Bloodstream infection after kidney transplantation: epidemiology, microbiology, associated risk factors, and outcome. Transplantation. 2010;90:581-587. [PMID: 20585281 DOI: 10.1097/tp.0b013e3181e8a680]

Diagnosing and Managing Urinary Tract Infections in Kidney Transplant Recipients

In the article, the authors review antibiotic treatment options for both acute uncomplicated UTI and complicated UTI. In addition, they review alternative regimens which are needed in the setting of drug-resistant pathogens including vancomycin-resistant Enterococcus, -extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E), carbapenem-resistant Enterobacterales, and carbapenem-resistant Pseudomonas, which are encountered with more frequency.

Bloodstream infections after solid organ transplantation: clinical epidemiology and antimicrobial resistance (2016-21)

Background

Solid organ transplant (SOT) recipients are at risk of bloodstream infections (BSIs) with MDR organisms (MDROs).

Objectives

To describe the epidemiology of BSI in the year after several types of SOT, as well as the prevalence of MDRO infections in this population.

Methods

We conducted a single-centre, retrospective study of kidney, liver, heart, and multi-organ transplantation patients. We examined BSIs ≤1 year from SOT and classified MDRO phenotypes for Staphylococcus aureus, enterococci, Enterobacterales, Pseudomonas aeruginosa and Candida spp. We compared BSI characteristics between SOT types and determined risk factors for 90 day mortality.

Results

We included 2293 patients [1251 (54.6%) kidney, 663 (28.9%) liver, 219 (9.6%) heart and 160 (7.0%) multi-organ transplant]. Overall, 8.5% of patients developed a BSI. BSIs were most common after multi-organ (23.1%) and liver (11.3%) transplantation (P < 0.001). Among 196 patients with BSI, 323 unique isolates were recovered, 147 (45.5%) of which were MDROs. MDROs were most common after liver transplant (53.4%). The most frequent MDROs were VRE (69.8% of enterococci) and ESBL-producing and carbapenem-resistant Enterobacterales (29.2% and 27.2% of Enterobacterales, respectively). Mortality after BSI was 9.7%; VRE was independently associated with mortality (adjusted OR 6.0, 95% CI 1.7-21.3).

Conclusions

BSI incidence after SOT was 8.5%, with a high proportion of MDROs (45.5%), especially after liver transplantation. These data, in conjunction with local antimicrobial resistance patterns and prescribing practices, may help guide empirical antimicrobial selection and stewardship practices after SOT.

Treatment of Asymptomatic Bacteriuria after Kidney Transplantation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives: Asymptomatic bacteriuria (ASB) is prevalent in kidney transplant recipients (KTRs) and is hypothesized to heighten the risk of subsequent urinary tract infections (UTIs). Whether antibiotic treatment of ASB in KTRs is beneficial has not been elucidated. Materials and Methods: We carried out a systematic review and meta-analysis of all randomized controlled trials (RCTs) and quasi-RCTs that examined the merits of managing asymptomatic bacteriuria in KTRs. The primary outcomes were rates of symptomatic urinary tract infections (UTIs) and antimicrobial resistance. Results: Five studies encompassing 566 patients were included. No significant difference in symptomatic UTI rates was found between antibiotics and no treatment groups (relative risk (RR) 1.05, 95% confidence interval (CI) = 0.78-1.41), with moderate heterogeneity (I2 = 36%). Antibiotic treatment was found to present an uncertain risk for the development of drug-resistant strains (RR = 1.51, 95% CI = 0.95-2.40, I2 = 0%). In all trials, no significant difference between study arms was demonstrated regarding patient and graft outcomes, such as graft function, graft loss, hospitalization due to UTI, all-cause mortality, or acute rejection. Conclusions: The practice of screening and treating kidney transplant patients for asymptomatic bacteriuria does not curtail the incidence of future symptomatic UTIs, increase antimicrobial resistance, or affect graft outcomes. Whether early treatment of ASB after kidney transplantation (<2 months) is beneficial requires more RCTs.

Risk Factors and Outcome of Gram-Negative Bloodstream Infection in Living-Donor Renal Transplant Recipients: A Case-Control Study From Pakistan

OBJECTIVES

Gram-negative rods are the most common cause of bloodstream infection in renal transplant recipients. Acute rejection, urologic abnormalities, and ureteral stents are risk factors. Graft dysfunction is independently associated with gram-negative rod bloodstream infection. Our aim is to investigate the incidence, risk factors, and outcome among living donor renal transplant recipients from Pakistan.

MATERIALS AND METHODS

In this case-control study, we reviewed the medical records until June 2021 of renal transplant recipients seen from 2015 to 2019 for gram negative bacteremia. For every case, controls were matched by age, date of transplant, and sex. Demographics, risk factors, graft function, and mortality were compared. Clinical features, immunosuppression, source of blood stream infection, and microbiology were noted in cases.

RESULTS

Of 1677 renal transplant recipients, 44 developed gram negative bacteremia. The incidence was 5.9 per 1000 person-years. Median time since transplant was 5 months. The most common source was urinary tract infection. On univariate analysis, antithymocyte globulin, urinary tract infection, and recurrent urinary tract infections were associated with gram negative bacteremia. On multivariate analysis, urinary tract infection (adjusted odds ratio = 3.46; 95% CI, 1.27-9.37) and recurrent urinary tract infections (adjusted odds ratio = 4.03; 95% CI, 1.15-14.15) were significant risk factors. We found no difference in 30-day mortality and estimated glomerular filtration rate on last follow-up between cases and controls. Kaplan-Meier survival curves showed significant differences in graft survival in patients with gram negative bacteremia. Escherichia coli was the most common organism, with 75% ceftriaxone and 13% imipenem resistance.

CONCLUSIONS

The most significant risk factor for gram negative rod bloodstream infection was recurrent urinary tract infections. Timely treatment and prevention of recurrent urinary tract infections areimperative for prevention of gram negative bacteremia.

Case Commentary: Unlocking the Potential of Bacteriophage to Prevent Recurrent Urinary Tract Infections after Kidney Transplantation

Recurrent urinary tract infections (UTIs) are common in kidney transplant recipients, and novel prevention approaches are needed. The case presented by Le et al. (Antimicrob Agents Chemother, in press) describes a patient with recurrent UTIs due to extended-spectrum β-lactamase-producing Klebsiella pneumoniae who was successfully treated with bacteriophage therapy. This commentary highlights the potential for bacteriophage therapy to prevent recurrent UTIs, as well as outstanding questions that require further investigation.

Bacteremia During the First Year After Solid Organ Transplantation: An Epidemiological Update

Background

There are limited contemporary data on the epidemiology and outcomes of bacteremia in solid organ transplant recipients (SOTr).

Methods

Using the Swiss Transplant Cohort Study registry from 2008 to 2019, we performed a retrospective nested multicenter cohort study to describe the epidemiology of bacteremia in SOTr during the first year post-transplant.

