概念

グラム陰性桿菌
通性嫌気性
腸内細菌科クレブシエラ属
厚い莢膜
運動能なし

肺炎の原因菌。日和見病原菌として院内感染も多い。
老人や小児の肺炎死亡例の原因菌であることが多い。
肺炎レンサ球菌(Streptococcus pneumoniae)による肺炎よりも劇症
喀痰は粘稠性
ペニシリン系薬に自然耐性

治療

WordNet

respiratory disease characterized by inflammation of the lung parenchyma (excluding the bronchi) with congestion caused by viruses or bacteria or irritants
a genus of nonmotile rod-shaped Gram-negative enterobacteria; some cause respiratory and other infections

PrepTutorEJDIC

肺炎

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/03/05 18:42:13」(JST)

wiki en

[Wiki en表示]

Klebsiella pneumoniae is a Gram-negative, non-motile, encapsulated, lactose-fermenting, facultative anaerobic, rod-shaped bacterium. Although found in the normal flora of the mouth, skin, and intestines,^[1] it can cause destructive changes to human lungs if aspirated.

In the clinical setting, it is the most significant member of the Klebsiella genus of Enterobacteriaceae.

Seven species of the Klebsiella genus, with demonstrated similarities in DNA homology are known. These are (1) Klebsiella pneumoniae, (2) Klebsiella ozaenae, (3) Klebsiella terrigena, (4) Klebsiella rhinoscleromatis, (5) Klebsiella oxytoca, (6) Klebsiella planticola, and (7) Klebsiella ornithinolytica. Of these, K oxytoca and K rhinoscleromatis have also been demonstrated in human clinical specimens.

In recent years, klebsiellae have become important pathogens in nosocomial infections.

It is closely related to K. oxytoca from which it is distinguished by being indole-negative and by its ability to grow on both melezitose and 3-hydroxybutyrate. It naturally occurs in the soil, and about 30% of strains can fix nitrogen in anaerobic conditions.^[2] As a free-living diazotroph, its nitrogen fixation system has been much-studied.

Members of the Klebsiella genus typically express 2 types of antigens on their cell surface. The first, O antigen is a component of the lipopolysaccharide (LPS), of which 9 varieties exist. The second is K antigen, a capsular polysaccharide with more than 80 varieties.^[3] Both contribute to pathogenicity and form the basis for serogrouping.

History[edit]

The Danish scientist Hans Christian Gram (1853–1938), developed the technique now known as Gram staining in 1884 to discriminate between K. pneumoniae and Streptococcus pneumoniae.

Klebsiella was named after the German bacteriologist Edwin Klebs (1834–1913).

Multiple-resistant Klebsiella pneumoniae have been killed in vivo via intraperitoneal, intravenous, or intranasal administration of phages in laboratory tests.^[4] While this treatment has been available for some time, a greater danger of bacterial resistance exists to phages than to antibiotics. Resistance to phages may cause a bloom in the number of the microbe in environment as well as among humans (if not obligate pathogenic). This is why phage therapy is used only in conjunction with antibiotics, to supplement their activity instead of replacing it altogether.^[5]

Clinical significance[edit]

K. pneumoniae can cause the disease Klebsiella pneumonia. They cause destructive changes to human lungs via inflammation and hemorrhage with cell death (necrosis) that sometimes produces a thick, bloody, mucoid sputum (currant jelly sputum). These bacteria gain access typically after a person aspirates colonizing oropharyngeal microbes into the lower respiratory tract.

As a general rule, Klebsiella infections are seen mostly in people with a weakened immune system. Most often illness affects middle-aged and older men with debilitating diseases. This patient population is believed to have impaired respiratory host defenses, including persons with diabetes, alcoholism, malignancy, liver disease, Chronic obstructive pulmonary diseases (COPD), glucocorticoid therapy, renal failure, and certain occupational exposures (such as paper mill workers). Many of these infections are obtained when a person is in the hospital for some other reason (a nosocomial infection).

The most common infection caused by Klebsiella bacteria outside the hospital is pneumonia, typically in the form of bronchopneumonia and also bronchitis. These patients have an increased tendency to develop lung abscess, cavitation, empyema, and ural adhesions. It has a high death rate of about 50% even with antimicrobial therapy. The mortality rate can be nearly 100% for persons with alcoholism and bacteremia.

In addition to pneumonia, Klebsiella can also cause infections in the urinary tract, lower biliary tract, and surgical wound sites. The range of clinical diseases includes pneumonia, thrombophlebitis, urinary tract infection (UTI), cholecystitis, diarrhea, upper respiratory tract infection, wound infection, osteomyelitis, meningitis, and bacteremia and septicemia. For patients with an invasive device in their body, contamination of the device becomes a risk; for example, respiratory support equipment and urinary catheters put patients at increased risk. Also, the use of antibiotics can be a factor that increases the risk of nosocomial infection with Klebsiella bacteria. Sepsis and septic shock can follow entry of the bacteria into the blood.

Two unusual infections of note that are from Klebsiella are rhinoscleroma and ozena. Rhinoscleroma is a chronic inflammatory process involving the nasopharynx. Ozena is a chronic atrophic rhinitis that produces necrosis of nasal mucosa and mucopurulent nasal discharge.

Research conducted at King's College, London has implicated molecular mimicry between HLA-B27 and two Klebsiella surface moleculars as the cause of ankylosing spondylitis.^[6]

New antibiotic resistant strains of K. pneumoniae are appearing, and it is increasingly found as a nosocomial infection.^[7]

Klebsiella ranks second to E. coli for urinary tract infections in older persons. It is also an opportunistic pathogen for patients with chronic pulmonary disease, enteric pathogenicity, nasal mucosa atrophy, and rhinoscleroma. Feces are the most significant source of patient infection, followed by contact with contaminated instruments.

