Introduction: A new hypervirulent (hypermucoviscous) variant of Klebsiella pneumoniae (K. pnuemoniae) had emerged. It has shown ability to cause serious infection in healthy ambulatory hosts as well as infect unusual sites. Though there have been numerous studies on severe infection by K. pneumoniae, little data has been documented on such infections involving Klebsiella oxytoca. (K. oxytoca). It is capable of causing metastatic spread of the infection even in healthy young individuals. This report was written to describe the clinical spectrum of a case of metastatic Klebsiella infection. Case presentation: We illustrate a case of a 73-year-old diabetic and hypertensive female presenting with headache and eye discharge. She was initially managed as the case of conjunctivitis as out-patient. After three weeks of topical ophthalmic antibiotics, she developed decrease in sensorium leading to her eventual admission. Workup pointed towards a disseminated infection to the eye, brain, and urinary tract. The patient was placed on broad-spectrum antibiotics and a vitreous tap was done. However, the patient’s sensorium decreased further, and was eventually intubated and started on inotropes. The indolent course of the disease, which unfortunately led to the demise of the patient, directed the attending physicians to suspect a more virulent infection. Discussion: Infection by hypervirulent variant of Klebsiella has been classically known to be nosocomial and opportunistic in nature. But cases have also been reported from the community setting. A common denominator in this population is that they are usually immunocompromised as in the case of our patient being elderly and diabetic. Unfortunately, there are no molecular or biochemical markers being used in the clinical setting to identify this strain. Hence, the attending physicians had to rely on the presentation of metastatic disease to diagnose our patient. Conclusion Early diagnosis, appropriate antibiotic treatment and drainage are keys in the management of these cases.
Infections

Introduction: Proton pump inhibitors (PPI) have been used as stress ulcer prophylaxis (SUP) in intensive care unit (ICU) patients due to their high risk for stress-related upper gastrointestinal (GI) bleeding. With its dramatic increase in prescription, studies have noted its misuse and associated complications. This study aimed to determine the appropriateness of the use of PPIs in adult patients in the ICU of Medical Center Manila (ManilaMed). Methods: This eight-month study conducted a retrospective chart review, and analyzed through descriptive statistics using Stata 13. Out of 292 patients, 188 satisfied the inclusion and exclusion criteria. The indication of use of PPI was based on the American Society of Health-System Pharmacists (ASHP) Therapeutic Guidelines on SUP. Results: The patients were mostly male, median age of 62 years, stay in the ICU of five days, overall hospital stay of 13 days, and 75% were admitted from the emergency room. About 58% of PPIs were prescribed in the intravenous route for an average of 10 days, 38% of which is prescribed by cardiology consultants. Of the 73% of patients prescribed PPIs, most were septic and intubated for >48 hours, as well as being older and with longer overall hospital stay. Only 53.7% were prescribed appropriately; adverse outcomes included pneumonia, GI bleeding, anemia, renal failure, combined complications and overall mortality. Discussion: The 46% inappropriate use of PPIs may indicate its routine use was common. The adverse outcomes, despite appropriate use, cannot be concluded as having causative effect owing to the nature of the study and given the possibility that these patients may have been sicker on admission hence prescribed the PPI. Conclusion Results indicated that PPI prescription in the ICU were mostly guidelines compliant. This paper recommends the development of ManilaMed’s own strategies to minimize its inappropriate use, in turn allowing proper allocation of funds and maximizing medical treatment.
Proton Pump Inhibitors