A threat of the Klebsiella pneumoniae carbapenemase-producing strains among transplant recipients

BACKGROUND

Infections due to Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae are associated with increased therapeutic failure and mortality. Our laboratory recognized several strains producing KPC, most of which originated from transplantation ward patients.

MATERIALS AND METHODS

All strains of K pneumoniae resistant to at least 1 carbapenem isolated in 2010 were examined for KPC production by disc diffusion and then verified by molecular methods.

RESULTS

All positive strains originated from 7 patients. Six of them were from transplantation wards. None of the KPC-producing strains was isolated from the patient's blood.

CONCLUSIONS

A quick, accurate diagnosis of KPC-producing strains enabled immediate isolation of carriers or infected persons. Isolation prevented spread of dangerous strains among immunocompromised patients and reduced the possibility of serious infections.

Urinary tract infections in the early posttransplant period after liver transplantation: etiologic agents and their susceptibility

BACKGROUND

We performed an analysis of etiologic agents for urinary tract infections in the early posttransplant period after orthotopic liver transplantation (OLT) in adult recipients.

PATIENTS AND METHODS

The study covered the first 4 weeks after OLT of 190 patients from September 2001 to the end of 2007. Immunosuppression consisted of steroids and tacrolimus. Antimicrobial prophylaxis was piperacillin/tazobactam, fluconazole, and SBD. Urine samples were cultured to identify microorganisms in accord with standard microbiological procedures and to test susceptibility using Clinical Laboratory and Standards Institute guidelines.

RESULTS

Urine specimens (n=539) examined from 185 recipients (97.4%) showed 210 microbial strains. The most common were Gram-negative (n=131; 62.4%) with predominance of Escherichia coli (28.2%), Enterobacter cloacae (19.1%), and Acinetobacter baumannii (11.4%). Extended-spectrum β- lactamases (ESBL(+)) strains were isolated in 38.5% of cases. Gram-positive bacteria comprised 28.6% (n=60): The most common strains were enterococci (85% including HLAR 80.4% and VRE 17.6%] and staphylococci 11.8% [MRSA/MRCNS; 100%]. There were 19 (9%) fungal strains.

CONCLUSIONS

In general, the identification in urine samples of multi-drug-resistant bacterial and fungal strains in patients after OLT such as ESBL(+) 38.5%; HLAR 80.4%; VRE 17.6%; and MRSA/MRCNS 100% requires better infection control.

Iron metabolism in solid‑organ transplantation: how far are we from solving the mystery?

Iron is the most abundant transition metal in the human body and an essential element required for growth and survival. Our understanding of the molecular control of iron metabolism has increased dramatically over the past 10 years due to the discovery of hepcidin, which regulates the uptake of dietary iron and its mobilization from macrophages and hepatic stores. Although general practitioners and internists encounter iron deficiency and anemia in their everyday practice, little is known about iron metabolism in patients after solid-organ transplantation. The aim of this review was to summarize the current knowledge on iron metabolism in kidney, heart, and liver transplant recipients. Iron deficiency and/or anemia, as well as iron overload, are frequently observed but the precise mechanism of these disturbances have not been fully elucidated. Iron deficiency is more prevalent in kidney and heart transplant patients, while iron overload in liver transplant recipients. Secondary and potentially reversible causes of these disturbances should be considered such as inflammation, graft failure, and type of immunosuppression. Iron status check‑up should be a part of long term follow-up because disturbances in iron metabolism are a possible risk factor of infections and mortality in solid transplant recipients. Internists and general practitioners are often the first doctors to take care of organ transplant recipients (before they will present at outpatient transplant clinics or hospital transplant units); therefore, knowledge about the disturbances in iron metabolism in this specific population would be useful for better diagnosis and treatment both before and after transplantation.

Tolerance of enteric-coated mycophenolate sodium in combination with calcineurin inhibitor in kidney transplant recipients: Polish experience

INTRODUCTION

Enteric-coated mycophenolate sodium (EC-MPS) was developed to reduce the incidence of gastrointestinal adverse effects. This multicenter observational study was designed to evaluate the safety profile and drug tolerance in kidney transplant recipients.

METHODS

Three hundred adult kidney recipients (median age 48 years) were enrolled over 3 years to receive EC-MPS de novo (n=175), as a switch from azathioprine (n=62) or mycophenolate mofetil MMF (n=63); in combination with calcineurin inhibitor. Drug doses, serum creatinine, estimated glomerular filtration rate (eGFR), as well as drug tolerance, patient and physician evaluation of therapy (on a 4-point scale) were recorded at enrollment and followed over 28 weeks. We modeled the probability of the highest level (ie, best result) of the categorical outcome variable.