Results

Of 4383 patients, 415 (9.5%) with 557 cases of bacteremia due to 627 pathogens were identified. One-year incidence was 9.5%, 12.8%, 11.4%, 9.8%, 8.3%, and 5.9% for all, heart, liver, lung, kidney, and kidney-pancreas SOTr, respectively (P = .003). Incidence decreased during the study period (hazard ratio, 0.66; P < .001). One-year incidence due to gram-negative bacilli (GNB), gram-positive cocci (GPC), and gram-positive bacilli (GPB) was 5.62%, 2.81%, and 0.23%, respectively. Seven (of 28, 25%) Staphylococcus aureus isolates were methicillin-resistant, 2/67 (3%) enterococci were vancomycin-resistant, and 32/250 (12.8%) GNB produced extended-spectrum beta-lactamases. Risk factors for bacteremia within 1 year post-transplant included age, diabetes, cardiopulmonary diseases, surgical/medical post-transplant complications, rejection, and fungal infections. Predictors for bacteremia during the first 30 days post-transplant included surgical post-transplant complications, rejection, deceased donor, and liver and lung transplantation. Transplantation in 2014-2019, CMV donor-negative/recipient-negative serology, and cotrimoxazole Pneumocystis prophylaxis were protective against bacteremia. Thirty-day mortality in SOTr with bacteremia was 3% and did not differ by SOT type.

Conclusions

Almost 1/10 SOTr may develop bacteremia during the first year post-transplant associated with low mortality. Lower bacteremia rates have been observed since 2014 and in patients receiving cotrimoxazole prophylaxis. Variabilities in incidence, timing, and pathogen of bacteremia across different SOT types may be used to tailor prophylactic and clinical approaches.

Acute Kidney Injury in Kidney Transplant Patients in Intensive Care Unit: From Pathogenesis to Clinical Management

Kidney transplantation is the first-choice treatment for end-stage renal disease (ESRD). Kidney transplant recipients (KTRs) are at higher risk of experiencing a life-threatening event requiring intensive care unit (ICU) admission, mainly in the late post-transplant period (more than 6 months after transplantation). Urosepsis and bloodstream infections account for almost half of ICU admissions in this population; in addition, potential side effects related to immunosuppressive treatment should be accounted for cytotoxic and ischemic changes induced by calcineurin inhibitor (CNI), sirolimus/CNI-induced thrombotic microangiopathy and posterior reversible encephalopathy syndrome. Throughout the ICU stay, Acute Kidney Injury (AKI) incidence is common and ranges from 10% to 80%, and up to 40% will require renal replacement therapy. In-hospital mortality can reach 30% and correlates with acute illness severity and admission diagnosis. Graft survival is subordinated to baseline estimated glomerular filtration rate (eGFR), clinical presentation, disease severity and potential drug nephrotoxicity. The present review aims to define the impact of AKI events on short- and long-term outcomes in KTRs, focusing on the epidemiologic data regarding AKI incidence in this subpopulation; the pathophysiological mechanisms underlying AKI development and potential AKI biomarkers in kidney transplantation, graft and patients' outcomes; the current diagnostic work up and management of AKI; and the modulation of immunosuppression in ICU-admitted KTRs.

Sporotrichosis in a Renal Transplant Patient: A Rare Case Report with a Review of the Literature

Sporotrichosis is a rare form of subacute and chronic fungal infection in renal transplant recipients caused by the ubiquitous fungus Sporothrix schenckii. It is usually described in renal allograft recipients who have not been treated with antifungal prophylaxis. We report a rare case of cutaneous sporotrichosis in a 39-year-old renal allograft recipient already on antifungal prophylaxis, who presented with skin lesions. The diagnosis was made from a skin biopsy. The patient had increased tacrolimus levels after starting treatment with itraconazole, which was later changed to terbinafine and cryotherapy. The patient responded to treatment with regression of his lesions.

The long-term impact of bloodstream infections on patient and graft survival following kidney transplantation

BACKGROUND

There are limited data on the impact of bloodstream infections (BSI) following kidney transplantation (KT) on long term patient outcome.

METHODS

This was a retrospective parallel-cohort study. We included 123 consecutive KT recipients who were admitted with a first episode of BSI between 1/2007-12/2016. They were matched with 225 KT recipients who did not have BSI. Multivariate regression analysis with BSI as time-dependent covariate was used for the effect of BSI on graft loss, all-cause mortality and long-term graft function (defined by the slope of mean serum creatinine level).

RESULTS

During a median follow-up of 89.4 months, post-transplant BSI was independently associated with all-cause mortality (HR 5.56, 95% CI 3.07-10.09, p<0.0001) and graft failure (HR-2.82, 95% CI 1.40-5.64, p = 0.003) after adjustment for potential confounders. This association remained irrespective of the source of infection or pathogen, but became non-significant when appropriate antibiotic therapy was administrated. Baseline kidney function was independently associated with graft failure. Recipients with BSI had lower baseline kidney function, however the BSI episode had no influence on the slope of change in serum creatinine over time.

CONCLUSION

BSI after KT was associated with long-term adverse outcome. This effect was mitigated by the early administration of appropriate antibiotics. This article is protected by copyright. All rights reserved.

Critically important outcomes for infection in trials in kidney transplantation: An international survey of patients, caregivers and health professionals

BACKGROUND

Infections are a common complication following kidney transplantation, but are reported inconsistently in clinical trials. This study aimed to identify the infection outcomes of highest priority for patients/caregivers and health professionals to inform a core outcome set to be reported in all kidney transplant clinical trials.

METHODS

In an international online survey, participants rated the absolute importance of 16 infections and 8 severity dimensions on 9-point Likert Scales, with 7-9 being critically important. Relative importance was determined using a best-worst scale. Means and proportions of the Likert-scale ratings and best-worst preference scores were calculated.

RESULTS

353 healthcare professionals (19 who identified as both patients/caregiver and healthcare professionals) and 220 patients/caregivers (190 patients, 22 caregivers, 8 who identified as both) from 55 countries completed the survey. Both healthcare professionals and patients/caregivers rated bloodstream (mean 8.4 and 8.5 respectively; aggregate 8.5), kidney/bladder (mean 7.9 and 8.4; aggregate 8.1) and BK virus (mean 8.1 and 8.6; aggregate 8.3) as the top 3 most critically important infection outcomes, whilst infectious death (mean 8.8 and 8.6; aggregate 8.7), impaired graft function (mean 8.4 and 8.7; aggregate 8.5) and admission to the intensive care unit (mean 8.2 and 8.3; aggregate 8.2) were the top 3 severity dimensions. Relative importance (best-worst) scores were consistent.

CONCLUSIONS

Healthcare professionals and patients/caregivers consistently identified bloodstream infection, kidney/bladder infections and BK virus as the three most important infection outcomes, and infectious death, admission to intensive care unit and infection impairing graft function as the three most important infection severity outcomes. This article is protected by copyright. All rights reserved.

Bacterial and Viral Infection and Sepsis in Kidney Transplanted Patients

Kidney transplanted patients are a unique population with intrinsic susceptibility to viral and bacterial infections, mainly (but not exclusively) due to continuous immunosuppression. In this setting, infectious episodes remain among the most important causes of death, with different risks according to the degree of immunosuppression, time after transplantation, type of infection, and patient conditions. Prevention, early diagnosis, and appropriate therapy are the goals of infective management, taking into account that some specific characteristics of transplanted patients may cause a delay (the absence of fever or inflammatory symptoms, the negativity of serological tests commonly adopted for the general population, or the atypical anatomical presentation depending on the surgical site and graft implantation). This review considers the recent available findings of the most common viral and bacterial infection in kidney transplanted patients and explores risk factors and outcomes in septic evolution.

