Combination of pre-adapted bacteriophage therapy and antibiotics for treatment of fracture-related infection due to pandrug-resistant Klebsiella pneumoniae.

A 30-year-old bombing victim with a fracture-related pandrug-resistant Klebsiella pneumoniae infection after long-term (>700 days) antibiotic therapy is treated with a pre-adapted bacteriophage along with meropenem and colistin, followed by ceftazidime/avibactam. This salvage therapy results in objective clinical, microbiological and radiological improvement of the patient's wounds and overall condition. In support, the bacteriophage and antibiotic combination is highly effective against the patient's K. pneumoniae strain in vitro, in 7-day mature biofilms and in suspensions.

Phenotypic and Genomic Comparison of Klebsiella pneumoniae Lytic Phages: vB_KpnM-VAC66 and vB_KpnM-VAC13.

Klebsiella pneumoniae is a human pathogen that worsens the prognosis of many immunocompromised patients. Here, we annotated and compared the genomes of two lytic phages that infect clinical strains of K. pneumoniae (vB_KpnM-VAC13 and vB_KpnM-VAC66) and phenotypically characterized vB_KpnM-VAC66 (time of adsorption of 12 min, burst size of 31.49 ± 0.61 PFU/infected cell, and a host range of 20.8% of the tested strains). Transmission electronic microscopy showed that vB_KpnM-VAC66 belongs to the Myoviridae family. The genomic analysis of the phage vB_KpnM-VAC66 revealed that its genome encoded 289 proteins. When compared to the genome of vB_KpnM-VAC13, they showed a nucleotide similarity of 97.56%, with a 93% of query cover, and the phylogenetic study performed with other Tevenvirinae phages showed a close common ancestor. However, there were 21 coding sequences which differed. Interestingly, the main differences were that vB_KpnM-VAC66 encoded 10 more homing endonucleases than vB_KpnM-VAC13, and that the nucleotidic and amino-acid sequences of the L-shaped tail fiber protein were highly dissimilar, leading to different three-dimensional protein predictions. Both phages differed significantly in their host range. These viruses may be useful in the development of alternative therapies to antibiotics or as a co-therapy increasing its antimicrobial potential, especially when addressing multidrug resistant (MDR) pathogens.

Identification of a newly isolated lytic bacteriophage against K24 capsular type, carbapenem resistant Klebsiella pneumoniae isolates.

The increasing incidence of carbapenemase-producing K. pneumoniae strains (CP-Kps) in the last decade has become a serious global healthcare problem. Therapeutic options for the treatment of emerging hospital clones have drastically narrowed and therefore novel approaches must be considered. Here we have isolated and characterized a lytic bacteriophage, named vB_KpnS_Kp13, that was effective against all Verona integron-encoded metallo-ß-lactamase (VIM) producing K. pneumoniae isolates originating from hospital samples (urine, blood, sputum and faeces), belonging to the ST15 clonal lineage and expressing the K24 capsule. Morphological characterization of vB_KpnS_Kp13 showed that the newly identified phage belonged to the Siphoviridae family, and phylogenetic analysis showed that it is part of a distinct clade of the Tunavirinae subfamily. Functional analysis revealed that vB_KpnS_Kp13 had relatively short latent period times (18 minutes) compared to other K. pneumoniae bacteriophages and could degrade biofilm by more than 50% and 70% in 24 and 48 hours respectively. Complete in vivo rescue potential of the new phage was revealed in an intraperitoneal mouse model where phages were administered intraperitoneally 10 minutes after bacterial challenge. Our findings could potentially be used to develop specific anti-CP-Kps bacteriophage-based therapeutic strategies against major clonal lineages and serotypes.

Non-active antibiotic and bacteriophage synergism to successfully treat recurrent urinary tract infection caused by extensively drug-resistant Klebsiella pneumoniae.

We report a case of a 63-year-old female patient who developed a recurrent urinary tract infection (UTI) with extensively drug-resistant Klebsiella pneumoniae (ERKp). In the initial two rounds of phage therapy, phage resistant mutants developed within days. Although ERKp strains were completely resistant to sulfamethoxazole-trimethoprim, the combination of sulfamethoxazole-trimethoprim with the phage cocktail inhibited the emergence of phage resistant mutant in vitro, and the UTI of patient was successfully cured by this combination. Thus, we propose that non-active antibiotic and bacteriophage synergism (NABS) might be an alternative strategy in personalized phage therapy.

Medical grade honey for the treatment of paediatric abdominal wounds: a case series.