Resistant strains[edit]

Infection with carbapenem-resistant Enterobacteriaceae (CRE) or carbapenemase-producing Enterobacteriaceae is emerging as an important challenge in health-care settings.^[8] One of many carbapenem-resistant Enterobacteriaceae (CRE) is Carbapenem-Resistant Klebsiella pneumoniae (CRKP). Over the past 10 years, a progressive increase in CRKP has been seen worldwide; however, this new emerging nosocomial pathogen is probably best known for an outbreak in Israel that began around 2006 within the healthcare system there.^[9] In the USA, it was first described in North Carolina in 1996;^[10] since then CRKP has been identified in 41 states;^[11] and is recovered routinely in certain hospitals in New York and New Jersey. It is now the most common CRE species encountered within the United States.

CRKP is resistant to almost all available antimicrobial agents, and infections with CRKP have caused high rates of morbidity and mortality, in particular among persons with prolonged hospitalization and those critically ill and exposed to invasive devices (e.g., ventilators or central venous catheters). The concern is that carbapenem is often used as a drug of last resort when battling resistant bacterial strains. The worry is that new slight mutations could result in infections for which there is very little, if anything, healthcare professionals can do to treat patients with resistant organisms.

There are a number of mechanisms of Carbapenem Resistance in Enterobacteriaceae. These include (1) Hyperproduction of ampC beta-lactamase with an outer membrane porin mutation (2) CTX-M extended-spectrum beta-lactamase with a porin mutation or drug efflux, and (3) Carbapenemase production. When Klebsiella pneumoniae bacteria produce the carbapenemase enzyme they are known as KPC-producing organisms or carbapenem-resistant Klebsiella pneumoniae (CRKP).^[12]

Put another way, the most important mechanism of resistance by CRKP is the production of a carbapenemase enzyme, blakpc. The gene that encodes the blakpc enzyme is carried on a mobile piece of genetic material (a transposon; the specific transposon involved is called Tn4401), which increases the risk for dissemination. CRE can be difficult to detect because some strains that harbor blakpc have minimal inhibitory concentrations (MICs) that are elevated but still within the susceptible range for carbapenems. Because these strains are susceptible to carbapenems, they are not identified as potential clinical or infection control risks using standard susceptibility testing guidelines. Patients with unrecognized CRKP colonization have been reservoirs for transmission during nosocomial outbreaks.

The extent and prevalence of CRKP within the environment is currently unknown. The mortality rate is also unknown but is suspected to be within a range of 12.5% to as high as 44%.^{[citation needed]} The likelihood of an epidemic or pandemic in the future remains uncertain.

The Centers for Disease Control and Prevention (CDC) released guidance for aggressive infection control to combat CRKP.

Place all patients colonized or infected with CRE or carbapenemase-producing Enterobacteriaceae on contact precautions. Acute-care facilities are to establish a protocol, in conjunction with the guidelines of the Clinical and Laboratory Standards Institute (CLSI) to detect nonsusceptibility and carbapenemase production in Enterobacteriaceae, in particular Klebsiella spp. and Escherichia coli, and immediately alert epidemiology and infection control staff members if identified. All acute-care facilities are to review microbiology records for the preceding 6--12 months to ensure that there have not been previously unrecognized CRE cases. If they do identify previously unrecognized cases, a point prevalence survey (a single round of active surveillance cultures) in units with patients at high risk (e.g., intensive-care units, units where previous cases have been identified, and units where many patients are exposed to broad-spectrum antimicrobials) is needed to identify any additional patients colonized with carbapenem-resistant or carbapenemase-producing Klebsiella spp. and E. coli. When a case of hospital-associated CRE is identified, facilities should conduct a round of active surveillance testing of patients with epidemiologic links to the CRE case (e.g., those patients in the same unit or patients having been cared for by the same health-care personnel).^[13]

One specific example of this containment policy could be seen in Israel in 2007.^[14] This policy had an intervention period from April, 2007 to May, 2008. A nationwide outbreak of CRE (which peaked in March, 2007 at 55.5 cases per 100,000 patient days) necessitated a nationwide treatment plan. The intervention entailed physical separation of all CRE carriers and appointment of a task force to oversee efficacy of isolation by closely monitoring hospitals and intervening when necessary. After the treatment plan (measured in May, 2008), the number of cases per 100,000 patient days decreased to 11.7. The plan was effective because of strict hospital compliance, wherein each was required to keep detailed documentation of all CRE carriers. In fact, for each increase in compliance by 10%, incidence of cases per 100,000 patient days decreased by 0.6. Therefore, containment on a nationwide scale requires nationwide intervention.

In the United States, the reasons that the CDC is recommending the detection of carbapenem resistance or carbapenemase production only for Klebsiella spp. and E. coli are 1) this facilitates performing the test in the microbiology laboratory without the use of molecular methods and 2) these organisms represent the majority of CRE encountered in the United States.

Effective sterilization and decontamination procedures are important to keep the infection rate of this antibiotic resistant strain, CRKP as low as possible.

Treatment[edit]

As with many bacteria, the recommended treatment has changed as the organism has developed resistances. Klebsiella organisms are often resistant to multiple antibiotics. Current evidence implicates a plasmid as the source of the resistant genes. Klebsiella with the ability to produce extended-spectrum beta-lactamases ESBL are resistant to many classes of antibiotics. The most frequent resistances include resistance to aminoglycosides, fluoroquinolones, tetracyclines, chloramphenicol, and trimethoprim/sulfamethoxazole.^[15]

The choice of a specific antimicrobial agent or agents depends on local susceptibility patterns and on the part of the body that is infected. For patients with severe infections, a prudent approach is the use of an initial short course (48-72 h) of combination therapy, followed by a switch to a specific mono-therapy once the susceptibility pattern is known for the specific patient.

