Recent Trend of Necrotizing Fasciitis in Taiwan: Focus on Monomicrobial Klebsiella pneumoniae Necrotizing Fasciitis

Cheng, Nai‐Chen; Yu, Yen-Chen; Tai, Hao–Chih; Hsueh, Po-Ren; Chang, Shan-Chwen; Lai, Shau-Yan; Yi, Wen-Ching; Fang, Chi-Tai

doi:10.1093/cid/cis565

Cited by 106 publications

(102 citation statements)

References 33 publications

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“…It can also affect ambulatory persons and cause community-acquired invasive diseases, including pyogenic liver abscess, endophthalmitis, meningitis, empyema, lung abscess, and necrotizing fasciitis (4)(5)(6)(7)(8)(9). The worldwide emergence of multidrug-resistant strains and hypervirulent strains of K. pneumoniae has become an increasing clinical challenge and public health concern (10,11).…”

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Rapid and Accurate Determination of Lipopolysaccharide O-Antigen Types in Klebsiella pneumoniae with a Novel PCR-Based O-Genotyping Method

et al. 2016

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b Klebsiella pneumoniae, a Gram-negative bacillus that causes life-threatening infections in both hospitalized patients and ambulatory persons, can be classified into nine lipopolysaccharide (LPS) O-antigen serotypes. The O-antigen type has important clinical and epidemiological significance. However, K. pneumoniae O serotyping is cumbersome, and the reagents are not commercially available. To overcome the limitations of conventional serotyping methods, we aimed to create a rapid and accurate PCR method for K. pneumoniae O genotyping. We sequenced the genetic determinants of LPS O antigen from serotypes O1, O2a, O2ac, O3, O4, O5, O8, O9, and O12. We established a two-step genotyping scheme, based on the two genomic regions associated with O-antigen biosynthesis. The first set of PCR primers, which detects alleles at the wzm-wzt loci of the wb gene cluster, distinguishes between O1/O2, O3, O4, O5, O8, O9, and O12. The second set of PCR primers, which detects alleles at the wbbY region, further differentiates between O1, O2a, and O2ac. We verified the specificity of O genotyping against the O-serotype reference strains. We then tested the sensitivity and specificity of O genotyping in K. pneumoniae, using the 56 K-serotype reference strains with known O serotypes determined by an inhibition enzyme-linked immunosorbent assay (iELISA). There is a very good correlation between the O genotypes and classical O serotypes. Three discrepancies were observed and resolved by nucleotide sequencing-all in favor of O genotyping. The PCR-based O genotyping, which can be easily performed in clinical and research microbiology laboratories, is a rapid and accurate method for determining the LPS O-antigen types of K. pneumoniae isolates. Klebsiella pneumoniae is an encapsulated Gram-negative bacillus that frequently causes outbreaks of nosocomial infections in hospitalized patients (1-3). It can also affect ambulatory persons and cause community-acquired invasive diseases, including pyogenic liver abscess, endophthalmitis, meningitis, empyema, lung abscess, and necrotizing fasciitis (4-9). The worldwide emergence of multidrug-resistant strains and hypervirulent strains of K. pneumoniae has become an increasing clinical challenge and public health concern (10, 11).K. pneumoniae strains can be distinguished by their capsular polysaccharide (CPS) K-antigen types (77 serotypes) and lipopolysaccharide (LPS) O-antigen types (9 serotypes) (2). The K type and O type of K. pneumoniae both have important clinical and epidemiological significance (8, 12, 13). K1 clonal complex 23 is a newly emerged hypervirulent clade, which causes pyogenic liver abscesses with septic ocular or central nervous system complications (8,14,15). Likewise, O1 is associated with hypervirulent strains that cause pyogenic liver abscess (12). The O:K typing also helps establish the clonality of K. pneumoniae in nosocomial outbreak investigations (13). K-genotyping methods are now available for quickly and correctly determining the K types in K. pneumoniae (8,16,17). O...

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Rapid and Accurate Determination of Lipopolysaccharide O-Antigen Types in Klebsiella pneumoniae with a Novel PCR-Based O-Genotyping Method

et al. 2016

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“…[14] Necrotizing fasciitis caused by K. pneumoniae is extremely rare in the western hemisphere, but necrotizing fasciitis caused by K. pneumoniae has been increasingly reported in the past decade, with fatality rates approaching 50%. [10,[17][18][19][20][21] In the current study, the mortality rates for diabetic patients in the V. vulnificus and K. pneumoniae groups were 10.5% and 27.2%, respectively, after early surgical debridement and adequate antibiotic treatment. We considered that capsule polysaccharides and lipopolysaccharides of K. pneumoniae can cause more immunologic defect and severe infections in the hyperglycemic status than that Metastatic infections with K. pneumoniae necrotizing fasciitis, which may be a consequence of transient bacteremia, have been reported.…”