Characteristics and Outcomes of Bloodstream Infections in a Tertiary-Care Pediatric Hematology-Oncology Unit: A 10-Year Study

Bloodstream infections (BSIs) after chemotherapy or hematopoietic stem cell transplantation (HSCT) are a leading cause of morbidity and mortality. Data on 154 BSIs that occurred in 111 onco-hematological patients (57 hematological malignancies, 28 solid tumors, and 26 non-malignant hematological diseases) were retrospectively collected and analyzed. Monomicrobial Gram-positive (GP), Gram-negative (GN), and fungal BSIs accounted for 50% (77/154), 38.3% (59/144), and 3.2% (5/154) of all episodes. Polymicrobial infections were 7.8% (12/154), while mixed bacterial-fungal infections were 0.6% (1/154). The most frequent GN isolates were Escherichia coli (46.9%), followed by Pseudomonas aeruginosa (21.9%), Klebsiella species (18.8%), and Enterobacter species (6.3%). Overall, 18.8% (12/64) of GN organisms were multidrug-resistant (seven Escherichia coli, three Klebsiella pneumoniae, and two Enterobacter cloacae), whereas GP resistance to glycopeptides was observed in 1% (1/97). Initial empirical antibiotic therapy was deemed inappropriate in 12.3% of BSIs (19/154). The 30-day mortality was 7.1% (11/154), while the bacteremia-attributable mortality was 3.9% (6/154). In multivariate analysis, septic shock was significantly associated with 30-day mortality (p = 0.0001). Attentive analysis of epidemiology and continuous microbiological surveillance are essential for the appropriate treatment of bacterial infections in pediatric onco-hematological patients.

Incidencia de infecciones en el postrasplante renal inmediato

Introducción: El receptor de un trasplante renal es un paciente de alto riesgo para sufrir infección debido a las potenciales complicaciones quirúrgicas y al tratamiento inmunosupresor que reciben.El desarrollo de infecciones supone un riesgo aumentado de pérdida del injerto y de la mortalidad. Objetivos: El objetivo principal fue conocer la incidencia de las infecciones más frecuentes en el paciente con un trasplante renal, durante el periodo postrasplante inmediato.Los objetivos secundarios fueron describir los gérmenes responsables de las infecciones más frecuentes y analizar la relación entre los tipos de infección estudiados y sus posibles factores de riesgo. Metodología: Estudio observacional retrospectivo en pacientes trasplantados renales entre enero de 2018 y diciembre de 2019 durante el periodo del postrasplante inmediato.Resultados: La incidencia de infección fue 69,4%, los síndromes descritos fueron infección del tracto urinario (48%), bacteriemia (9,2%), infección relacionada con catéter (8,2%) e infección por citomegalovirus (4,1%). Los microorganimos más frecuentemente implicados, en estos procesos infecciosos fueron Escherichia coli (16,3%), Enterococus faecium (12,2%) y Enterobacter cloacae (8,1%).Se ha encontrado relación significativa entre la aparición de infección y la duración del ingreso, así como con la presencia o no del antecedente personal de hipertensión arterial. También entre la incidencia de infección relacionada con el catéter venoso central y el tiempo que permaneció insertado. Conclusiones: La infección más frecuente encontrada en el postrasplante renal inmediato fue la infección del tracto urinario, mientras que el microorganismo más presente habitualmente en los procesos infecciosos fue la Escherichia coli.

Vancomycin Nephrotoxicity Causing Renal Transplant Acute Kidney Injury

Nephrotoxicity is a rather frequent side effect of vancomycin treatment. Attributes of vancomycin nephrotoxicity (VN) are well documented, including its clinical manifestations and renal morphologic changes. However, VN has not been emphasized as the cause of acute kidney injury (AKI) in the renal transplant setting. We report the first 3 such cases. In each of these cases, AKI developed concurrently with vancomycin treatment and resolved after its cessation. As compared with the general population, VN in the renal transplant setting displayed some unusual clinical behaviors. Its development was rather capricious, being noted in some but not every episode of vancomycin treatment, even in the same individual. AKI developed gradually in conjunction with protracted vancomycin treatment, in contrast to a precipitous course in the nontransplant setting. However, renal transplant biopsies showed typical features of VN in each case. VN is an unusual but now well-documented cause of AKI in renal transplant recipients. VN in this setting may display some atypical features, setting it apart from that in the general population. However, renal transplant biopsy changes are characteristic and are amenable to a definitive diagnosis.

Blood Stream Infections from MDR Bacteria

BACKGROUND

Bloodstream infections (BSIs) constitute a growing public health concern, are among the most severe nosocomial pathologies, and are considered a worldwide cause of unfaithful outcomes, increasing treatment costs and diagnostic uncertainties. BSIs are one of the most frequent lethal conditions that are managed in intensive care units (ICUs). In the case of septic shock, immune deficiency, and delayed treatment, even with adequate antimicrobial therapy and/or source control, the outcomes are often unfavorable.

METHODS

this review article summarizes the epidemiological and microbiological characteristics of BSIs with a particular focus on ICU acquired BSIs (ICU-BSIs), which are usually caused by multidrug-resistant (MDR) pathogens. For this reason, their antimicrobial resistance patterns and therapeutic options have also been compiled.

RESULTS

ICU-acquired BSIs prevail in 5-7% of ICU patients. Klebsiella pneumoniae, Escherichia coli, Acinetobacter baumannii, and Pseudomonas aeruginosae are the pathogens most often responsible for MDR infections. MDR Enterobacteriaceae have seen their prevalence increase from 6.2% (1997-2000) to 15.8% (2013-2016) in recent years.

CONCLUSIONS

Considering that prevention and treatment of sepsis is nowadays considered a global health priority by the World Health Organization, it is our obligation to invest more resources into solving or reducing the spread of these unfaithful infections. It is relevant to identify patients with risk factors that make them more susceptible to BSIs, to guarantee earlier molecular or microbiological diagnoses, and more rapidly appropriate treatment by using de-escalation strategies where possible.

Recommendations of the AFU Infectious Diseases Committee on the prevention, diagnosis and treatment of infections of endo-ureteral equipment

INTRODUCTION

No recent national guidelines exist regarding the management of urinary tract infections (UTIs) in the presence of ureteral stent. This situation could lead to discrepancies in clinical management and less opportunity for a favorable patient's outcome.

METHODS

All available data published on Medline® between 1998 and 2018 were systematically searched and reviewed. All papers assessing adult patients carrying ureteral stent were included for analysis. After studies critical analysis, national guidelines for clinical management were elaborated in order to answer clinical questions.

RESULTS

A total of 451 articles were identified, of which 58 have been included. The prevalence of urinary tract infections in the presence of ureteral stent remains unknown. After 3 months, all endo-ureteral devices were colonized on microbiological study. These patients also presented a positive urine culture in 25 to 70% of the cases, often polymicrobial. Staphylococci, E. coli, Klebsiella, Pseudomonas, Enterococcus and Candida were the commonest micro-organisms responsible for urinary colonization or infection. The risk of UTI on endo-ureteral devices seemed higher the longer it stayed implanted. There is no justification in the literature to recommend a systematic change of endo-ureteral devices following a urinary tract infection.