OBJECTIVE: Children are at high risk of injuries and wounds. The application of medical grade honey is a promising approach to improving the healing of wounds of various origin and severity. However, the use of medical grade honey in young paediatric patients remains limited. The aim of this study is to show the safety, efficacy and usefulness of medical grade honey in abdominal wounds, of different causes, in paediatric patients. METHOD: This was a prospective, observational case series evaluating five young infants with abdominal wounds at the General Hospital in Thessaloniki. All wounds were treated in the same manner with daily medical grade honey applied to the wound area and closely monitored. RESULTS: All treated wounds rapidly presented granulation tissue formation and underwent re-epithelialisation. Peripheral oedema and inflammation decreased upon initial application. Necrotic tissue was effectively debrided when present. Slough was removed and no signs of infection were detected, irrespective of initial wound presentations. Scar formation was minimal and the full range of motion was preserved in all cases. CONCLUSION: Based on this case study, medical grade honey is safe and effective in treating different abdominal wounds, including infected or dehisced wounds as well as burns. The easy application and broad applicability make medical grade honey recommendable as a first-line treatment in paediatric patients.

A Dutch Case Report of Successful Treatment of Chronic Relapsing Urinary Tract Infection with Bacteriophages in a Renal Transplant Patient.

We report a case of a 58-year-old renal transplant patient who developed a recurrent urinary tract infection with an extended-spectrum ß-lactamase (ESBL)-positive Klebsiella pneumoniae strain in the first month posttransplant. Even though it tested susceptible to carbapenems and despite repeated meropenem treatment, his infection recurred. The infection eventually evolved into epididymitis that was successfully treated with meropenem and bacteriophages. This case demonstrates the difficulty of treating relapsing ESBL-positive Gram-negative infections in renal transplant patients.

Immune stealth-driven O2 serotype prevalence and potential for therapeutic antibodies against multidrug resistant Klebsiella pneumoniae.

Emerging multidrug-resistant bacteria are a challenge for modern medicine, but how these pathogens are so successful is not fully understood. Robust antibacterial vaccines have prevented and reduced resistance suggesting a pivotal role for immunity in deterring antibiotic resistance. Here, we show the increased prevalence of Klebsiella pneumoniae lipopolysaccharide O2 serotype strains in all major drug resistance groups correlating with a paucity of anti-O2 antibodies in human B cell repertoires. We identify human monoclonal antibodies to O-antigens that are highly protective in mouse models of infection, even against heavily encapsulated strains. These antibodies, including a rare anti-O2 specific antibody, synergistically protect against drug-resistant strains in adjunctive therapy with meropenem, a standard-of-care antibiotic, confirming the importance of immune assistance in antibiotic therapy. These findings support an antibody-based immunotherapeutic strategy even for highly resistant K. pneumoniae infections, and underscore the effect humoral immunity has on evolving drug resistance.

Hyperbaric oxygen suppresses growth of Klebsiella pneumoniae and enhances effect of tigecycline in vitro.

OBJECTIVES: (1) To examine whether hyperbaric oxygen (HBO2) will inhibit growth of multidrug-resistant Klebsiella pneumoniae (MDR-K. pneumoniae) and extensively drug-resistant Klebsiella pneumoniae (XDR-K. pneumoniae); (2) To determine whether the effect of tigecycline on XDR-K. pneumoniae will be enhanced by HBO2. METHODS: The effects of 1.5 hours of treatment with normoxia (21% O2, 1 atmosphere absolute/ATA) or HBO2 (100% O2, 2 ATA) on bacterial counts of eight isolates of MDR-K. pneumoniae and eight isolates of XDR-K. pneumoniae were studied. The effects of five hours of treatment with normoxia (21% O2, 1 ATA), tigecycline (21% O2, 1 ATA), HBO2 (100% O2, 3 ATA) or HBO2 + tigecycline (100% O2, 3 ATA) on proliferation of 10 isolates of XDR-K. pneumoniae were investigated. RESULTS: HBO2 at 100% O2, 2 ATA, 1.5 hours suppressed growth of MDR-K. pneumoniae but had no effect on XDR-K. pneumoniae. HBO2 at 100% O2, 3 ATA, five hours enhanced the effects of tigecycline on XDR-K. pneumoniae. CONCLUSIONS: HBO2 in combination with or without tigecycline can be used to eliminate K. pneumoniae in vitro, and such treatment may be beneficial for patients with infections caused by K. pneumoniae.

Hemodialysis Catheter Heat Transfer for Biofilm Prevention and Treatment.

