Klebsiella pneumoniae

Question

My son is 7 month old now. The diagnosis has been made in November 2010 after a really severe phase with atelectasis and pneumonia. After that and until now he is doing obviously fine and he is even overweight. Since then we gave him prophylactically ampicillin and sulbactam. At the end of january Klebsiella bacteria have been found and the antibiotic has been changed to cefuroxim. Today the actual swab showed, that the Klebsiella bacteria have not been deminished, however even multiplied and 2 stems have been detected. Our center is of the opinion, that those germs are not "illness-relevant" but however they do insist on the antibiotic therapy. This was the sole information and my questions to the members of the center were obviously unwanted. It is very contradictory. According to the antibiogram, the germs should be sensitive to ampicillin and sulbactam as well as to cefuroxim, however the swab proves otherwise. The multiplication of those facultatively pathogenic germs is after all expected to make a pneumonia again more possible in case of further multiplication (alone due to the ammonia), especially if a virus joins in or the immune system is weakened due to the ongoning antibiotic therapy? Does one assume that those germs are not in the lungs and if yes, on what is that based on? Can one treat complementarily with Ribomunyl®? Many thanks in advance

Answer

Hello,
the answer to your question is not easy. Klebsiella bacteria are ubiquitous emerging bacteria, which belong to the normal flora of i.a. the airways. On the other hand it is also known, that Klebsiella (e.g. Klebsiella pneumoniae) can cause pneumonias. To weigh these 2 facts against each other is not easy. Of course the long-term therapy with the by you mentioned antibiotics (which are administered with the aim to avoid the infection with Staphylococcus aureus, an infection which is clearly more feared in connection with CF) will for sure change the spectrum of the normal flora. Probably, those germs have been selected like this, that means that they were only able to multiply like this because other germs have been forced back by the antibiotic. The question, why these germs can not be eradicated completely by the actual effective antibiotics, can be probably answered by this, that the antibiotic dosage that you give is not a high-dosage antibiotic therapy. There are, especially also in CF-patients, regions of the body, in which the dosage of a rather prophylactically given antibiotic is not high enough in order to kill always all germs, which leads to survival of some germs and a selection. But also if one would eradicate those Klebsiella, one would see probably other germs as a colonization. Possibly one never gets the mucosa totally free of germs. Of course the question, if those germs could probably suddenly be a problem for your child, should not be denied. In here caution should be exercised as always in such patients and it is important, to go on controlling the thraot swab. That you have here now 2 stems of Klebsiella has not to be regarded negative in any case, should always be controlled however. 2 germs could also mean that the bacteria, which are impaired in the body, regrow on the aritficial agar-plate of the mircorbiological diagnostic, however one could not be superior over the other in the body due to the antiobiotic inhibition. AS I hear from your question, for you the question arises about the sense of continuing the antibiotic, Staphyloccocal-effective therapy? It is a fact that young CF-children (e.g. under one year of age) obviously profit from it. They have less infections with Staphylococci, however, many questions remain unanswered. It is o.k., however, if one follows such strategy in the intererst of the children, like your CF-center does. In case your child did not have any further lung infections caused by bacteria despite the first episode, this can be for sure traced to the antibiotic therapy. As therefore the aim has been achieved, I would continue the therapy under the mentioned controls of the throat swab.
I can not answer the question if a so-called multibacterial immuno-stimulizing drug like Ribomunyl®, with dead, not multiplying germs can help here. According to my knowledge there are at the moment no secure studies, which prove an advantage for such an immuno-stimulizing drug in such a situation.
Yours sincerely,
Olaf Sommerburg

14.04.2011