DISCUSSION

The existing literature is rich but of poor methodological quality, and therefore does not allow to draw robust conclusions. The greatest difficulty faced in this work was to accurately differentiate urinary colonizations from true infections, including clinical symptoms and not only microbiological results.

CONCLUSION

These guidelines propose a standardized management of such common clinical situations. Well-designed studies are needed to upgrade the level of evidence of these guidelines.

Asymptomatic Bacteriuria in Post Renal Transplant Patients: To Treat or Not?

Urinary tract infections (UTIs) can commonly occur within the first few weeks following kidney transplantation procedures. Although the management of asymptomatic bacteriuria and acute graft pyelonephritis is important to reduce the risk of graft rejections following kidney transplantation, the efficacy of antibiotics administration remains controversial among studies in the literature. The aim of this review is to elaborate more on asymptomatic bacteriuria following kidney transplantation and try to formulate proper evidence about the efficacy of antibiotics administration on eliminating the frequency of infections and enhancing the quality of care for patients. Most studies in the literature are observational, which are usually biased in the interventions. However, the current evidence regarding the management and screening of asymptomatic bacteriuria seems to discourage such an approach. Almost all of the included studies reported that antibiotic administration did not significantly lower the rates of secondary symptomatic UTIs or enhance the functions of the graft. In addition, there is no significant impact on mortality and other clinical outcomes. Lastly, the frequent administration of antibiotics can significantly increase the risk of recurrence due to the emergence of novel strains of bacteria that are resistant to the currently administered antibiotics making it unfavorable.

Bacterial and fungal bloodstream infections in pediatric liver and kidney transplant recipients

Background

Bacterial and fungal bloodstream infections (BSI) are common after pediatric liver and kidney transplantations and associated with morbidity and mortality. However, knowledge about incidence rates, pathogen composition, and resistance patterns is limited. We aimed to describe the pattern of bacterial and fungal BSI in a cohort of pediatric liver and kidney transplant recipients.

Methods

A prospective study of 85 pediatric liver and kidney transplant recipients transplanted from 2010 to 2017 with a total of 390 person-years of follow-up. Clinical characteristics and BSI were retrieved from national registries assuring nationwide follow-up for at least 1 year. BSI incidence rates and pathogen composition were investigated and stratified by the time post-transplantation and type of transplanted organ.

Results

A total of 29 BSI were observed within the first 5 years post-transplantation with 16 different pathogens. The overall incidence rate of first BSI was 1.91 per 100 recipients per month (95% CI, 1.1–3.1) in the first year post-transplantation. The most common pathogens were Enterococcus faecium, Candida albicans, Escherichia coli, and Klebsiella pneumoniae. The pathogen composition depended on the transplanted organ with a higher proportion of BSI with Enterobacterales in kidney transplant recipients than in liver transplant recipients (67% vs. 20%, p = 0.03), while multiple pathogens were detected in the liver transplant recipients.

Conclusions

BSI were common in pediatric liver and kidney transplant recipients and the pathogen composition differed between liver and kidney transplant recipients. Guidelines for empiric antibiotic therapy should consider the type of transplanted organ as well as the local resistance patterns.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06224-2.

Epidemiology and Risk Factors Associated With Mortality in Consecutive Patients With Bacterial Bloodstream Infection: Impact of MDR and XDR Bacteria

Background

 Mortality related to bloodstream infections (BSIs) is high. The epidemiology of BSIs is changing due to the increase in multidrug resistance, and it is unclear whether the presence of multidrug-resistant (MDR) organisms, per se, is an independent risk factor for mortality. Our objectives were, first, to describe the epidemiology and outcome of BSIs and, second, to determine the risk factors associated with mortality among patients with BSI.

Methods

 This research used a single-center retrospective observational study design. Patients were identified through microbiological reports. Data on medical history, clinical condition, bacteria, antimicrobial therapy, and mortality were collected. The primary outcome was crude mortality at 30 days. The relationships between mortality and demographic, clinical, and microbiological variables were analyzed by multivariate analysis.

Results

 A total of 1049 inpatients were included. MDR bacteria were isolated in 27.83% of patients, where 2.14% corresponded to an extremely drug-resistant (XDR) isolate. The crude mortality rates at days 7, 30, and 90 were 12.11%, 25.17%, and 36.13%, respectively. Pitt score >2, lung and abdomen as site of infection, and XDR Pseudomonas aeruginosa were independent risk factors for 7-, 30-, and 90-day mortality. Charlson score >4, carbapenem-resistant Klebsiella pneumoniae, and XDR Acinetobacter baumannii were independent risk factors for 30- and 90-day mortality. Infection by XDR gram-negative bacteria, Charlson score >4, and immunosuppression were independent risk factors for mortality in patients who were stable at the time of BSI.

Conclusions

 BSI is an event with an extreme impact on mortality. Patients with severe clinical condition are at higher risk of death. The presence of XDR gram-negative bacteria in blood is strongly and independently associated with patient death.

Bloodstream infections by gram-negative bacteria in kidney transplant patients: Incidence, risk factors, and outcome

BACKGROUND

Kidney transplant recipients (KTRs) are at increased risk of infections.

METHODS

The aims of this study were to describe the incidence of bloodstream infections (BSIs) by gram-negative bacteria in a cohort of KTRs, the risk factors for BSI due to multi-drug-resistant (MDR) gram-negative bacteria, and the predictors for unfavorable outcome, defined as death or nephrectomy or return to dialysis, within 30 days from BSI. We conducted a retrospective cohort study at the renal transplant unit of a tertiary care hospital in Athens, Greece.

RESULTS

In a total of 1962 KTRs, we recorded 195 BSI episodes in 182 single patients (male/female = 97/85), with a median (interquartile range) age of 57.2 (44-64.9) years. The incidence was 1.393/100 patient-years. The most common source of infection was urinary tract (70.9%), and Escherichia coli (63.7%) was the most common pathogen. 19.2% of the infecting organisms were MDR; previous antibiotic use (OR 8.2; CI 2.1-32.9) and previous stay in the intensive care unit (OR 34.2; CI 1.6-730.2) were associated with MDR BSIs. 6% of patients died, and 2.2% underwent nephrectomy, while no patients had to return to dialysis. Diabetes mellitus (OR 8.1; 95% CI 1.3-50.3), Pseudomonas aeruginosa BSI (OR 46.1; 95% CI 3.9-552.3), and septic shock (OR 46.7; 95% CI 1.7-1304.9) were independent predictors of unfavorable outcome.

CONCLUSION

Bloodstream infections in KTRs have a significant impact on allograft and patients outcome.

Epidemiology and Outcomes of Bloodstream Infections in HIV-Patients during a 13-Year Period

No data on antibiotic resistance in bloodstream infection (BSI) in people living with HIV (PLWH) exist. The objective of this study was to describe BSI epidemiology in PLWH focusing on multidrug resistant (MDR) organisms. A retrospective, single-center, observational study was conducted including all positive blood isolates in PLWH from 2004 to 2017. Univariable and multivariable GEE models using binomial distribution family were created to evaluate the association between MDR and mortality risk. In total, 263 episodes (299 isolates) from 164 patients were analyzed; 126 (48%) BSI were community-acquired, 137 (52%) hospital-acquired. At diagnosis, 34.7% of the patients had virological failure, median CD4 count was 207/μL. Thirty- and 90-day mortality rates were 24.2% and 32.4%, respectively. Thirty- and 90-day mortality rates for MDR isolates were 33.3% and 46.9%, respectively (p < 0.05). Enterobacteriaceae were the most prevalent microorganisms (29.8%), followed by Coagulase-negative staphylococci (21.4%), and S. aureus (12.7%). In BSI due to MDR organisms, carbapenem-resistant K. pneumoniae and methicillin-resistant S. aureus were associated with mortality after adjustment for age, although this correlation was not confirmed after further adjustment for CD4 < 200/μL. In conclusion, BSI in PLWH is still a major problem in the combination antiretroviral treatment era and it is related to a poor viro-immunological status, posing the question of whether it should be considered as an AIDS-defining event.

