Understanding the Risks Behind an Infection is so Critical
How a Kluyvera ascorbata UTI was Developed
by Dr. Andrew Pugliese
Several weeks back an OB/GYN colleague called me about one of her patients with a very unique problem. She saw a young woman with a documented Urinary Tract Infection (UTI) who was not responding to oral treatment. The reason for no response was that the woman’s infection was due to Kluyvera ascorbate and that there were no oral antibiotics sensitive to this particular organism. It was, however, sensitive to ceftriaxone and the patient responded very well to IV treatment.
The larger question, though, was how and why this woman, with no significant medical history, developed such a resistant and relatively unknown infection. Kluyvera species is a newly-identified bacteria that, up until the last few decades, was not recognized as a pathogen. Recently, however, there has been an increasing number of case reports of Kluyvera causing infections, especially involving the urinary tract and gastrointestinal system. This is just another example of, as the human race evolves with the advancements of medical sciences, so will the organisms that can cause harm to us.
In this particular case, the reason why she developed such an infection was found in the review of systems during her initial history and physical exam. The patient, since moving to metro-Atlanta two years ago from Illinois, had had multiple sinus infections and was on oral antibiotics more than she was off them. This most likely was the reason for the Kluyvera infection in the first place. With multiple courses of antibiotics, more antibiotic sensitive organisms were selected out and the Kluyvera was allowed to become a predominant organism in the patient’s gastrointestinal tract, setting up the patient for a hard-to-treat UTI.
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This is a perfect example of overuse of antibiotics causing an infection with a resistant organism, and for many, the story would stop here with the simple answer that the patient doesn’t need antibiotics – she can’t possibly be having all those sinus infections. The reality is that she does have recurrent sinus infections due to underlying risk factors that weren’t being identified. What was not realized, however, as with many patients with recurrent chronic sinusitis, is that the cause for chronic sinusitis is completely different from that of acute sinusitis.
In acute sinusitis, the resultant bacterial infection is due to initial damage from either a viral syndrome or some sort of acute injury such as smoke inhalation. In these instances, the organisms usually involved are strep, Morexalla or Hemophilus and respond well to oral antibiotics. With chronic sinusitis, damage to the sinus mucosa is recurrent and cannot be properly addressed until the underlying risk factor or factors have been addressed. In these instances, the bacterial makeup for the infection is usually multiple organisms, also known as polymicrobial, and more difficult to treat. In many instances, the microbial makeup may help in determining what exactly the underlying cause of the chronic sinusitis is.
In this patient’s case, blood work revealed a highly elevated IgE level, over 1400, and the subsequent workup showed that the patient was severely allergic to several molds endemic to the area. She probably didn’t have this problem in northern Illinois because the mold burden here in the Southeast is much higher than that of the upper Midwest. Hopefully, allergy immunotherapy, along with topical nasal sprays, will minimize the patient’s sinus issues, thereby avoiding the need for further necessary antibiotic therapy. In the meantime, the patient is also doing probiotics along with prebiotics to establish good healthy gastrointestinal flora to address the issue of the Kluyvera.
Antibiotic stewardship is an important concept, but it goes way beyond not prescribing antibiotics for a self-limiting viral infection. In cases where patients are taking repeat courses of antibiotics for sinus issues, a comprehensive workup needs to be done to figure out why the patient continues to suffer and not just be dismissed.