If the specific Klebsiella in a particular patient does not have antibiotic resistance, then the antibiotics used to treat such susceptible isolates include ampicillin/sulbactam, piperacillin/tazobactam, ticarcillin/clavulanate, ceftazidime, cefepime, levofloxacin, norfloxacin, gatifloxacin, moxifloxacin, meropenem, and ertapenem. Some experts recommend the use of meropenem for patients with ESBL producing Klebsiella. The claim is that meropenem produces the best bacterial clearing.

The use of antibiotics is usually not enough. Surgical clearing (frequently done as interventional radiology drainage) is often needed after the patient is started on antimicrobial agents. Preventing Klebsiella from spreading: To prevent spreading Klebsiella infections between patients, healthcare personnel must follow specific infection control precautions: [Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007].^[16] These precautions may include strict adherence to hand hygiene and wearing gowns and gloves when they enter rooms where patients with Klebsiella–related illnesses are housed. Healthcare facilities also must follow strict cleaning procedures to prevent the spread of Klebsiella.

To prevent the spread of infections, patients also should clean their hands very often, including:

Before preparing or eating food
Before touching their eyes, nose, or mouth
Before and after changing wound dressings or bandages
After using the restroom
After blowing their nose, coughing, or sneezing
After touching hospital surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone.

References[edit]

^ Ryan, KJ; Ray, CG, eds. (2004). Sherris Medical Microbiology (4th ed.). McGraw Hill. ISBN 0-8385-8529-9.
^ Postgate, J (1998). Nitrogen Fixation (3rd ed.). Cambridge University Press. ISBN 978-0521640473.
^ Podschun, R; Ullmann, U (October 1998). "Klebsiella spp. as Nosocomial Pathogens: Epidemiology, Taxonomy, Typing Methods, and Pathogenicity Factors". Clinical Microbiology Reviews 11 (4): 589–603. PMC 88898.
^ Bogovazova, GG; Voroshilova, NN; Bondarenko, VM (April 1991). "The efficacy of Klebsiella pneumoniae bacteriophage in the therapy of experimental Klebsiella infection". Zhurnal mikrobiologii, epidemiologii, i immunobiologii (in Russian) (Russia: Moskva) (4): 5–8. ISSN 0372-9311. PMID 1882608.
^ Chanishvili, N, ed. (2012). A Literature Review of the Practical Application of Bacteriophage Research. Hauppauge, NY: Nova Science. ISBN 9781621008514.
^ Rashid, T; Ebringer, A (June 2007). "Ankylosing spondylitis is linked to Klebsiella--the evidence". Clinical Rheumatology 26 (3): 858–864. doi:10.1007/s10067-006-0488-7. PMID 17186116.
^ Groopman, J (2008-08-11). "Superbugs". The New Yorker. Retrieved 2013-07-07. "The new generation of resistant infections is almost impossible to treat."
^ Limbago, BM; Rasheed, JK; Anderson, KF; Zhu, W et al. (December 2011) [Epub 2011-10-12]. "IMP-Producing Carbapenem-Resistant Klebsiella pneumoniae in the United States". Journal of Clinical Microbiology 49 (12): 4239–4245. doi:10.1128/JCM.05297-11. PMC 3233008. PMID 21998425.
^ Berrie, C (2007-04-04). "Carbapenem-resistant Klebsiella pneumoniae outbreak in an Israeli hospital". Medscape. Medical News. WebMD. Retrieved 2013-07-07.
^ Yigit, H; Queenan, AM; Anderson, GJ; Domenech-Sanchez, A et al. (April 2001). "Novel carbapenem-hydrolyzing beta-lactamase, KPC-1, from a carbapenem-resistant strain of Klebsiella pneumoniae". Antimicrobial Agents and Chemotherapy 45 (4): 1151–1161. doi:10.1128/AAC.45.4.1151-1161.2001. PMC 90438.
^ Vastag, Brian (2012-08-22). "‘Superbug’ stalked NIH hospital last year, killing six". The Washington Post. Retrieved 2013-07-07.
^ Los Angeles County Department of Public Health. "Diseases & Conditions: Carbapenem-Resistant Klebsiella Pneumoniae (CRKP)". lacounty.gov. Acute Communicable Disease Control. Retrieved 2013-07-07.
^ Lledo, W; Hernandez, M; Lopez, E; Molinari, OL et al. (2009-03-20). "Guidance for Control of Infections with Carbapenem-Resistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities". Morbidity and Mortality Weekly Report (CDC) 58 (10): 256–260.
^ Schwaber, MJ; Lev, B; Israeli, A; Solter, E et al. (2011-04-01) [Epub 2011-02-11]. "Containment of a country-wide outbreak of carbapenem-resistant Klebsiella pneumoniae in Israeli hospitals via a nationally implemented intervention". Clinical Infectious Diseases 52 (7): 848–855. doi:10.1093/cid/cir025. PMID 21317398.
^ Nathisuwan, S; Burgess, DS; Lewis, JS (August 2001) [Epub 2012-01-07]. "Extended-Spectrum β-Lactamases: Epidemiology, Detection, and Treatment". Pharmacotherapy 21 (8): 920–928. doi:10.1592/phco.21.11.920.34529.
^ http://www.cdc.gov/HAI/organisms/klebsiella/klebsiella.html

External links[edit]

Wikispecies has information related to: Klebsiella pneumoniae

Wikimedia Commons has media related to Klebsiella pneumoniae.