Management of Antimicrobial Agents in Abdominal Organ Transplant Patients in Intensive Care Unit

PURPOSE OF REVIEW

Early diagnosis of infections and immediate initiation of appropriate antimicrobials are crucial in the management of patients before and after organ transplantation. We reviewed the most recent literature and guidelines in this field and organized the current recommendations for healthcare professionals caring for critically ill organ transplant recipients.

RECENT FINDINGS

The incidence of multidrug-resistant organisms is increasing. Multidrug-resistant Gram-negative bacteria comprise about 14% of organisms. Vancomycin-resistant enterococci bloodstream infections are also on the rise, as 20.5% of nosocomial enterococci are now vancomycin-resistant, changing empiric antibiotic selection. Fluconazole-resistant Candida species comprise up to 46% of cases of candidemia in hospitalized patients. Consequently, new guidelines recommend primary use of echinocandins in patients with candidemia who have moderate-to-severe disease. Finally, the incidence of emergence of ganciclovir-resistant cytomegalovirus infection in patients is 5-12%, requiring early recognition and change to alternative regimens in the case of poor response to therapy.

SUMMARY

Bloodstream infections are a major cause of mortality and morbidity in solid organ transplantation. Mortality as high as 24% and 50% have been reported with sepsis and septic shock respectively. As such, bloodstream infections should be diagnosed rapidly and intravenous antibiotics should be started immediately. Appropriate resuscitation should be initiated and the number and/or dose of immunosuppressive drugs should be reduced. Proper source control must also be achieved with radiologic drainage or surgical intervention as appropriate. Initial antibiotic treatment of these patients should cover both Gram-positive organisms, especially in the presence of intravascular catheters, and Gram-negative bacteria. Echinocandins like caspofungin should also be considered especially in critically ill patients, particularly if a patient has been on total parenteral nutrition or broad-spectrum antibiotics.

Risk factors for complications and graft failure in kidney transplant patients with sepsis

Immunosuppressive therapies decrease the incidence of acute kidney rejection after kidney transplantation, but also increase the risk of infections and sepsis. This study aimed to identify the risk factors associated with complications and/or graft failure in kidney transplant patients with sepsis. A total of 14,658 kidney transplant patients with sepsis, identified in the National Inpatient Sample (NIS) database (data from 2005-2014), were included in the study and classified into three groups: patients without complications or graft failure/dialysis (Group 1), patients with complications only (Group 2), and patients with complications and graft failure/dialysis (Group 3). Multinomial logistic regression analyses were conducted to evaluate factors associated with kidney transplant recipients. Multivariate analysis showed that, compared to Group 1, patients from Group 2 or Group 3 were more likely to be Black and to have cytomegalovirus infection, coagulopathy, and glomerulonephritis (p ≤ 0.041). Also, Group 2 was more likely to have herpes simplex virus infection, and Group 3 was more likely to have hepatitis C infection and peripheral vascular disorders, compared to Group 1 (p ≤ 0.002). In addition, patients in Group 3 were more likely to be Black and to have hepatitis C infection, peripheral vascular disorders, coagulopathy, and hypertension compared to Group 2 (p ≤ 0.039). Age and female gender were associated with lower odds of complications after kidney transplantation regardless of graft rejection/dialysis (p ≤ 0.049). Hyperlipidemia and diabetes decreased the chance of complications and graft failure/dialysis after kidney transplant (p < 0.001). In conclusion, the study highlights that black race, male gender, and specific comorbidities can increase the risk of complications and graft failure in kidney transplant patients with sepsis.

Antibiotic Treatment Versus No Treatment for Asymptomatic Bacteriuria in Kidney Transplant Recipients: A Multicenter Randomized Trial

Background

Whether antibiotic treatment of asymptomatic bacteriuria (AB) can prevent acute graft pyelonephritis (AGP) in kidney transplant (KT) recipients has not been elucidated.

Methods

In this multicenter, open-label, nonblinded, prospective, noninferiority, randomized controlled trial, we compared antibiotic treatment with no treatment for AB in KT recipients in the first year after transplantation when urinary catheters had been removed. The primary endpoint was the occurrence of AGP. Secondary endpoints included bacteremic AGP, cystitis, susceptibility of urine isolates, graft rejection, graft function, graft loss, opportunistic infections, need for hospitalization, and mortality.

Results

We enrolled 205 KT recipients between 2013 and 2015. AB occurred in 41 (42.3%) and 46 (50.5%) patients in the treatment and no treatment groups, respectively. There were no differences in the primary endpoint in the intention-to-treat population (12.2% [5 of 41] in the treatment group vs 8.7% [4 of 46] in the no treatment group; risk ratio, 1.40; 95% confidence interval, 0.40–4.87) or the per-protocol population (13.8% [4 of 29] in the treatment group vs 6.7% [3 of 45] in the no treatment group; risk ratio, 2.07, 95% confidence interval, 0.50–8.58). No differences were found in secondary endpoints, except for antibiotic susceptibility. Fosfomycin (P = .030), amoxicillin-clavulanic (P < .001) resistance, and extended-spectrum β-lactamase production (P = .044) were more common in KT recipients receiving antibiotic treatment for AB.

Conclusions

Antibiotic treatment of AB was not useful to prevent AGP in KT recipients and may increase antibiotic resistance. However, our findings should be regarded with caution, due to the small sample size analyzed.

Urinary tract infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of urinary tract infections (UTI) in solid organ transplantation, focusing on kidney transplant (KT) recipients. KT recipients have unique risk factors for UTI, including indwelling stents and surgical manipulation of the genitourinary tract. KT recipients experience multi-drug antibiotic-resistant infections-UTI prevention and management strategies must consider risks of antimicrobial resistance. Non-antimicrobial prevention strategies for UTI in KT recipients are reviewed. It is important to recognize that some renal transplant recipients with UTI may primarily present with fever, malaise, leukocytosis, or a non-specific sepsis syndrome without symptoms localized to the urinary tract. However, asymptomatic bacteriuria (AB) must be distinguished from UTI because AB is not necessarily a disease state. Accumulating data indicate that there are no benefits of antibiotics for treatment of AB in KT recipients more than 2 months after post-transplant. Further research is needed on management of AB in the early (<2 months) post-transplant period, prophylaxis for UTI in this era of antibiotic resistance, recurrent UTI, non-antimicrobial prevention of UTI, and uropathogens identified in donor urine and/or preservative fluid cultures.

