimal access to health-care facilities
             None of 90 CAP case had K. P. Infection
 Discussion
 K.   pneumoniae liver abscess
   Exclusively       in patients from Taiwan
          In this study = 17 : 1
   Growing        number from Asia
        >900 cases from Asian in recent 10 years
        23 cases from the US, Europe, and Australia
Discussion
 K.   pneumoniae meningitis
   Africa        and Asia > other countries
           In this study = 7 : 0
                Taiwan : 5
                South Africa : 2
                5 of 7 cases had Diabetes mellitus
      A 115 cases study of K. pneumoniae meningitis
       reported from Taiwan
           84% were community acquired
           64% had concurrent Klebsiella bacteremia
      Mortality
           71% in this study
           57% in other study
Discussion
 K.   pneumoniae endophthalmitis
   Onlyone in this study
   More common in Asia
        >50 cases in the last 10 years from Asia
        10 cases from the US, Europe, and Australia

        >50% case from Asia have had concurrent

         liver abscess
Discussion
            K. pneumoniae bacteremia
 Distinctive
  syndrome is common in Asia
   The   really reason is unknown
      Bacterial variables (phenotypic and genotypic
       differences)
      Host variables (ex. DM, alcoholism)

      Socioeconomic factors

      Genetic susceptibility (different racial groups)
Summary
   US, Europe, Argentina
       Hospital-acquired K. P. infections predominate
       Community-acquired K. P. infections
            UTI, vascular catheter infection, cholangitis
   In South Africa
       Pneumonia (especially in alcoholics) is an
        important community-acquired infection
   In Taiwan
       Community-acquired pneumonia persists
       Distinctive infections
Thanks for Your Attention

				
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