Virtual museum of bacteria page on K. pneumoniae
What're the complications of pneumonia? (health-cares.net)
Klebsiella Infection (emedicine.com)
Klebsiella Genome Projects from Genomes OnLine Database
Klebsiella pneumoniae-Associated Vertebral Osteomyelitis After Laparoscopic Cholecystectomy

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

1. 肺炎桿菌（肺炎クレブシエラ）感染症の臨床的特徴、診断、および治療 clinical features diagnosis and treatment of klebsiella pneumoniae infection
2. 肺炎桿菌感染症の微生物学および病因 microbiology and pathogenesis of klebsiella pneumoniae infection
3. 肺炎桿菌による浸潤性肝膿瘍症候群 invasive liver abscess syndrome caused by klebsiella pneumoniae
4. 成人におけるグラム陰性桿菌菌血症 gram negative bacillary bacteremia in adults
5. カルバペネマーゼ carbapenemases

English Journal

Time-kill synergy tests of tigecycline combined with imipenem, amikacin, and ciprofloxacin against clinical isolates of multidrug-resistant Klebsiella pneumoniae and Escherichia coli.

Yim H, Woo H, Song W, Park MJ, Kim HS, Lee KM, Hur J, Park MS.SourceDepartment of Burn Surgery, Hallym University Medical Center and College of Medicine, Seoul, Korea.
Annals of clinical and laboratory science.2011 Fall;41(1):39-43.
This study evaluated the activity of tigecycline combined with imipenem, amikacin, and ciprofloxacin against clinical isolates of multidrug-resistant Klebsiella pneumoniae and Escherichia coli co-producing extended-spectrum β-lactamases and acquired AmpC β-lactamases. Broth microdilution tests wer
PMID 21325253

An atomic force microscopy study of Galleria mellonella apolipophorin III effect on bacteria.

Zdybicka-Barabas A, Januszanis B, Mak P, Cytry?ska M.AbstractApolipophorin III (apoLp-III) is an abundant hemolymph protein involved in lipid transport and immune response in insects. As revealed by LIVE/DEAD staining, incubation of Gram-negative and Gram-positive bacteria in the presence of Galleria mellonella apoLp-III led to growth inhibition of selected bacteria. An atomic force microscopy (AFM) study of bacterial cells after apoLp-III treatment showed considerable alterations in the cell surface of Bacillus circulans, Klebsiella pneumoniae and Salmonella typhimurium. Our results clearly demonstrate that apoLp-III disturbed the proper structure of the bacterial cell surface. The alterations were dissimilar to those caused by cationic antimicrobial peptide, cecropin B, suggesting a different mode of action against bacteria. The present results indicate that AFM provides a powerful tool for studying the interactions of apoLp-III with microbial cells.
Biochimica et biophysica acta.2011 Jul;1808(7):1896-906. Epub 2011 Mar 28.
Apolipophorin III (apoLp-III) is an abundant hemolymph protein involved in lipid transport and immune response in insects. As revealed by LIVE/DEAD staining, incubation of Gram-negative and Gram-positive bacteria in the presence of Galleria mellonella apoLp-III led to growth inhibition of selected b
PMID 21453676

Bacterial decolorization and detoxification of black liquor from rayon grade pulp manufacturing paper industry and detection of their metabolic products.

Chandra R, Abhishek A, Sankhwar M.SourceEnvironmental Microbiology Section, Indian Institute of Toxicology Research (CSIR), Post Box 80, M.G. Marg, Lucknow 226001, Uttar Pradesh, India.
Bioresource technology.2011 Jun;102(11):6429-36. Epub 2011 Mar 22.
This study deals with the decolorization of black liquor (BL) by isolated potential bacterial consortium comprising Serratia marcescens (GU193982), Citrobacter sp. (HQ873619) and Klebsiella pneumoniae (GU193983). The decolorization of BL was studied by using the different nutritional as well as envi
PMID 21482463

Japanese Journal

肺炎桿菌--Hypermucoviscosity--転移性膿瘍 (特集呼吸器病原体--病原因子--生体反応)

原田壮平
呼吸器内科 19(1), 17-21, 2011-01
NAID 40018717956

Acute Klebsiella pneumoniae interface keratitis after deep anterior lamellar keratoplasty

Zarei-Ghanavati Siamak,Sedaghat Mohammad-Reza,Ghavami-Shahri Ali
Japanese journal of ophthalmology 55(1), 74-76, 2011-01
NAID 40017664447

当院[昭和大学横浜市北部病院]でみられたメタロ-β-ラクタマーゼ産生菌検出症例におけるK.pneumoniaeの増加

杉本太路,木村聡,仲間恵美子 [他]
臨床病理 58(6), 553-558, 2010-06
NAID 40017193091

Related Pictures

★リンクテーブル★

国試過去問	「114C062」「114C061」「114C060」「096D015」「095D057」「105A051」「112F064」「097H071」
リンク元	「腸内細菌科」「尿路感染症」「日和見感染菌」「クレブシエラ属」「莢膜」
関連記事	「pneumoniae」

「114C062」

Klebsiella pneumoniae
	K. pneumoniae on a MacConkey agar plate.
Scientific classification
Kingdom:	Bacteria
Phylum:	Proteobacteria
Class:	Gamma Proteobacteria
Order:	Enterobacteriales
Family:	Enterobacteriaceae
Genus:	Klebsiella
Species:	K. pneumoniae
Binomial name
	Klebsiella pneumoniae; (Schroeter 1886); Trevisan 1887

　　[★]