Section: Discussionmentioning

confidence: 92%

“…Capsule polysaccharides and lipopolysaccharides, such as K1 and K2, are the most virulent serotypes and important virulence factors of K. pneumoniae. [17,18,20,22] Our previous studies showed that patients with hepatic dysfunction had significant associations with V. vulnificus infections; however, V. vulnificus can also produce severe sepsis in diabetic patients with or without other chronic illnesses. [14] Necrotizing fasciitis caused by K. pneumoniae is extremely rare in the western hemisphere, but necrotizing fasciitis caused by K. pneumoniae has been increasingly reported in the past decade, with fatality rates approaching 50%.…”

Section: Discussionmentioning

confidence: 99%

“…[13][14][15][16] Necrotizing skin and soft-tissue infections caused by K. pneumoniae are often associated with liver abscesses and diabetes mellitus; specifically, diabetes mellitus was present in 62.5-100% of such patients. [10,[17][18][19][20][21] K. pneumoniae is a non-motile, rod-shaped, gram-negative bacterium with a prominent polysaccharide capsule. The polysaccharide capsule encases the entire cell surface and provides resistance against many host defense mechanisms.…”

Section: Discussionmentioning

confidence: 99%

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Necrotizing fasciitis and sepsis caused by Vibrio vulnificus and Klebsiella pneumoniae in diabetic patients

Hsu¹,

Shen²,

Yang³

et al. 2015

Biomed J

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Background: Vibrio vulnificus related necrotizing fasciitis is a fatal, rapidly progressive soft-tissue infection. Necrotizing fasciitis caused by Klebsiella pneumoniae is rare, which is indistinguishable from V. vulnificus infection in the emergency room. The purpose of this study was to compare the clinical characteristics and outcome between these two pathogens in diabetic patients. Methods:Thirty diabetic patients were retrospectively reviewed over an 8-year period. Necrotizing fasciitis caused by V. vulnificus was found in 19 patients and by K. pneumoniae in 11 patients. The demographic, clinical, and laboratory characteristics, and the outcome between diabetic patients with V. vulnificus and K. pneumoniae infections were compared. Results:Two patients in the V. vulnificus group (10.5%) and three patients in the K. pneumoniae group (27.3%) died. Fourteen patients in the V. vulnificus group (73.6%) had a history of exposure to seawater or raw seafood, and eight patients in the K. pneumoniae group (72.8%) had abrasions or chronic ulcers over the site of infection. We found that the time interval between onset of illness and presentation to the hospital was significantly shorter in the V. vulnificus group than in the K. pneumoniae group (2.47 days vs. 5.45 days, p < 0.001). Conclusions:The exposure history and the time from exposure to hospital presentation with severe sepsis syndromes should alert clinicians to distinguish between necrotizing soft-tissue infections with V. vulnificus (contact with seawater or raw seafood) and K. pneumoniae (abrasions or chronic ulcers) in diabetic patients. Infection with V. vulnificus progresses more rapidly than infection with K. pneumoniae during the initial clinical course. (Biomed J 2015;38:136-142) Key words: klebsiella pneumonia, necrotizing fasciitis, Vibrio vulnificus At a Glance Commentary Scientific background of the subjectThe purpose of this study was to compare the specific characteristics and clinical outcomes between V. vulnificus and K. pneumoniae necrotizing fasciitis.

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“…Moreover, 80% of these patients were diabetic. 9 A few fatal cases of Klebsiella NF have been reported from North America. 10 Interestingly, the cases of Klebsiella were more common among Asian population and those of Asian descent, hence raising the possibility of genetic susceptibility in these infections.…”

Section: Discussionmentioning

confidence: 99%

A case of necrotizing fasciitis due to Klebsiella following local application of steroids

Abdul

George

2016

Asian J Med Sci

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Klebsiella organisms are known to cause a spectrum of clinical syndromes in human beings which include pneumonia, urinary tract infection, abdominal infection, surgical site infection, soft tissue infection and infection of intravascular devices. The incidence is higher among immunocompromised individuals and those with chronic debilitating diseases like diabetes, alcoholism etc. We present an elderly diabetic male who developed necrotizing fasciitis of the leg following local application of steroids. The causative organism turned out to be Klebsiella, which is an unusual pathogen.Moreover, necrotizing fasciitis due to Kleibsella in the absence of other infectious foci is a rare scenario.

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Recent Trend of Necrotizing Fasciitis in Taiwan: Focus on Monomicrobial Klebsiella pneumoniae Necrotizing Fasciitis

Abstract: K. pneumoniae has become a common pathogen of monomicrobial NF in Taiwan. Physicians treating patients with monomicrobial KP-NF should be aware of the risk of concomitant distant abscesses, particularly in cases caused by genotype K1.

Cited by 106 publications

References 33 publications

Rapid and Accurate Determination of Lipopolysaccharide O-Antigen Types in Klebsiella pneumoniae with a Novel PCR-Based O-Genotyping Method

Rapid and Accurate Determination of Lipopolysaccharide O-Antigen Types in Klebsiella pneumoniae with a Novel PCR-Based O-Genotyping Method

Necrotizing fasciitis and sepsis caused by Vibrio vulnificus and Klebsiella pneumoniae in diabetic patients

A case of necrotizing fasciitis due to Klebsiella following local application of steroids

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