POST TRANSPLANT INFECTIONS

POST TRANSPLANT INFECTIONS:

POST TRANSPLANT INFECTIONS SUJAL KUMAR SHETTY DEPARTMENT OF GENERAL MEDICINE Jump to: navigation , search

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ORGAN TRANSPLANTATION IS MOVING OF AN ORGAN FROM ONE BODY TO ANOTHER, OR FROM A DONOR SITE ON THE PATIENT’S OWN BODY, FOR THE PURPOSE OF REPLACING THE RECIPIENT’S DAMAGED OR ABSENT ORGAN.

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(1)ORGANS TRANSPLANTED ARE HEART, KIDNEY, LIVER, LUNGS, PANCREAS, INTESTINE, HEART-LUNG AND THYMUS. (2)TISSUES INCLUDE BONES, TENDONS, CORNEA, SKIN, HEART VALVES AND VEINS.

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INFECTION RISKS IN TRANSPLANT PATIENTS RISK DERIVED FROM ORIGINAL DISEASE ( eg RENAL FAILURE) RISK OF HOSPITAL ADMISSION AND SURGERY. RISK OF DISEASE CONTRACTED FROM TRANSPLANTED TISSUE ( eg TOXOPLASMOSIS)

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EARLY RISK OF OPPORUNISTIC INFECTIONS DURING STRONG IMMUNOSUPPRESSION. LATER RISK OF OPPURTUNISTIC INFECTIONS DUE TO CHRONIC SUPPRESSION OF CELL MEDIATED IMMUNITY.

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THE LEVEL OF IMMUNOSUPPRESION IN ANY GIVEN PATIENT IS DETERMINED BY (1) IMMUNOSUPPRESSIVE MEDICATIONS : DOSE, DURATION AND TEMPORAL SEQUENCE (2) METABOLIC ABNORMALITIES SUCH AS PROTEIN MALNUTRITION, UREMIA, HYPERGLYCEMIA. (3) IMMUNOMODULATING VIRUSES SUCH AS CMV AND HIV CONTRIBUTE TO THE NET LEVEL OF IMMUNOSUPPRESSION.

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INFECTIONS IN THE 1ST POST TRANSPLANT MONTH(PERITRANSPLANT PERIOD) PNEUMONIA, WOUND INFECTION, LINE SEPSIS, UTI SECONDARY TO FOLEY CATHETER. OPPORTUNISTIC INFECTIONS ARE UNCOMMON. MOST COMMON ORGANISMS: E.COLI (UTI), S.AUREUS + S.VIRIDANS (LINE SEPSIS AND WOUND INFECTIONS) AND S.PNEUMONIAE (PNEUMONIA).

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INFECTIONS IN THE REMAINDER OF THE 1ST POST TRANSPLANT YEAR EARLY TRANSPLANT PERIOD(1-6MONTHS) OPPORTUNISTIC INFECTIONS ARE MOST COMMON AFTER THE FIRST MONTH. CMV (10-25% OF RECIPIENTS). CMV DISEASE: FEVER, ELEVATED LFTS, LEUKOPAENIA, ANAEMIA, THROMBOCYTOPAENIA, ARTHRALGIAS, MYALGIAS AND LYMPHADENOPATHY. IN MORE SEVERE CASES, TISSUE-INVASIVE CMV INFECTION OCCURS (PULMONARY, UPPER OR LOWER GIT, CNS). LATE TRANSPLANT PERIOD(6-12MONTHS ) OPPOTUNISTIC INFECTIONS ARE UNCOMMON.

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INFECTIONS AFTER THE 1ST POST TRANSPLANT YEAR COMMUNITY-ACQUIRED INFECTIONS UNRELATED TO IMMUNE SUPPRESSION ARE MORE COMMON

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TYPE OF INFECTION INCIDENCE OF INFECTION IN PTS RECEIVING LIVER KIDNEY HEART LUNG/ PANCREAS HEART-LUNG BACTERIAL 33-68 47 21-30 54 35 CMV 22-29 8-32 9-35 39-41 50 HSV 3-44 53 1-42 10-18 06 VZV 5-10 4-12 1-12 8-15 09 CANDIDA SPP. 1-26 02 1-5 10-16 32 P.CARINII 4-11 5-10 1-8 15

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MAJOR INFECTIONS TRANSMITTED BY DONATED TISSUES TYPE OF TISSUES INFECTIVE AGENT KIDNEY, HEART, LIVER , LUNG CMV HEART, KIDNEY TOXOPLASMOSIS HEART TRYPANOSOMA CRUZI KIDNEY, LIVER HSV KIDNEY HHV-8 KIDNEY, HEART, LIVER HIV-1,HBV, HCV, WEST NILE VIRUS KIDNEY, LIVER, LUNG LCV KIDNEY, LIVER, CORNEA RABIES