RESULTS

Two hundred seventy-three patients completed the study (91%). In the pooled study group (1) best drug tolerance was expected more frequently with tacrolimus versus cyclosporine (odds ratio [OR] 2.12, P<.05); (2) best physician evaluation, with earlier EC-MPS introduction (OR for 4-week delay: 0.99, P<.03) and higher eGFR (OR for 5 mL/min increase: 1.21, P<.01). Among the EC-MPS de novo administrations group: (1) best drug tolerance was expected more frequently with coadministered tacrolimus versus cyclosporine (OR 3.14, P<.02); (2) best patient evaluation, with higher eGFR (OR for 1 mL/min increase: 1.04, P<.04); and (3) best physician evaluation, with higher eGFR (OR for 1 mL/min increase: 1.04, P<.001) and earlier EC-MPS introduction (OR for 4-week delay: 0.99, P<.03). In the conversion from MMF to EC-MPS group: (1) best drug tolerance was expected less frequently with coadministered cyclosporine versus tacrolimus (OR 0.05, P<.04) and more frequently with younger recipients (OR .001, P<.04); (2) best physician evaluation was expected more frequently with lower EC-MPS dose (OR for 360-mg dose increase: 0.4, P<.01) and with higher eGFR (OR for 5 mL/min increase: 1.42, P<.002). Adverse events were reported among 49/300 patients (16 serious adverse events).

CONCLUSIONS

EC-MPS was tolerated better by younger kidney recipients, when combined with tacrolimus versus cyclosporine, and when introduced earlier after transplantation. EC-MPS tolerance decreased gradually with renal function deterioration.

[Polish multicenter study on safety and efficacy of adefovir dipivoxil in the treatment of lamivudine resistant chronic hepatitis B in adults (HEP 2008)]

Initiated in April 2008 Polish multicenter study HEP2008 aimed clinical data concerning safety and efficacy of adefovir dipivoxil (ADV, Hepsera, Gilead Sciences) in adult chronically infected HBV with lamivudine (LAM) resistance after earliest treatment. We examined 38 men (70.4%) and 16 women (29.6%) with chronic hepatitis B in age 23-81 (average 53) mostly HBeAg positive (70.4%). Majority of patients received earlier LAM (72%), but others additional entekawir and\ or pegylated interferon. Average time from discovering infection HBV was 95 +/- 77 (10-307) months. Majority of patients received monotherapy ADV, but physicians decided at 12 (22%) persons about continuation of LAM therapy. Median HBV DNA level decreased from a baseline value 6.73 +/- 1.71 (1.8-9.0) to 3.25 log10 copies/mL. At least HBV DNA drop 1 log10 and 2 log10 get 78.8 and 60.6% in 24 week, 84.8 and 69.7% in 48 week. HBV DNA reduction below level 300 and 50 copies/mL it observed in 15.2 and 6.1% in 24 week, 39.4 and 30.3% in 48 week. Patients with undetectable Mean ALT activity dropped significantly and were below limit norm at 24 week in 40%, and at 48 week in 58% of patients. Patients treated ADV and LAM reached great reduction of ALT activity but was no influence on HBV DNA reduction. Results of research have confirmed efficiency and safety 48-week's therapy ADV in patients with LAM resistance.

The efficacy and safety of ciclosporin (Equoral®) capsules after renal transplantation: A multicentre, open-label, phase IV clinical trial

BACKGROUND

The use of bioequivalent generic ciclosporin is a cost-effective alternative to non-generic ciclosporin in renal transplant patients. This study aims to explore the efficacy, safety and tolerability of Equoral®, a generic ciclosporin, in adult de novo renal transplant patients.

MATERIAL/METHODS

This was a multicentre, open label, phase IV clinical study consisting of a 6-month treatment and 3-month follow-up periods. Patients underwent renal transplantation supported by an immunosupressive regimen of azathioprine (or mofetil mycophenylate [MMF]), prednisolone and Equoral® (10 mg/kg/day, given 12 hours before patients' surgical procedure, and a maintenance ciclosporin dose of 4-6 mg/kg/day thereafter). The primary endpoint was the rate of occurrence of acute graft rejection over the 6-month period after renal transplantation.