Central line-associated bloodstream infections (CLABSIs) are not easily treated, and many catheters (e.g., hemodialysis catheters) are not easily replaced. Biofilms (the source of infection) on catheter surfaces are notoriously difficult to eradicate. We have recently demonstrated that modest elevations of temperature lead to increased staphylococcal susceptibility to vancomycin and significantly soften the biofilm matrix. In this study, using a combination of microbiological, computational, and experimental studies, we demonstrate the efficacy, feasibility, and safety of using heat as an adjuvant treatment for infected hemodialysis catheters. Specifically, we show that treating with heat in the presence of antibiotics led to additive killing of Staphylococcus epidermidis with similar trends seen for Staphylococcus aureus and Klebsiella pneumoniae. The magnitude of temperature elevation required is relatively modest (45-50°C) and similar to that used as an adjuvant to traditional cancer therapy. Using a custom-designed benchtop model of a hemodialysis catheter, positioned with tip in the human vena cava as well as computational fluid dynamic simulations, we demonstrate that these temperature elevations are likely achievable in situ with minimal increased in overall blood temperature.

Use of maggot therapy for treating a diabetic foot ulcer colonized by multidrug resistant bacteria in Brazil.

This study reports the efficacy of maggot therapy in the treatment of diabetic foot ulcer infected with multidrug resistant microorganisms. A 74 year old female patient with diabetes for over 30 years, was treated with maggot therapy using larvae of Chrysomya megacephala. The microbiological samples were collected to evaluate aetiology of the infection. The therapy done for 43 days resulted in a reduction of necrosis and the ulcer's retraction of 0.7 cm [2] in area. Analysis of the bacteriological swabs revealed the presence of Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. Further studies need to be done to confirm the role of maggot therapy in wound healing using a large sample and a proper study design.

A method for generation phage cocktail with great therapeutic potential.

BACKGROUND: Bacteriophage could be an alternative to conventional antibiotic therapy against multidrug-resistant bacteria. However, the emergence of resistant variants after phage treatment limited its therapeutic application. METHODOLOGY/PRINCIPAL FINDINGS: In this study, an approach, named "Step-by-Step" (SBS), has been established. This method takes advantage of the occurrence of phage-resistant bacteria variants and ensures that phages lytic for wild-type strain and its phage-resistant variants are selected. A phage cocktail lytic for Klebsiella pneumoniae was established by the SBS method. This phage cocktail consisted of three phages (GH-K1, GH-K2 and GH-K3) which have different but overlapping host strains. Several phage-resistant variants of Klebsiella pneumoniae were isolated after different phages treatments. The virulence of these variants was much weaker [minimal lethal doses (MLD)>1.3×10(9) cfu/mouse] than that of wild-type K7 countpart (MLD = 2.5×10(3) cfu/mouse). Compared with any single phage, the phage cocktail significantly reduced the mutation frequency of Klebsiella pneumoniae and effectively rescued Klebsiella pneumoniae bacteremia in a murine K7 strain challenge model. The minimal protective dose (MPD) of the phage cocktail which was sufficient to protect bacteremic mice from lethal K7 infection was only 3.0×10(4) pfu, significantly smaller (p<0.01) than that of single monophage. Moreover, a delayed administration of this phage cocktail was still effective in protection against K7 challenge. CONCLUSIONS/SIGNIFICANCE: Our data showed that the phage cocktail was more effective in reducing bacterial mutation frequency and in the rescue of murine bacteremia than monophage suggesting that phage cocktail established by SBS method has great therapeutic potential for multidrug-resistant bacteria infection.

Hyperbaric oxygen therapy in a mouse model of implant-associated osteomyelitis.

Implant associated osteomyelitis (OM) is difficult to treat with antibiotics, and outcomes remain poor. Some reports suggest that hyperbaric oxygen treatment is a safe and effective means of treating OM. We tested this hypothesis in a murine model. Clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and Klebsiella pneumoniae were used. The mice were infected with each of the three pathogens, treated with 100% oxygen at high pressure, hyperbaric oxygen (HBO), and monitored for the ability of HBO to prevent and/or clear the OM infection. Assessments included bacterial burden of the tibias and lesion scores, as well as receptor activator of NF-κB ligand (RANKL) and myeloperoxidase (MPO) concentrations. HBO resulted in more severe lesion scores and higher RANKL and MPO concentrations for MRSA. A significant positive correlation was found between RANKL concentration and lesion score. No significant difference was found with HBO in P. aeruginosa infections and K. pneumoniae seems to either not infect bone well or get cleared before establishing an infection. The model is useful for studying OM infections caused by MRSA and P. aeruginosa, but HBO does not appear to be an efficacious treatment of an implant-associated OM infection.