Bacteremia in kidney transplant recipients: Burden, causes, and consequences

Bacteremia is an important complication after kidney transplantation. We examined bacteremia and its outcomes in a large cohort of kidney transplant recipients. Kidney transplants from 1-Jul-2004 to 1-Dec-2014 at the Toronto General Hospital were eligible for study inclusion. Bacteremia was defined as two blood culture positives for common skin contaminants or one blood culture positive for other organisms. The cumulative incidence of first bacteremia was estimated using the Kaplan-Meier method, and risk factors were examined in a Cox proportional hazards model. The risk of graft failure or death was assessed in a time-dependent Cox model. Over follow-up, 154 of 1333 patients had at least one bacteremia episode. The cumulative incidence of first bacteremia was 6.8% (6 months) and 11.9% (5 years). Risk factors included recipient diabetes mellitus, time on dialysis, dialysis modality, delayed graft function, donor age, and donor eGFR. Bacteremia increased the risk of total graft failure (hazard ratio 2.11 [95% CI: 1.50, 2.96]), death-censored graft failure (1.73 [0.99, 3.02]), and death with graft function (2.52 [1.63, 3.89]). In conclusion, bacteremia is common after kidney transplantation and impacts both graft and patient survival. Identifying high-risk patients for targeted preventive strategies may reduce the burden and adverse consequences of this important complication.

Comparison of interventional and surgical myocardial revascularization in kidney transplant recipients - A single-centre retrospective analysis

Background

Kidney transplant recipients (KTR) reflect a high-risk population for coronary artery disease (CAD). CAD is the most common cause for morbidity and mortality in this population. However, only few data are available on the favourable revascularization strategy for these patients as they were often excluded from studies and not mentioned in guidelines.

Methods

This retrospective single-centre study includes patients with a history of kidney transplantation undergoing myocardial revascularization for multivessel or left main CAD by either percutaneous coronary intervention (PCI, n = 27 patients) or coronary artery bypass grafting (CABG, n = 24 patients) at University Hospital Frankfurt, Germany, between 2005 and 2015.

Results

In-hospital mortality was higher in the CABG group (20.8% vs. 14.8% PCI group; p = 0.45). In Kaplan-Meier analysis, one-year-survival showed better outcome in the PCI group (85.2% vs. 75%). After four years, outcome was comparable between both strategies (PCI 66.5% vs. CABG 70.8%; log-rank p = 0.94).

Acute kidney injury (AKI), classified by Acute Kidney Injury Network, was observed more frequently after CABG (58.3% vs. 18.5%; p < 0.01). After one year, graft survival was 95.7% in the PCI group and 94.1% in the CABG group. Four year follow-up showed comparable graft survival in both groups (76.8% PCI and 77.0% CABG; p = 0.78).

Conclusion

In this retrospective single-centre study of KTR requiring myocardial revascularization, PCI seems to be superior to CABG with regard to in-hospital mortality, acute kidney injury and one-year-survival. To optimise treatment of these high-risk patients, larger-scaled studies are urgently warranted.

Epidemiology, susceptibility, and risk factors for acquisition of MDR/XDR Gram-negative bacteria among kidney transplant recipients with urinary tract infections

Background

Multiple drug resistant/extensively drug resistant (MDR/XDR) Gram-negative urinary tract infections (UTIs) represent a growing threat to kidney transplant recipients. This retrospective study aimed to assess the incidence and microbiological profile of MDR/XDR Gram-negative UTIs, to identify drug susceptibility of MDR/XDR bacteria, and to determine the potential risk factors for MDR/XDR UTIs in kidney recipients.

Materials and methods

During the study period, 1569 patients underwent consecutive kidney transplantation in two transplantation centers. We studied the demographics, clinical characteristics, and urine culture data from kidney recipients with MDR/XDR Gram-negative UTIs, and verified the risk factors associated with MDR/XDR infections.

Results

Eighty-one kidney recipients yielded 88 episodes of MDR/XDR Gram-negative UTIs with five patients (6.2%) succumbing to all-cause in-hospital mortality. The most frequently isolated bacterium was Escherichia coli (62.5%). Almost all MDR/XDR Gram-negative bacteria were resistant to first- and second-generation cephalosporin, and monocyclic beta-lactam. They were relatively sensitive to meropenem, amikacin, and tigecycline. As for the 12 XDR bacteria, all of them were resistant to meropenem and 25% of them were resistant to tigecycline. All XDR Acinetobacter baumannii and E. coli were susceptible to tigecycline. Nosocomial infection (odds ratio [OR] = 11.429, 95% CI = 1.311–99.625, P = 0.027) was the only independent predictor of MDR/XDR Gram-negative UTIs. Non-fermenting bacterial infection (OR = 20.161, 95% CI = 3.409–119.240, P = 0.001), polycystic kidney disease (OR = 39.871, 95% CI = 1.979–803.384, P = 0.016), and serum creatinine level > 1.5 mg/dL (OR = 8.688, 95% CI = 1.354–55.747, P = 0.023) were significantly different between XDR and MDR Gram-negative UTIs.

Conclusion

Meropenem, amikacin, and/or tigecycline can be prescribed for MDR/XDR Gram-negative infections. Tigecycline can also be prescribed for XDR A. baumannii and E. coli. Nosocomial infection was a risk factor for MDR/XDR Gram-negative UTIs, while XDR UTIs were associated with non-fermenting bacterial infection, polycystic kidney disease, and impaired renal function.

Epidemiology and management of healthcare-associated bloodstream infections in non-neutropenic immunosuppressed patients: a review of the literature

Advancements in medicine have led to a considerable increase in the proportion of patients living with severe chronic diseases, malignancies, and HIV infections. Most of these conditions are associated with acquired immune-deficient states and treatment-related immunosuppression. Although infections as a result of neutropenia have long been recognized and strategies for management were developed, non-neutropenic immunosuppression has been overlooked. Recently, community-acquired infections in patients with frequent, significant exposure to healthcare settings and procedures have been classified as 'healthcare-associated infections' since they are more similar to hospital-acquired infections. Most of the non-neutropenic immunosuppressed patients have frequent contact with the healthcare system due to their chronic and severe diseases. In this review, we focus on the healthcare-associated bloodstream infections in the most common non-neutropenic immunosuppressive states and provide an update of the recent evidence for the management of these infections.

Genitourinary Tract Infections

Similarly to the general population, genitourinary tract infections are common conditions in theimmunocompromised host. They can be furthermore divided into infections of the urinary tract and genital tract infections. Transplant recipients are more likely to have infections of the urinary tract infections while persons with human immunodeficiency virus (HIV) are at higher risk for the second group of infections, especially sexually transmitted infections (STIs). Manifestations of these diseases can be associated with more complications and can be more severe. We provide an overview of manifestations, diagnosis, and management of these disorders.

Urinary Tract Infections in Kidney Transplant Recipients Hospitalized at a Transplantation and Nephrology Ward: 1-Year Follow-up

INTRODUCTION

The aim of this study was to investigate risk factors for urinary tract infections (UTI), the causative organisms of UTI and also their management and treatment. In addition, we evaluated the effects of UTI on renal graft function.

METHODS

This analysis included 107 kidney transplant recipients (64% women) with a diagnosis of UTIs confirmed by positive results on urine culture. Type of pathogens, sensitivity to drugs, risk factors for infection, incidence of urosepsis, hospitalization period, treatment methods, and recurrence rates were analyzed. Statistical analysis was performed by using Pearson's χ(2) test, Yates' χ(2) test, the Student t test, Welch's t test, the Mann-Whitney U test, Fisher's exact test, and the Shapiro-Wilk normality test.