RESULTS

A total of 54 patients were enrolled and constituted the intention-to-treat/safety population, while 52 patients forming the per-protocol population were assessed for efficacy. There were 13 episodes of acute graft rejection reported in 12 patients, and two of these episodes resulted in withdrawal from the study. The probability of acute rejection in patients was less then 24% for the duration of the study including the observation period which is within the usual range. There were no deaths and one graft loss during the study, and the safety and tolerability profile reported was typical of that of ciclosporin in use in de-novo renal transplant patients.

CONCLUSIONS

The use of the generic ciclosporin Equoral® is effective and is associated with the usual safety and tolerability profile of ciclosporin when used as the calcineurin-inhibitor component of an immunosuppressive regimen in de novo renal transplant patients.

Optimal mycophenolic acid and mycophenolic acid glucuronide levels at the early period after kidney transplantation are the key contributors to improving long-term outcomes

INTRODUCTION

Suboptimal mycophenolic acid (MPA) and its metabolite MPA glucuronide (MPAG) levels are associated with significant increased incidences of graft loss. This study assessed the influence of MPA and MPAG C(0) levels on glomerular filtration rate (GFR) values and histopathologic changes in protocol biopsies of kidney allograft recipients.

PATIENTS AND METHODS

This prospective study of 42 low-risk patients receiving mycophenolate mofetil, prednisone, and a low or normal cyclosporine dose included histological assessment, according to the Banff'97 classification, of protocol biopsies before and at 3, 12, and 36 months after transplantation, as well as GFR at 1, 3, 12, 36, and 60 months and MPA enzyme-linked immunosorbent assay, MPAG (HPLC/UV) C(0) levels at 7 days as well as at 1, 3, 12, and 36 months.

RESULTS

We observed nonlinear, significant correlations between MPA, MPAG C(0) levels and subclinical rejection episodes (SCR) according to chronic interstitial changes (ci), chronic tubulitis (ct), arteriolar hyalinization (ah) and chronic allograph nephropathy (CAN) indices in protocol biopsies. MPA C(0) levels below 1.0 to 1.5 microg/mL at day 7 were associated with an increased risk of SCR (P < .03), ci > or = 2 (P < .05), CAN > or = 2 (P < .04), and ah > or = 2 (P < .07). MPAG C(0) levels above 100 to 150 microg/mL at day 7 were associated with a decreased risk of ct > or = 2 (P < .01), ci > or = 2 (P < .04), or CAN > or = 2 (P < .04). We also observed a significant linear positive correlation between MPA C(0) level and a significant negative correlation between MPAG C(0) level at 1 month with GFR.

CONCLUSION

Optimal MPA and MPAG exposure in the early posttransplant period may improve renal graft outcomes.

Safety and tolerance of sodium mycophenolate in patients after renal transplantation--an observational study

BACKGROUND

Enteric-coated mycophenolate sodium (EC-MPS) was developed as an alternative agent to mycophenolate mofetil (MMF), aimed at reduction of gastrointestinal (GI) complications.

METHODS

Seventy-four patients (mean age 42.3 years) switched from MMF to MPS were included in the study and followed-up for 3 months (Visit 0, Visit 2 after 1 month and Visit 3 after 3 months). The mean time from transplantation to switch was 3.7 years. During Visit 2 and 3 the following were recorded: impact of treatment change on the severity of GI symptoms (4 point scale: 1-worsening, 2-no change, 3-improvement, 4-resolution), EC-MPS tolerance, adverse events (AEs), patient compliance and physician satisfaction with treatment (4 point scale: 1-bad, 2-fair, 3-good, 4-very good).

RESULTS

Sixty-three patients completed the study (85.1%). EC-MPS dose ranged from 720 to 1440 mg. GI symptom severity score averaged at 3.41. Symptoms most commonly compelling a conversion were: abdominal pain, diarrhea, abdominal colic, nausea, anorexia and vomiting. Out of 175 complaints, 144 (82%) either improved or resolved, 5 (2.86%) aggravated, and 25 (14.86%) persisted. Patient compliance and mean physician satisfaction score averaged at 3.70 and 3.02 at Visit 3, respectively. 9 AEs (2 severe) were reported. Causal relationship with the medication was suspected in 5 cases (1 case of SAE). The most common AEs were: anemia, infection (including sepsis), GI symptoms (abdominal pain, diarrhea).

CONCLUSIONS

The following was concluded in our study: (1) sodium mycophenolate is well tolerated; (2) after switching from MMF to EC-MPS, gastrointestinal symptoms alleviated; (3) EC-MPS is a safe medication, with a low adverse events rate.