Bacteriophage versus antimicrobial agents for the treatment of murine burn wound infection caused by Klebsiella pneumoniae B5055.

This study was planned to evaluate the efficacy of silver nitrate and gentamicin in the treatment of burn wound infection and to compare it with phage therapy using an isolated and well-characterized Klebsiella-specific phage, Kpn5. A full-thickness burn wound was induced in mice and infected with Klebsiella pneumoniae B5055 via the topical route. Different concentrations of silver nitrate or gentamicin were applied topically daily after establishment of infection. Phage Kpn5 mixed in hydrogel was also applied topically at an m.o.i. of 200 on the burn wound site. The efficacy of these antimicrobial agents was assessed on the basis of percentage survival of infected mice following treatment. The results showed that a single dose of phage Kpn5 resulted in a significant reduction in mortality (P<0.001). Daily applications of silver nitrate and gentamicin at 0.5 % and 1000 mg l(-1), respectively, provided significant protection (P<0.001) compared to lower concentrations of the two agents. However, the level of protection given by these two agents was lower than that given by the phage therapy. The results strongly suggest that phage Kpn5 has therapeutic utility in treating burn wound infection in mice as a single topical application of this phage was able to rescue mice from infection caused by K. pneumoniae B5055 in comparison to multiple applications of silver nitrate and gentamicin.

Evidence to support the therapeutic potential of bacteriophage Kpn5 in burn wound infection caused by Klebsiella pneumoniae in BALB/c mice.

The emergence of antibiotic-resistant bacterial strains is one of the most critical problems of modern medicine. Bacteriophages have been suggested as an alternative therapeutic agent for such bacterial infections. In the present study, we examined the therapeutic potential of phage Kpn5 in the treatment of Klebsiella pneumoniae B5055-induced burn wound infection in a mouse model. An experimental model of contact burn wound infection was established in mice employing K. pneumoniae B5055 to assess the efficacy of phage Kpn5 in vivo. Survival and stability of phage Kpn5 were evaluated in mice and the maximum phage count in various organs was obtained at 6 h and persisted until 36 h. The Kpn5 phage was found to be effective in the treatment of Klebsiella-induced burn wound infection in mice when phage was administered immediately after bacterial challange. Even when treatment was delayed up to 18 h post infection, when all animals were moribund, approximately 26.66% of the mice could be rescued by a single injection of this phage preparation. The ability of this phage to protect bacteremic mice was demonstrated to be due to the functional capabilities of the phage and not due to a nonspecific immune effect. The levels of pro-inflammatory cytokines (IL-1beta and TNF-alpha) and anti-inflammatory cytokines (IL-10) were significantly lower in sera and lungs of phage-treated mice than phage untreated control mice. The results of the present study bring out the potential of bacteriophage therapy as an alternate preventive approach to treat K. pneumoniae B5055- induced burn wound infections. This approach not only helps in the clearance of bacteria from the host but also protects against the ensuing inflammatory damage due to the exaggerated response seen in any infectious process.

Emphysematous prostatitis caused by Klebsiella pneumoniae.

Emphysematous prostatitis is a rare condition that is characterized by gas and abscess accumulation in the prostate. We report a 60-year-old man with emphysematous prostatitis caused by Klebsiella pneumoniae. He had a history of recently diagnosed diabetes mellitus and a 16-year history of alcoholic liver cirrhosis. He was admitted due to fever, dysuria and difficult urination. Physical examination revealed lower abdominal tenderness and prostatic fluctuance on digital examination. Leukocytosis, pyuria and elevated C-reactive protein were found. Abdominal radiography disclosed a collection of abnormal air pockets in the lower pelvic cavity and computed tomography scans corroborated the existence of extensive air collection in the prostate. Under the impression of emphysematous prostatitis, the patient was successfully treated with transurethral incision of the prostate and antibiotics for 6 weeks; there were no urinary sequelae during 6 months of follow-up.

The effect of dietary fish oil on survival after infection with Klebsiella pneumoniae or Streptococcus pneumoniae.