LUNG TRANSPLANTATION:

LUNG TRANSPLANTATION Indications COPD Idiopathic Pulmonary Fibrosis Cystic fibrosis alpha 1 anti- trypsin deficiency Primary Pulmonary Hypertension Sarcoidosis Bronchiectasis Eisenmenger’s syndrome Lymphoangioleiomyomatosis Re-transplantation

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CAUSES OF INFECTION IN TRANSPLANTED LUNG BLUNTED IMMUNE RESPONSE FROM IMMUNOSUPRESSIVE DRUGS NORMAL DEFENCES ARE BREACHED COUGH REFLEX DIMINISHED MUCOCILIARY CLEARANCE IS IMPAIRED.

CAUSATIVE ORGANISMS:

CAUSATIVE ORGANISMS BACTERIA: P.AEROGINOSA OR MRSA IS OFTEN THE CULPRIT BRONCHITIS OR PNEUMONIA CAN OCCUR AT ANYTIME BUT ARE ALMOST UNIVERSAL IN POSTOPERATIVE PERIOD.

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VIRAL INFECTION :CMV IS THE MOST FREQUENT. MOST EPISODES OCCUR IN THE FIRST 6 MONTHS TREATEMENT WITH GANCICLOVIR IS EFFECTIVE. DOSE: IV INFUSION OVER 1HR, 5MG/KG 12 HRLY FOR 14-21 DAYS MAY BE CONTIUED AT 5MG/KG DAILY IF RISK OF RECURRENCE EXISTS.

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SIDE EFFECTS OF GANCICLOVIR: NEUTROPENIA, THROMBOCYTOPENIA AND ONCOGENESIS. FOSCARNET USED FOR CMV RETINITIS IN AIDS IS NOT RECOMMENDED FOR OTHER CMV INFECTION. IT IS EXTREMELY TOXIC CAUSING RENAL IMPAIRMENT AND MAKING CYCLOSPORINE THERAPY DIFFICULT. VALGANCICLOVIR IS A COST EFFECTIVE AND BIOAVAILABLE ORAL FORM OF GANCICLOVIR.

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FUNGAL INFECTION: ASPERGILLUS SPECIES HAVE BEEN THE MOST PROBLEMATIC AND DESSIMINATED ASPERGILLAL INFECTION HAS NEARLY 100% MORTALITY DESPITE AMPHOTERICIN USE. ORAL AZOLES AND INHALED AMPHOTERICIN ARE MOST WIDELY USED AGENTS.

KIDNEY TRANSPLANTATION:

KIDNEY TRANSPLANTATION THE MOST COMMON OPPURTUNISTIC INFECTIONS: PERITRANSPLANT(<1MONTH) WOUND INFECTIONS HERPESVIRUS ORAL CANDIDIASIS UTI

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EARLY(1-6MONTHS) P.CARINII CMV LEGIONELLA LISTERIA HEPATITIS B HEPATITIS C

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LATE (>6MONTHS) ASPERGILLUS NOCARDIA BK VIRUS HERPES ZOSTER HEPATITIS B HEPATITIS C.

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MORE RECENTLY CMV AND OTHER OPPORTUNISTIC INFECTIONS HAVE COME UNDER CONTROL AND CONVENTIONAL BACTERIAL PATHOGEN HAVE BECOME RELATIVELY MORE COMMON. EXTENDED COURSE OF ANTIBIOTICS IS USED IN PTS WHO HAVE SEVERE GRAFT PYELONEPHRITIS OR RECURRENT INFECTIONS WITH THE SAME ORGANISM.

CARDIAC TRANSPLANTATION:

CARDIAC TRANSPLANTATION MOST COMMON INFECTIONS ARE BACTERIAL PNEUMNIA, UTI, HSV AND INVASIVE FUNGAL INFECTION. MEDIASTENITIS AND STERNAL WOUND INFECTIONS ARE UNIQUE TO HEART AND HEART-LUNG TRANSPLANT RECIPIENTS. S.AUREUS AND S.EPIDERMIDIS ARE PREDOMINANT PATHOGENS. OTHER PATHOGENS ARE M.HOMINIS, LEGIONELLA, ASPERGILLUS AND NOCARDIA.

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OTHER INFECTIONS ARE TOXOPLASMOSIS, NOCARDIA AND CHAGA’S DISEASE. TOXOPLASMA SERONEGATIVE HEART RECIPIENTS ARE AT INCREASED RISK FOR TOXOPLASMOSIS BECAUSE INFECTION CAN BE ACQUIRED FROM ORGANISMS ENCYSTED IN THE HEART MUSCLE. CLINICAL TOXOPLASMOSIS IS NOW UNCOMMON BECAUSE OF THE USE OF TMP-SMX FOR PNEUMOCYSTIS PROPHYLAXIS.