Serum concentration of vitamin D and parathyroid hormone after living kidney donation

BACKGROUND

Metabolic consequences resulting from loss of renal mass in living kidney donors remain uncertain. There is recent focus on the changes in the active form of vitamin D because it is an agent for cancer regulation. The objective of the study was to measure serum concentrations of 1,25-dihydroxycholecalciferol, parathyroid hormone and insulin-like growth factor-1 (IGF-1) in living donors after kidney donation.

PATIENTS AND METHODS

Forty living kidney donors reported for follow-up visits. Their mean age was 46.14 years. They were women in 52.5% of cases. The mean observation period was 65.6 months. Serum 1,25(OH)2D3 and IGF-1 concentrations were measured by radioimmunoassay after extraction. Serum intact parathyroid hormone (PTH) was quantified using an enhanced chemiluminescence immunoassay system.

RESULTS

1,25-dihydroxycholecalciferol deficiency in 57.5% patients after nephrectomy was the most important change we noted. No correlation was observed between 1,25(OH)2D3 and PTH. A decreased serum IGF-1 concentration was observed in 17.5% of donors. However, decreases in both serum IGF-1 and 1,25(OH)2D3 concentrations were observed in 12.5% of donors.

CONCLUSION

Prospective studies may be essential to determine metabolic changes after nephrectomy among living kidney donors.

CTX-M and TEM as predominant types of extended spectrum beta-lactamases among Serratia marcescens isolated from solid organ recipients

BACKGROUND

Serratia marcescens is an important pathogen in hospital infections since organisms resistant to multiple antimicrobials pose a special threat particularly among transplant patients. The aim of this work was to assess the number of strains producing beta-lactamases with extended spectrum (ESBL) among S. marcescens isolated from our patients.

MATERIALS AND METHODS

We investigated S. marcescens isolated from 2005 to 2008 for ESBL. The phenotype methods were applied and additionally we chose strains for polymerase chain reactions using primers for the most popular types of ESBL.

RESULTS

Over the investigated time, 257 patients were infected with S. marcescens with 188 (73%) displaying an ESBL-positive phenotype. A Molecular analysis showed that most of them produced both CTX-M and TEM beta-lactamases. In the last year, the percentage of ESBL-producing strains decreased, but also in the last year, we isolated S. marcescens resistant to carbapenems from three patients.

CONCLUSIONS

The CTX-M type of ESBL predominated among ESBLs produced by strains of S. marcescens. The appearance of strains resistant to carbapenems is alarming.

Resistance to carbapenems among Pseudomonas aeruginosa isolated from patients of transplant wards

BACKGROUND

The aim of the study was to estimate the carbapenems resistance and occurrence of metallo-beta-lactamase (MBL) production among Pseudomonas aeruginosa isolated from patients during the last 2 years.

MATERIALS AND METHODS

We investigated all P aeruginosa strains derived from Transplantation Institute patients, hospitalized from January 2007 to December 2008. E-tests as well as the three-discs method with imipenem, ceftazidime were used for MBL detection. For the chosen strains, a PCR method was applied for detection of genes determining VIM, IMP, and SMP.

RESULTS

Among 311 isolated strains from 228 patients only one strain was used for each patient. We showed increased resistance to carbapenems among P aeruginosa in 2008 compared with 2007: from 14% to 22%. About 60% of resistant strains displayed the MBL phenotype. Upon PCR analysis, the VIM-type metallo-beta-lactamase was detected in 70% of them.

CONCLUSIONS

Despite similar numbers of P aeruginosa-infected patients in 2007 and 2008, the percentage of MBL-producing strains increased from 7% to 15%. Most MBLs belonged to the VIM type.

Bacterial infections in the early period after liver transplantation: etiological agents and their susceptibility

BACKGROUND

The study comprises an analysis of bacterial infections in the early period after liver transplantation (LT) in adults.

MATERIAL/METHODS

Eighty-three patients were followed for four weeks after LT. Samples comprised mainly blood, urine, surgical-site specimens, sputum, and stool. Culture and identification of the isolated microorganisms was done in accordance with standard microbiological procedures. Susceptibility testing was carried out using CLSI guidelines. Statistical analysis was done with Medi-Stat.