次の文を読み、60～62の問いに答えよ。
46歳の女性。急性虫垂炎の手術のため入院中である。
現病歴：3日前に急性虫垂炎のため虫垂切除術を施行した。昨日から38.0℃の発熱を認めているため、本日の朝に診察を行った。
既往歴：特記すべきことはない。
生活歴：喫煙歴と飲酒歴はない。
家族歴：父親が膵癌のため68歳で死亡。
現症：意識レベルはJCSⅠ-1、GCS 15(E4V5M6)。身長 155cm、体重 48kg。体温 37.2℃。脈拍 112/分、整。血圧 78/40mmHg。呼吸数 28/分。SpO2 94%(room air)。頸部リンパ節に腫脹を認めない。心音に異常を認めない。呼吸音は左下胸部で減弱し、coarse cracklesを聴取する。腹部は平坦、軟で、肝・脾を触知しない。腹部の手術創部に異常を認めない。背部に叩打痛を認めない。両下腿に浮腫を認める。
検査所見：血液所見：赤血球 388万、Hb 11.2g/dL、Ht 36%、白血球 9,800(桿状核好中球 39%、分葉核好中球 45%、好酸球 3%、好塩基球 2%、単球 4%、リンパ球 7%)、血小板 18万、Dダイマー 3.4μg/mL(基準 1.0以下)。血液生化学所見：総蛋白 6.5g/dL、アルブミン 2.9g/dL、尿素窒素 21mg/dL、クレアチニン 1.2mg/dL、Na139mEq/L、K 4.1mEq/L、Cl 108mEq/L。CRP 12mg/dL、乳酸 14mg/dL(基準 5～20)。胸部エックス線写真(別冊No. 14)を別に示す。血液培養2セットからKlebsiella pneumoniaeが検出された。

酸素投与とともに、生理食塩液1,500mLを輸液したところ、体温 38.1℃、脈拍96/分、整。血圧 112/64mmHg、呼吸数 24/分、SpO2 97%(鼻カニューラ 3L/分酸素投与下)となった。
抗菌薬治療を開始した。効果判定にまず用いるべき指標はどれか。

a　呼吸数の減少
b　下腿浮腫の消失
c　CRP値の正常化
d　白血球数の正常化
e　Dダイマーの正常化

[正答]

※国試ナビ4※　［114C061］←［国試_114］→［114C063］

「114C061」

　　[★]

次の文を読み、60～62の問いに答えよ。
46歳の女性。急性虫垂炎の手術のため入院中である。
現病歴：3日前に急性虫垂炎のため虫垂切除術を施行した。昨日から38.0℃の発熱を認めているため、本日の朝に診察を行った。
既往歴：特記すべきことはない。
生活歴：喫煙歴と飲酒歴はない。
家族歴：父親が膵癌のため68歳で死亡。
現症：意識レベルはJCSⅠ-1、GCS 15(E4V5M6)。身長 155cm、体重 48kg。体温 37.2℃。脈拍 112/分、整。血圧 78/40mmHg。呼吸数 28/分。SpO2 94%(room air)。頸部リンパ節に腫脹を認めない。心音に異常を認めない。呼吸音は左下胸部で減弱し、coarse cracklesを聴取する。腹部は平坦、軟で、肝・脾を触知しない。腹部の手術創部に異常を認めない。背部に叩打痛を認めない。両下腿に浮腫を認める。
検査所見：血液所見：赤血球 388万、Hb 11.2g/dL、Ht 36%、白血球 9,800(桿状核好中球 39%、分葉核好中球 45%、好酸球 3%、好塩基球 2%、単球 4%、リンパ球 7%)、血小板 18万、Dダイマー 3.4μg/mL(基準 1.0以下)。血液生化学所見：総蛋白 6.5g/dL、アルブミン 2.9g/dL、尿素窒素 21mg/dL、クレアチニン 1.2mg/dL、Na139mEq/L、K 4.1mEq/L、Cl 108mEq/L。CRP 12mg/dL、乳酸 14mg/dL(基準 5～20)。胸部エックス線写真(別冊No. 14)を別に示す。血液培養2セットからKlebsiella pneumoniaeが検出された。

酸素投与とともに、生理食塩液1,500mLを輸液したところ、体温 38.1℃、脈拍96/分、整。血圧 112/64mmHg、呼吸数 24/分、SpO2 97%(鼻カニューラ 3L/分酸素投与下)となった。
この患者の状態はどれか。2つ選べ。

[正答]

※国試ナビ4※　［114C060］←［国試_114］→［114C062］

「114C060」

　　[★]

次の文を読み、60～62の問いに答えよ。
46歳の女性。急性虫垂炎の手術のため入院中である。
現病歴：3日前に急性虫垂炎のため虫垂切除術を施行した。昨日から38.0℃の発熱を認めているため、本日の朝に診察を行った。
既往歴：特記すべきことはない。
生活歴：喫煙歴と飲酒歴はない。
家族歴：父親が膵癌のため68歳で死亡。
現症：意識レベルはJCSⅠ-1、GCS 15(E4V5M6)。身長 155cm、体重 48kg。体温 37.2℃。脈拍 112/分、整。血圧 78/40mmHg。呼吸数 28/分。SpO2 94%(room air)。頸部リンパ節に腫脹を認めない。心音に異常を認めない。呼吸音は左下胸部で減弱し、coarse cracklesを聴取する。腹部は平坦、軟で、肝・脾を触知しない。腹部の手術創部に異常を認めない。背部に叩打痛を認めない。両下腿に浮腫を認める。
検査所見：血液所見：赤血球 388万、Hb 11.2g/dL、Ht 36%、白血球 9,800(桿状核好中球 39%、分葉核好中球 45%、好酸球 3%、好塩基球 2%、単球 4%、リンパ球 7%)、血小板 18万、Dダイマー 3.4μg/mL(基準 1.0以下)。血液生化学所見：総蛋白 6.5g/dL、アルブミン 2.9g/dL、尿素窒素 21mg/dL、クレアチニン 1.2mg/dL、Na139mEq/L、K 4.1mEq/L、Cl 108mEq/L。CRP 12mg/dL、乳酸 14mg/dL(基準 5～20)。胸部エックス線写真(別冊No. 14)を別に示す。血液培養2セットからKlebsiella pneumoniaeが検出された。

