Suspected community-acquisition of carbapenem-resistant hypervirulent Klebsiella pneumoniae (CRhvKp) in Germany: a case report and implications for infection control.

Abstract

Aim: Hypervirulent Klebsiella pneumoniae (hvKp) has emerged as a disease threat due to a higher morbidity and mortality associated with specific virulence genes. The acquisition of carbapenem-resistance (CRhvKp) in some strains limits treatment options, posing a serious clinical challenge. While healthcare-associated transmissions have been reported, the epidemiological dynamics and infection prevention implications of CRhvKp remain insufficiently elucidated. In Germany, routine diagnostics for Gram-negative pathogens rarely include specific identification of hvKp or systematic detection of its virulence markers, and there is no mandatory notification of CRhvKp cases.

Methods: We established a two-step screening approach for the routine diagnostic detection of hvKp, combining loop-mediated isothermal amplification (LAMP) with confimatory whole-genome sequencing (WGS). This workflow was applied to all carbapenemase producing K. pneumoniae and to clinical isolates considered at increased risk for hvKp.

Results: We report the case of a 1973-born male patient with a history of Child-Pugh class B cirrhosis who was admitted due to acute liver failure and ascites triggered by infection. The patient had no recent travel history but had been recently admitted to local hospitals in Thuringia, Germany. Ascitic fluid obtained by paracentesis appeared putrid and yielded an ESBL-producing and fluoroquinolone-resistant Escherichia coli. In addition, a lower urinary tract infection due to CRhvKp was identified. The CRhvKp infection was deemed community-acquired, with the route of acquisition remaining unknown. The isolate belonged to ST147 and carried the bla _NDM-5 and bla _OXA-48 carbapenemase genes. The patient was successfully treated with cefiderocol (Fetcroja, Shionogi & Co. Ltd.) over the course of 14 days. Standard infection prevention precautions for patients with carbapenem-resistant Enterobacterales were applied. No intra-hospital transmission of this strain was detected in our routine WGS-based surveillance.

Conclusion: CRhvKp can occur in patients without establishes epidemiological or clinical risk factors, suggesting a broader reservoir than currently assumed. Further research regarding prevalence, transmissibility, environmental persistence, and colonization dynamics of CRhvKp strains are urgently needed to determine their implications for infection prevention and control in hospitals in Germany.