RESULTS

The most common species isolated from urine samples included Escherichia coli (42%), Klebsiella pneumoniae (15%), and Enterococcus faecalis (10%). The percentage of multidrug-resistant strains was 31%, and urosepsis was diagnosed in 16% of patients. Recurrences developed in 76% of infected patients. Bricker ureterointestinal anastomosis was performed in 11% of patients. Risk factors for severe infections included: pre-transplantation urinary tract surgery (P = .02), double-J stent insertion (more common in men) during KTx (N = 34; 32%), (P = .021), reoperations following transplantation (P = .36), elevated tacrolimus levels at the time of infection (P = .024). Severe infections were diagnosed in patients with lower eGFRs, were associated with a need for longer hospitalization (P = .04) and escalation of antibacterial treatment. Carbapenems were used in 22 patients (20.5%).

CONCLUSIONS

UTIs were more common in women, in patients with impaired function of the kidney transplant, and in those with a history of urinary tract interventions. Severe infections were associated with a risk of urosepsis, longer hospitalization, and a need for escalation of antibiotic treatment.

Factors influencing mortality in abdominal solid organ transplant recipients with multidrug-resistant gram-negative bacteremia

Background

Although multidrug-resistant (MDR) gram-negative bacteremia (GNB) has been recognized as an important cause of morbidity and mortality among abdominal solid organ transplant (ASOT) recipients, there are no data on its prognostic factors after an interim standard definition of MDR was proposed in 2012. The objective of this study was to describe the epidemiology, microbiology, and predictors of infection-related 30-day mortality in ASOT recipients with MDR GNB.

Methods

We performed a retrospective, double-center analysis of ASOT patients with MDR GNB over a 13-year study period. Univariate and multivariate analyses were performed to identify the risk factors for mortality.

Results

During the observational period, 2169 subjects underwent ASOT. Ninety-nine episodes of MDR GNB were diagnosed in 91 (4.6%) ASOT recipients, with a predominance of E.coli (29 isolates, 29.3%) and A.baumanii (24 isolates, 24.2%). The median age of these 91 recipients was 45 years (interquartile range 35–54). Mortality after the first episode of MDR GNB was 39.6% (36 deaths). The univariate analysis identified the following variables as predictors of MDR GNB-related mortality: lung focus (P = 0.001),nosocomial origin (P = 0.002), graft from donation after cardiac death or deceased donors (P = 0.023), presence of other concomitant bloodstream infection (P < 0.001), temperature of 40 °C or greater at the onset of MDR GNB (P = 0.039), creatinine > 1.5 mg/dl (P = 0.006), albumin < 30 g/L (P = 0.009), platelet count < 50,000/mm³ (P < 0.001), and septic shock (P < 0.001). In the multivariate logistic regression analysis, septic shock (odds ratio (OR) = 160.463, 95% confidence interval (CI) = 19.377–1328.832, P < .001), as well as creatinine > 1.5 mg/dl (OR = 24.498, 95% CI = 3.449–173.998, P = 0.001), nosocomial origin (OR = 23.963, 95% CI = 1.285–46.991, P = 0.033), and presence of other concomitant bloodstream infections (OR = 27.074, 95% CI = 3.937–186.210, P = 0.001) were the variables associated with MDR GNB-related 30-day mortality.

Conclusions

MDR GNB was associated with high morbidity and mortality in ASOT recipients, with a predominant causative organisms being E.coli and A.baumanii. Nosocomial origin, as well as presence of other concomitant bloodstream infections, increased creatinine level and septic shock were the main predictors of MDR GNB-related 30-day mortality.

Risk and prognosis of bacteremia and fungemia among first-time kidney transplant recipients: a population-based cohort study

BACKGROUND

Bacterial infections are common complications in kidney transplant recipients (KTRs). Little is known about incidence rates of bacteremia and fungemia (BAF) in KTRs.

METHODS

In this population-based cohort study, we used medical and administrative registries to identify episodes of BAF among KTRs in the Central Denmark and North Denmark Regions during 1995-2010. KTRs were followed from the date of their first transplantation to the earliest of BAF, graft loss, death, emigration or 31 December 2010. We calculated incidence rates of first BAF episode overall and stratified by time from transplantation. Potential risk factors were assessed using Cox regression analysis. The Kaplan-Meier analysis was used to estimate 30- and 90-day mortality.

RESULTS

Among 612 KTRs, we identified 138 first episodes of bacteremia during 2397 person-years of follow-up (PYFU). The overall incidence rate (IR) was 5.8 BAF episodes per 100 PYFU (95% confidence interval [CI]: 4.9-6.8). The incidence rate declined from 84.0 per 100 PYFU (95% CI: 61.6-114.5) during post-transplant day 0-30 to 2.3 per 100 PYFU (95% CI: 1.7-3.0) from post-transplant day 365 and onwards. Hospital-onset BAF comprised 39% of the episodes of BAF. The most frequently isolated microorganisms were Escherichia coli and Klebsiella species causing 49 (35.5%) and 29 (21.0%) episodes of BAF, respectively. The 30-day mortality was 2.1% (95% CI: 0.7-6.6).

CONCLUSIONS

While the risk of BAF in KTRs was high, thirty-day mortality was low. After the first post-transplant year, the IR of bacteremia was substantially lower than in the immediate post-transplant period.

Hypogammaglobulinemia and risk of severe infection in kidney transplant recipients

BACKGROUND

Recent data have outlined a link between hypogammaglobulinemia (HGG) and infection risk and suggested that HGG correction may decrease post-transplant infections.

METHODS

We analyzed the risk factors of HGG and the relationship between HGG and the risk of severe infection in a cohort of 318 kidney transplant recipients (KTR) who were transplanted between 2003 and 2013. Immunoglobulin (Ig) concentration was measured prospectively at day 15 (D15), month 6 (M6), month 12 (M12), and month 24 (M24) post transplant.

RESULTS

The prevalence of IgG HGG was 56% and 36.8% at D15 and M6, respectively. Age was the sole identified risk factors for D15 IgG HGG (odds ratio [OR] 1.02, P = 0.019). Risk factors for M6 IgG HGG were the presence of D15 IgG HGG (OR 6.41, P < 0.001) and treatment of acute rejection (OR 2.63, P = 0.014). Most infections occurred between D15 and M6 post transplant. Only age (hazard ratio 1.03, P < 0.001) was identified as a risk factor of infection between D15 and M6 post transplant. Survival free of infection (overall infections and bacterial or viral infections) did not differ significantly between patients with or without D15 IgG HGG. Only septicemia occurring between M6 and M12 post transplant was more frequently observed in patients with HGG. The low prevalence of severe HGG (<400 mg/dL) did not allow conclusions on the infectious risk associated with this patient subgroup.

CONCLUSIONS

This study does not support the existence of a strong link between post-transplant HGG and the risk of severe infections in KTR. Correction of HGG to minimize the risk of severe infections in KTR is thus questionable and needs to be reevaluated in prospective studies.

Early Infections in Renal Transplant Recipients: Incidence, Risk Factors, and Causative Microorganisms

OBJECTIVES

This study aimed to compare renal transplant recipients with and without infection with respect to demographic and clinical characteristics as well as risk factors; to determine the incidence of posttransplant infections; and to study the antibiotic resistance patterns of bacterial species identified as the causative organisms in posttransplant infections.