診断として最も考えられるのはどれか。

a　肺炎
b　腎盂腎炎
c　創部感染
d　急性胆管炎
e　化膿性脊椎炎

[正答]

※国試ナビ4※　［114C059］←［国試_114］→［114C061］

「096D015」

　　[★]

42歳の女性。2日前から発熱と膿性痰とがあり来院した。10年前から咳嗽と喀痰とを認め、2年前から労作時の息切れが出現した。小児期から慢性副鼻腔炎がある。体温37.8℃。脈拍82/分、整。全肺野にfine crackles (捻髪音)を聴取する。白血球12,500(桿状核好中球8％、分葉核好中球66％、好酸球2％、単球2％、リンパ球22％)。CRP10.2mg/dl(基準0.3以下)。呼吸機能検査：％VC 88％、FEV1.0％ 62％。胸部エックス線写真では全肺野にびまん性粒状影を認める。予想される起因菌はどれか。

a. (1)(2)
b. (1)(5)
c. (2)(3)
d. (3)(4)
e. (4)(5)

[正答]

※国試ナビ4※　［096D014］←［国試_096］→［096D016］

「095D057」

　　[★]

76歳の男性。微熱と全身倦怠感とが続くため来院した。2か月前に経尿道的前立腺切除術を受けている。心尖部に最強点をもつ3/6度の汎収縮期雑音を聴取する。血液所見：赤沈50mm/1時間、白血球12,500(桿状核好中球10％、分葉核好中球66％、好酸球2％、単球4％、リンパ球18％)。CRP12.6mg/dl(基準0.3以下)。血液培養で予想される起炎菌はどれか。

[正答]

※国試ナビ4※　［095D056］←［国試_095］→［095D058］

「105A051」

　　[★]

56歳の男性。発熱と膿性痰とを主訴に来院した。 3日前から38℃台の発熱と膿性痰とを認めている。既往歴と家族歴とに特記すべきことはない。胸部エックス線写真にて右下肺野に浸潤影を認める。喀痰のGram染色で好中球と菌体とを多数認める。
考えられる起炎菌はどれか。2つ選べ。

a　Chlamydophila pneumoniae Chlamydia pneumoniae
b　Haemophilus influenzae
c　Klebsiella pneumoniae
d　Mycoplasma pneumoniae
e　Streptococcus pneumoniae

[正答]

※国試ナビ4※　［105A050］←［国試_105］→［105A052］

「112F064」

　　[★]

90歳の女性。発熱を主訴に来院した。6年前に脳出血を発症し日常生活動作(ADL)が低下したため、現在は介護老人保健施設に入所している。3日前から38℃台の発熱があり、胸部エックス線写真で肺炎と診断された。
この患者の喀痰から検出される可能性が最も高い菌はどれか。

[正答]

※国試ナビ4※　［112F063］←［国試_112］→［112F065］

「097H071」

　　[★]

急性単純性膀胱炎の最も一般的な起因菌はどれか。

[正答]

※国試ナビ4※　［097H070］←［国試_097］→［097H072］

「腸内細菌科」

　　[★]

英: Enterobacteriaceae
関: 細菌

代表的なもの８つを覚ておく！

エンテロバクター属 Enterobacter
エシェリキア属  Escherichia
クレブシエラ属 Klebsiella
プロテウス属 Proteus
サルモネラ属 Salmonella
セラチア属 Serratia
シゲラ属 Shigella
エルシニア属 Yersinia

腸内細菌科 (SMB.163)

属	菌種	日和見感染菌	感染症
Citrobacter	Citrobacter freundii		尿路感染、骨髄炎、下痢
Edwardsiella	Edwardsiella tarda	○	腸管外感染症
Enterobacter	Enterobacter aerogenes	○	肺炎、尿路感染
	Enterobacter cloacae
	Enterobacter gergoviae
	Enterobacter sakazakii		新生児敗血症、髄膜炎
Escherichia	Escherichia coli		下痢、腸炎、腸管外感染症(尿路感染症、骨髄炎)
Hafnia	Hafnia alvei		腸管外感染症
Klebsiella	Klebsiella oxytoca		下痢
Klebsiella	Klebsiella pneumoniae	○	肺炎、尿路感染
Kluyvera	Kluyvera ascorbata	○
Kluyvera	Kluyvera cryocrescens	○
Morganella	Morganella morganii		尿路感染症
Proteus	Proteus mirabilis	○	尿路感染症
Proteus	Proteus vulgaris	○	尿路感染症
Providencia	Providencia alcalifaciens		尿路感染症、下痢
	Providencia rettgeri		尿路感染症、下痢
	Providencia stuartii		尿路感染症
Salmonella	Salmonella enterica		腸チフス、急性胃腸炎(食中毒)
Serratia	Serratia liquefaciens	○
Serratia	Serratia marcescens	○
Shigella	Shigella boydii		細菌性赤痢
	Shigella dysenteriae
	Shigella flexneri
	Shigella sonnei
Yersinia	Yersinia enterocolitica		急性胃腸炎(食中毒)、回腸末端炎、結節性紅斑
	Yersinia pestis		ペスト
	Yersinia pseudotuberculosis		腸間膜リンパ節炎、関節炎