RESULTS

In total, 913 samples from LT recipients were cultured. Of the 469 isolated strains, 331 (70.6%) were Gram-positive bacteria, 133 (28.4%) were Gram-negative bacteria, and 5 (1.0%) were yeast-like fungal strains. Of the 284 surgical-site isolates, 222 (78%) were Gram-positive and 61 (21.5%) were Gram-negative bacteria. Of the 99 blood culture isolates, 75 (75.8%) were Gram-positive and 22 (22.2%) of Gram-negative bacterial strains. Of the 73 urine samples, 46 (63.0%) were strains of Gram-negative, 25 (34.0%) of Gram-positive bacteria, and 2 (3.0%) fungal strains. In the 13 respiratory tract samples were 9 (69.0%) Gram-positive and 4 (31.0%) Gram-negative strains. In the 54 stool samples, 63.0% and 16.7% were C. difficile toxin- and culture-positive, respectively. In total, 138 strains of MRCNS, 10 of MRSA, 80 of HLAR, and 19 ESBL(+) were detected.

CONCLUSIONS

The isolation of MDR bacterial strains such as MRSA (52.6%), MRCNS (81.7%), HLAR (86.0%), and ESBL(+) Gram-negative rods (12.5%) from patients after LT indicates the need for strict adherence to infection control procedures.

Molecular epidemiology of vancomycin-resistant Enterococcus faecalis among patients of transplantology wards

OBJECTIVE

Vancomycin-resistant enterococci (VRE) require epidemiological monitoring especially in transplantation wards. The aim of our work was to perform a molecular analysis of vancomycin-resistant Enterococcus faecalis (VREfl) strains among solid organ recipients during various years.

MATERIALS AND METHODS

Strains were examined for the presence of different genes determining vancomycin resistance: vanA, vanB, vanD, or vanG by polymerase chain reaction (PCR). Restriction fragment length polymorphism (RFLP)-pulsed field gel electrophoresis (PFGE) was performed on bacterial DNA digested with SmaI enzyme.

RESULTS

From 2003 to 2006, we isolated 12 strains of VREfl from 8 patients (2 liver and 6 kidney transplantations). All strains harbored the vanA gene. Among the strains, 5 displayed patterns similar to each other, despite being isolated from different patients, and were susceptible to ampicillin with high resistance to aminoglycosides.

CONCLUSIONS

These results suggested that a single strain of VREfl was present for 3 years in closely related hospital wards, but it disappeared in the following years.

Factors predisposing to urinary tract infections in adult kidney allograft recipients with lower urinary tract reconstruction

OBJECTIVE

Urinary bladder augmentation or urinary diversion may be necessary for successful kidney transplantation in cases of serious urinary tract dysfunction. Patients with reconstructions of the urinary collecting system show noninferior graft survival, although urinary tract infections (UTI) may threaten kidney and recipient survivals. Herein we sought to identify risk factors for serious UTIs in cases of urinary collecting system reconstructions and to evaluate kidney survival and function.

PATIENTS AND METHODS

This prospective, case-controlled study included 24 kidney allograft recipients with urinary tract reconstructions who were engrafted from 1999 to 2008. As controls we selected recipients of standard kidney transplants who were matched (1:3) for sex, age, donor type, procedure date, and immunosuppressive regimen.

RESULTS

At posttransplantation 33.6 +/- 28 months follow-up, kidney allograft survival was 83% among the reconstructed and 97% among the control groups (P = NS). Kidney allograft function at 3 months in the reconstruction group showed estimated glomerular filtration rate (eGFR) calculated by the Cockcroft-Gault (C-G) equation of 70.4 +/- 20.8 vs 78.8 +/- 19.2 mL/1.73 m(2) in controls (P = .39), and at the end of follow-up, 66.3 +/- 18.1 vs 77.1 +/- 18.9 mL/1.73 m(2), respectively (P = .26). Urinary tract reconstruction patients experienced UTI in 91.7% of cases (n = 22) vs 45.6% in controls (n = 31; P < .0001). A necessity for in-hospital treatment was observed in 67% vs 28% of cases (P < .001). Urosepsis occurred in 4 study patients and 4 controls (P = NS). We observed an increased risk for serious UTI and a trend to diminished graft function (odds ratio [OR] = 1.6 per 10 ml/min of eGFr C-G; 95% confidence interval (CI) 0.97-2.77; P = .055; and OR = 14.7 per 1 mg/dL of serum creatinine; 95% CI 0.61-352.3; P = .097). Another predictor for UTI was cytomegalovirus disease (CMV).

CONCLUSION

Kidney recipients requiring urinary tract reconstructions additionally benefit from obtaining the best quality allografts and CMV prophylaxis.