Liver transplantation:

Liver transplantation MOST DEATHS OF TRANPLANT RECIPIENT ARE ASSOCIATED WITH INFECTION. BACTERIA ARE THE MC PATHOGEN CAUSING SERIOUS INFECTION. 80% OF FUNGAL INFECTION OCCUR DURING THE FIRST MONTH AND 90% DURING THE FIRST 2 MONTHS AFTER TRANSPLANTATION. CANDIDA IS THE PREDOMINANT PATHOGEN(62-88% OF THE INVASIVE FUNGAL INFECTION.)

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IDENTIFIED RISKS FOR INFECTION PROLONGED DURATION OF SURGERY TRANSFUSION OF LARGE QUANTITY OF BLOOD. USE OF CHOLEDOCHOJEJUNOSTOMY FOR BILE DRAINAGE. REPEAT TRANSPLANTATION.

PANCREAS TRANSPLANTATION:

PANCREAS TRANSPLANTATION THE POSTOPERATIVE INFECTION RATE AND CAUSATIVE PATHOGENS DEPEND PRIMARILY ON THE TECHNIQUE USED FOR DRAINAGE OF EXOCRINE SECRETIONS OF PANCREAS. ENTERIC DRAINAGE HAS BEEN ASSOCIATED WITH LOWER RATES OF UTI. HOWEVER INTRAABDOMINAL INFECTION REMAIN SIGNIFICANT COMPLICATION. AEROBIC AND ANAEROBIC ENTERIC FLORA PREDOMINANT.

SMALL BOWEL TRANSPLANT:

SMALL BOWEL TRANSPLANT >90% OF SMALL BOWEL TRANSPLANT RECIPIENTS DEVELOP SIGNIFICANT INFECTIONS. INTRAABDOMINAL PYOGENIC INFECTION AND BLOOD STREAM INFECTION PREDOMINANT. TRANSPLANTED GUT IS VERY SUSCEPTIBLE TO CMV INFECTION INCLUDING TENDENCY TO RELAPSE AFTER SUCCESSFUL ANTIVIRAL TREATMENT.

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THE INCIDENCE OF EBV ASSOCIATED LYMPHOPROLIFERATIVE DISORDERS APPROACHES 10% AND THE TUMORS OFTEN INVOLVE THE GUT.

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ANTIMICROBIAL PROPHYLACTIC REGIMENS TOXOPLASMOSIS TMP-SMX PYRIMETHAMINE HSV ACYCLOVIR CMV GANCICLOVIR ACYCLOVIR IMMUNOGLOBULIN INFLUENZA OSELTAMIVIR

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CANDIDA FLUCONAZOLE NYSTATIN CLOTRIMAZOLE. ASPERGILLUS ITRACONAZOLE VORICONAZOLE POSACONAZOLE LIPOSOMAL AMPHOTERICIN B PNEUMOCYSTIS TMP-SMX DAPSONE INHALED PENTAMIDINE

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WOUND INFECTION VARIABLE UTI TMP-SMX NEUTROPENIC QUINOLONES INECTIONS TB ISONIAZID PNEUMOCOCCUS PENCILLIN

  Fecal transplants to cure Clostridium difficile infection :

Fecal transplants to cure Clostridium difficile infection SELECT A STOOL SPECIMEN (PREFERABLY A SOFT SPECIMEN) WITH A WEIGHT OF 30 G . ADD 50-70 ML OF STERILE 0.9 N NACL TO THE STOOL SAMPLE AND HOMOGENISE IT . FILTER THE SUSPENSION USING A PAPER COFFEE FILTER. ALLOW ADEQUATE TIME FOR SLOW FILTRATION TO COME TO AN END. REFILTER THE SUSPENSION.

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25 ML OF THE SUSPENSION IS THEN TRANSFERRED TO THE RECIPIENT, WHO'S ALREADY BEEN PREPARED FOR THE TRANSPLANT VIA TREATMENT WITH VANCOMYCIN (TO KILL OFF AS MUCH EXISTING C. DIFFICILE AS POSSIBLE) AND OMEPRAZOLE(TO DECREASE STOMACH ACID PRODUCTION). THE TUBE IS THEN FLUSHED WITH SALT SOLUTION AND REMOVED, AND THE RECIPIENT IS FREE TO GO.

BIBLIOGRAPHY:

BIBLIOGRAPHY HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 17 TH EDITION INFECTIOUS DISEASE BY BARBARA A. BANNISTER, NORMAN T. BEGG AND STEPHEN H. GILLESPIE. MANDELLE, DOUGLAS AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASE. 7 TH EDITION. WWW.SCIENCEBLOGS.COM CLINICAL MICROBIOLOGY REVIEWS JAN 1997.

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