「尿路感染症」

　　[★]

英: urinary tract infection, UTI, urinary tract infections, UTIs
関: 尿路感染

定義

尿路(腎、尿管、膀胱、尿道など)の感染症。尿道炎は別に取り扱われるらしい

疫学

尿路感染症は特に女性に多く、30歳になるまでに4人に1人が罹患。
入院患者の1/3は尿路感染症であり、さらにその3/4以上は膀胱カテーテルを留置されいる患者で起こる。

分類

背景

一般細菌の上行性感染によって起こることがほとんどであり、
単純性尿路感染症：尿路に明らかな基礎疾患がない。

急性、20-30歳代の女性に多い

複雑性尿路感染症：尿路に感染を起こしやすくなる基礎疾患がある。

慢性、高齢の男性に多い

部位

上部尿路感染症：腎盂腎炎
下部尿路感染症：膀胱炎

病因

特異性尿路感染症
非特異性尿路感染症

一般的な尿路感染症

病原体

SMB.607

外来患者

院内感染患者

first aid p.162

Ambulatory..E. coli (50-80%), Klebsiella (8-10%).

Staphylococcus saprophyticus (10-30%) is the 2nd most common cause of UTI in young ambulatory women.

Hospital..E. coli, Proteus, Klebsiella, Serratia,Pseudomonas.

感染経路

外尿道口からの上行性感染

病因

冷え、過度の排尿自制、尿流の停滞、経尿道的操作など

症状

腎盂腎炎：発熱、腰痛など、
膀胱炎では頻尿、排尿痛、残尿感、頻尿など

小児科 SPE.615

年長児：

上部：発熱、腰痛
下部：排尿痛、頻尿、尿の混濁

乳幼児：発熱、嘔吐、下痢、食欲不振など非特異的な全身症状
新生児：乳幼児の症状　＋　脱水、体重減少、黄疸など。

検査

尿検査

尿：混濁
尿沈渣：1視野(400倍)5個以上の白血球(膿尿)
尿培養：1ml中10^5個以上の細菌　←　中間尿の定量培養

症状(頻尿、排泄痛、残尿感)ががあれば、これ以下の菌数でも病因的意義がある。

治療

「日和見感染菌」

　　[★]

関: 日和見感染、日和見感染症

腸内細菌科

属	菌種	感染症
Edwardsiella	Edwardsiella tarda	腸管外感染症
Enterobacter	Enterobacter aerogenes	肺炎、尿路感染
	Enterobacter cloacae
	Enterobacter gergoviae
Klebsiella	Klebsiella pneumoniae	肺炎、尿路感染
Kluyvera	Kluyvera ascorbata
Kluyvera	Kluyvera cryocrescens
Proteus	Proteus mirabilis	尿路感染症
Proteus	Proteus vulgaris	尿路感染症
Serratia	Serratia liquefaciens
Serratia	Serratia marcescens

「クレブシエラ属」

　　[★]

英: Klebsiella
同: 肺炎桿菌属、Klebsiella属、クレブシエラ
関: 細菌、莢膜

概念

グラム陰性桿菌
腸内細菌科
通性嫌気性
厚い莢膜を有する
腸内常在菌。気道、消化管、泌尿生殖器などにも生息。
鞭毛を持たず、線毛を持つ　→　運動能なし(腸内細菌群の中で運動能を持たないのは、原則クレブシエラ属とシゲラ属のみ) (SMB.179)
βラクタマーゼを有し、セファロスポリン、アミノグリコシド、テトラサイクリンなどに耐性を獲得しやすい。
全てのKebsiellaはアミノベンジルペニシリンに抵抗性を有する　→　菌交代症が起こりやすい。Klebsiella oxytocaはアミノベンジルペニシリンやアモキシシリンの投与後に菌交代症による下痢を起こす

クレブシエラ属

Klebsiella pneumoniae subspecies

Klebsiella pneumoniae：肺炎。日和見感染菌。院内感染を起こしやすい。Streptococcus pneumoniaeより劇症。ペニシリン系抗菌薬に自然耐性。
Klebsiella rhinoscleromatis：鼻硬化症
Klebsiella ozaenae：臭鼻症を起こす。

Klebsiella oxytoca：肺炎、腸炎(下痢原性)

-Klebsiella

「莢膜」

　　[★]

英: capsule
関

機能

食細胞による貪食をのがれる

抗体を介した貪食による (SMB.43)

抗体の産生には1週間ていどかかるらしい

補体は無効

補体が莢膜に接着しない

膜攻撃複合体が細胞膜に達しない

莢膜を有する病原体

炭疽菌：ポリペプチド(D-グルタミン酸)
肺炎球菌：多糖
肺炎桿菌：多糖
A群連鎖球菌

莢膜を有する病原体(First Aid 2006 p.137)

SHNK

Streptococcus pneumoniae (pneumococcus)　　　　　　：gram-positive
Haemophilus influenzae (especially B serotype)　　：gram-negative
Neisseria meningitidis (meningococcus)　　　　　　　：gram-negative
Klebsiella pneumoniae　　　　　　　　　　　　　　　　　　：gram-negative

検査

Positive quellung reaction

if encapsulated bug is present, capsule swells when specific anticapsular antisera are added.