Dietary fish oil is believed to have a beneficial effect in various infections and in autoimmune disorders. This effect may correspond to an altered immune response. In order to discover whether the effect of dietary fish oil is different in various infections, we studied the survival of mice fed fish oil or corn oil supplemented diets and infected in the lungs with either Klebsiella pneumoniae or Streptococcus pneumoniae. 120 NMRI mice were divided into 4 groups, of which 2 groups were fed a fish oil supplemented diet and 2 a corn oil supplemented diet. After 6 weeks the mice were infected in the lungs with Klebsiella pneumoniae (fish oil groups and corn oil groups) or with Streptococcus pneumoniae serotype 3 (both groups). The survival rate was monitored. The experiment was performed twice. The survival of the mice fed fish oil enriched diet and infected with Klebsiella pneumoniae was significantly better compared with the mice fed corn oil enriched diet (p = 0.0001 and p = 0.0013). No difference was found between the mice fed corn oil enriched diet or fish oil enriched diet and infected with Streptococcus pneumoniae serotype 3 (p = 0.74 and p = 0.15). Our results indicate that dietary fish oil has a beneficial effect on survival of mice after experimental pneumoniae when infected with Klebsiella pneumoniae, but not after infection with Streptococcus pneumoniae serotype 3.

Retroperitoneal abscess complicated by acupuncture: case report.

With acupuncture treatment becoming an increasingly popular analgesic, there have been increasing reports on its associated complications. Although pneumothorax is the most frequently reported injury caused by acupuncture needles, infectious complications may not be uncommon. Most infectious complications show less serious clinical manifestations than pneumothorax, but retroperitoneal or intraabdominal abscess caused by acupuncture may be much more serious conditions. We experienced a 56-yr-old male diabetic patient presenting with serious retroperitoneal abscess after acupuncture treatments. Emergency operative drainage with adequate antibiotic therapy was performed. Bacterial culture of blood and closed pus specimens recovered Klebsiella pneumoniae. In addition to application of better knowledge on anatomy, appropriate antiseptic practice by practitioners will reduce many serious complications associated with acupuncture.

Klebsiella meningitis in adults: clinical features, prognostic factors and therapeutic outcomes.

Sixty adult Klebsiella meningitis patients have been identified at Kaohsiung Chang Gung Memorial Hospital in a period of 13 years. Most cases were associated with debilitating diseases, and devastating metastatic septic abscesses are common in diabetic patients with K. pneumoniae meningitis. Although the mortality rate has been significantly reduced in recent years, there has been an increase in nosocomial infections and the emergence of multi-antibiotic resistant strains. Significant prognostic factors include appropriate antibiotic therapy, the presence of septic shock, disseminated intravascular coagulation, and high cerebrospinal fluid protein levels and white blood cell counts. Initial empiric therapy with a third generation cephalosporin should be considered for community-acquired meningitis while antibiotics such as carbapenems should be considered as initial empiric therapy for patients with postneurosurgical meningitis. Early diagnosis and the use of appropriate antibiotics are of crucial importance.

Infección del tracto urinario en Pediatría Etiología y tratamiento / Urinary tract infection in pediatrics: etiology and treatment

La infección urinaria (ITU) en pediatria es frecuente y el tratamiento antibiotico inicial es empirico, basada en la sensibilidad conocida de las bacterias del medio. Para averiguar dicha sensibilidad, se seleccionaron 61 pacientes entre 4 meses y 13 años, que acudieron al Servicio de Emergencia Pediátrica del Hospital Nacional Cayetano Heredia, con cuadro clínico de ITU y urocultivo positivo. Las bacterias aisladas fueron: E. coli, en 49 cultivos(80.3 por ciento), Klebsiella sp. en 10 cultivos (16.4 por ciento) y Proteus mirabilis en 2 casos (3.3 por ciento). La sensibilidad in vitro fue de un 100 por ciento a la Gentamicina, ceftriaxone, ceftazidime, y norfloxacina; 95.9 por ciento a amikacina, 94.1 por ciento a nitrofurantoina, 91.4 por ciento a acido nalidixico, 81.7 por ciento a cefalotina, 46.6 por ciento a cotrimoxazole y 18.8 por ciento a ampicilina

[Interferon type I in protective body reactions in an experimental Klebsiella infection]. / Interferon tipa I v zashchitnykh reaktsiiakh organizma pri éksperimental'noi klebsielleznoi infektsii.

The study on mice with experimental generalized Klebsiella infection, carried out with the use of microbiologic, immunologic and pathomorphologic methods, revealed that the intraperitoneal injection of type I interferon into the animals prevented their death and led to the rapid elimination of the infective agent from their body, enhanced the phagocytic and metabolic activity of polymorphonuclear lymphocytes of their peritoneal exudate, decreased the manifestation of microcirculatory and dystrophic changes in the parenchyma of their internal organs.