「pneumoniae」

　　[★] Streptococcus pneumoniae、Klebsiella pneumoniae、Mycoplasma pneumoniae、Chlamydia pneumoniae、Chlamydophila pneumoniae

[Sherris-1] Ryan, KJ; Ray, CG, eds. (2004). Sherris Medical Microbiology (4th ed.). McGraw Hill. ISBN 0-8385-8529-9.

[Postgate_1998-2] Postgate, J (1998). Nitrogen Fixation (3rd ed.). Cambridge University Press. ISBN 978-0521640473.

[3] Podschun, R; Ullmann, U (October 1998). "Klebsiella spp. as Nosocomial Pathogens: Epidemiology, Taxonomy, Typing Methods, and Pathogenicity Factors". Clinical Microbiology Reviews 11 (4): 589–603. PMC 88898.

[4] Bogovazova, GG; Voroshilova, NN; Bondarenko, VM (April 1991). "The efficacy of Klebsiella pneumoniae bacteriophage in the therapy of experimental Klebsiella infection". Zhurnal mikrobiologii, epidemiologii, i immunobiologii (in Russian) (Russia: Moskva) (4): 5–8. ISSN 0372-9311. PMID 1882608.

[5] Chanishvili, N, ed. (2012). A Literature Review of the Practical Application of Bacteriophage Research. Hauppauge, NY: Nova Science. ISBN 9781621008514.

[Rashid_2006-6] Rashid, T; Ebringer, A (June 2007). "Ankylosing spondylitis is linked to Klebsiella--the evidence". Clinical Rheumatology 26 (3): 858–864. doi:10.1007/s10067-006-0488-7. PMID 17186116.

[7] Groopman, J (2008-08-11). "Superbugs". The New Yorker. Retrieved 2013-07-07. "The new generation of resistant infections is almost impossible to treat."

[8] Limbago, BM; Rasheed, JK; Anderson, KF; Zhu, W et al. (December 2011) [Epub 2011-10-12]. "IMP-Producing Carbapenem-Resistant Klebsiella pneumoniae in the United States". Journal of Clinical Microbiology 49 (12): 4239–4245. doi:10.1128/JCM.05297-11. PMC 3233008. PMID 21998425.

[9] Berrie, C (2007-04-04). "Carbapenem-resistant Klebsiella pneumoniae outbreak in an Israeli hospital". Medscape. Medical News. WebMD. Retrieved 2013-07-07.

[10] Yigit, H; Queenan, AM; Anderson, GJ; Domenech-Sanchez, A et al. (April 2001). "Novel carbapenem-hydrolyzing beta-lactamase, KPC-1, from a carbapenem-resistant strain of Klebsiella pneumoniae". Antimicrobial Agents and Chemotherapy 45 (4): 1151–1161. doi:10.1128/AAC.45.4.1151-1161.2001. PMC 90438.

[11] Vastag, Brian (2012-08-22). "‘Superbug’ stalked NIH hospital last year, killing six". The Washington Post. Retrieved 2013-07-07.

[12] Los Angeles County Department of Public Health. "Diseases & Conditions: Carbapenem-Resistant Klebsiella Pneumoniae (CRKP)". lacounty.gov. Acute Communicable Disease Control. Retrieved 2013-07-07.

[13] Lledo, W; Hernandez, M; Lopez, E; Molinari, OL et al. (2009-03-20). "Guidance for Control of Infections with Carbapenem-Resistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities". Morbidity and Mortality Weekly Report (CDC) 58 (10): 256–260.

[Jenniferiscool-14] Schwaber, MJ; Lev, B; Israeli, A; Solter, E et al. (2011-04-01) [Epub 2011-02-11]. "Containment of a country-wide outbreak of carbapenem-resistant Klebsiella pneumoniae in Israeli hospitals via a nationally implemented intervention". Clinical Infectious Diseases 52 (7): 848–855. doi:10.1093/cid/cir025. PMID 21317398.

[15] Nathisuwan, S; Burgess, DS; Lewis, JS (August 2001) [Epub 2012-01-07]. "Extended-Spectrum β-Lactamases: Epidemiology, Detection, and Treatment". Pharmacotherapy 21 (8): 920–928. doi:10.1592/phco.21.11.920.34529.

[16] ttp://www.cdc.gov/HAI/organisms/klebsiella/klebsiella.html

Klebsiella pneumoniae

K. pneumoniae on a MacConkey agar plate.
Scientific classification
Kingdom:	Bacteria
Phylum:	Proteobacteria
Class:	Gamma Proteobacteria
Order:	Enterobacteriales
Family:	Enterobacteriaceae
Genus:	Klebsiella
Species:	K. pneumoniae
Binomial name
*Klebsiella pneumoniae* (Schroeter 1886) Trevisan 1887

匿名

検索

案内

Klebsiella pneumoniae

概念

治療

WordNet

PrepTutorEJDIC

Wikipedia preview

wiki en

Contents

History[edit]

Clinical significance[edit]

Resistant strains[edit]

Treatment[edit]

See also[edit]

References[edit]

External links[edit]

UpToDate Contents

English Journal

Japanese Journal

Related Links

Related Pictures

★リンクテーブル★

「114C062」

「114C061」

「114C060」

「096D015」

「095D057」

「105A051」

「112F064」

「097H071」

「腸内細菌科」

腸内細菌科 (SMB.163)

「尿路感染症」

定義

疫学

分類

背景

部位

病因

病原体

外来患者

院内感染患者

first aid p.162

感染経路

病因

症状

小児科 SPE.615

検査

尿検査

治療

「日和見感染菌」

腸内細菌科

「クレブシエラ属」

概念

クレブシエラ属

「莢膜」

機能

莢膜を有する病原体

莢膜を有する病原体(First Aid 2006 p.137)

検査

「pneumoniae」