MATERIALS AND METHODS

This study included a total of 136 patients undergoing renal transplant in a 4-year period. The patients were categorized into 2 groups. The 2 groups were compared with each other with respect to general clinical and demographic variables and the number and frequency of infectious attacks within a 1-year follow-up, infection type, and antibiotic resistance patterns.

RESULTS

Ninety-two (67.6%) of the subjects were male and 44 (32.4%) were female. A total of 57 (41.9%) patients developed 128 infectious attacks. Urinary tract infections were the most common infections (42.1%). There was a significant correlation between a clinically relevant urinary culture proliferation and postoperative infection rate (P = .002). There was a significant correlation between antimicrobial resistance and the number of infectious attacks (P = .023). There was a significant correlation between the proliferation of Extended Spectrum Beta Lactamase-positive Enterobactericeae species and the number of infectious attacks (P = .000).

CONCLUSIONS

Presence of a clinically relevant proliferation in the preoperative urinary culture, which was identified as a risk factor for infection, increased the number of infectious attacks. Moreover, Extended Spectrum Beta Lactamase-positive Enterobactericeae species increased the number of infections. These 2 principle results should be taken into account in patient management.

The Distribution and Resistance of Pathogens Among Solid Organ Transplant Recipients with Pseudomonas aeruginosa Infections

Background

Pseudomonas aeruginosa infection remains a life-threatening complication after solid organ transplantation (SOT). We aimed to investigate the distribution and drug susceptibility of pathogens, and clinical characteristics of SOT recipients with Pseudomonas aeruginosa infections.

Material/Methods

A total of 55 SOT recipients who developed 61 episodes of Pseudomonas aeruginosa infections between January 1, 2003 and July 31, 2015 were retrospectively analyzed. The distribution and the drug susceptibility of Pseudomonas aeruginosa were reviewed.

Results

The most common site from which 61 Pseudomonas aeruginosa rods were isolated were the lungs (57.4%, n=37), followed by the blood (27.9%, n=17). There were 35, 18, and 9 recipients accompanied with a serum creatinine level of >1.5 mg/dL, lymphocyte count of <300/mm³, and a serum albumin level of <30 g/L, respectively. Seven patients each presented with white blood cell count of >15 000/mm³ and platelet count of <50 000/mm³. There were 6 (10.9%) cases of septic shocks and 18 (32.7%) deaths. Antibiotic resistance rate of all Pseudomonas aeruginosa to 4 of 10 antibiotics investigated was more than 50%. Of these 61 Pseudomonas aeruginosa isolates, 47.5% were carbapenem-resistant. The rods were relatively sensitive to piperacillin-tazobactam, levofloxacin, amikacin, and cefoperazone-sulbactam (resistance rate <40%).

Conclusions

The clinical presentation of Pseudomonas aeruginosa infections included high body temperature, decreased platelet count, elevated white blood cell count, a high nosocomial origin and mortality, and onset in the late period after transplantation. According to our findings, piperacillin-tazobactam, levofloxacin, amikacin, and cefoperazone-sulbactam, alone or combination, are recommended to treat SOT recipients with Pseudomonas aeruginosa infections.

Demographics and prevalence of positive QuantiFERON-TB Gold In-Tube test in renal transplant candidates

BACKGROUND

Latent tuberculosis infection (LTBI) screening prior to solid organ transplantation is standard of care. QuantiFERON-TB Gold In-Tube (QFT-GIT) test is the preferred diagnostic test for renal transplant candidates (RTC). QFT-GIT reversions and the potential delay of living-donor kidney transplantation (LDKT) because of QFT-GIT positivity have not been examined previously in RTC.

METHODS

We evaluated the prevalence of positive QFT-GIT in RTC from January 1 through December 31, 2011. In addition, we examined the demographic and renal disease data differences between QFT-GIT-positive and -negative patients, changes in QFT-GIT results, and positive QFT-GIT results reverting to negative. Lastly, we evaluated if QFT-GIT-positive patients were less likely to undergo LDKT within 6 months of QFT-GIT testing.

RESULTS

In total, 722 RTC were analyzed, 16% of whom had positive QFT-GIT. The QFT-GIT-positive patients were more likely to be older and foreign-born, P < 0.0001. Haitians had the highest prevalence. Of the 119 QFT-GIT-positive patients, 25% had low/intermediate-positive results and were more likely to revert to negative, compared with patients with high-positive QFT-GIT results (50% vs. 0%, P = 0.01). A trend was seen toward fewer QFT-GIT-positive patients undergoing LDKT, compared with QFT-GIT-negative patients (0% vs. 3%, P = 0.09).

CONCLUSIONS

Our high prevalence was likely a result of the high number of foreign-born RTC. Half of our small subset of low/intermediate-positive QFT-GIT patients reverted to negative. QFT-GIT-positive patients were more likely to have their LDKT delayed.

The Critically Ill Kidney Transplant Recipient: A Narrative Review

Kidney transplantation is the most common solid organ transplantation performed worldwide. Up to 6% of kidney transplant recipients experience a life-threatening complication that requires ICU admission, chiefly in the late posttransplantation period (≥ 6 months). Acute respiratory failure and septic shock are the main reasons for ICU admission. Cardiac pulmonary edema, bacterial pneumonia, acute graft pyelonephritis, and bloodstream infections account for the vast majority of diagnoses in the ICU. Pneumocystis jirovecii pneumonia is the most common opportunistic infection, and one-half of the patients so infected require mechanical ventilation. The incidence of cytomegalovirus visceral infections in the era of preemptive therapy has dramatically decreased. Drug-related neutropenia, sirolimus-related pneumonitis, and posterior reversible encephalopathy syndrome are among the most common immunosuppression-associated toxic effects. Importantly, the impact of critical illness on graft function is worrisome. Throughout the ICU stay, acute kidney injury is common, and about 40% of the recipients require renal replacement therapy. One-half of the patients are discharged alive and free from dialysis. Hospital mortality can reach 30% and correlates with acute illness severity and reason for ICU admission. Transplant characteristics are not predictors of short-term survival. Graft survival depends on pre-ICU graft function, disease severity, and renal toxicity of ICU investigations and treatments.

Bloodstream infections after solid-organ transplantation

Solid-organ transplantation (SOT) has become the preferred strategy to treat a number of end-stage organ disease, because a continuous improvement in survival and quality of life. While preventive strategies has decreased the risk for classical opportunistic infections (such as viral, fungal and parasite infections), bacterial infections, and particularly bloodstream infections (BSIs) remain the most common and life-threatening complications in SOT recipients. The source of BSI after transplant depends on the type of transplantation, being urinary tract infection, pneumonia, and intraabdominal infections the most common infections occurring after kidney, lung and liver transplantation, respectively. The risk for candidemia is higher in abdominal-organ than in thoracic-organ transplantation. Currently, the increasing prevalence of multi-drug resistant (MDR) Gram-negative pathogens, such as extended-spectrum betalactamase-producing Enterobacteriaciae and carbapenem-resistant Klebsiella pneumoniae, is causing particular concerns in SOT recipients, a population which presents several risk factors for developing infections due to MDR organisms. The application of strict preventive policies to reduce the incidence of post transplant BSIs and to control the spread of MDR organisms, including the implementation of specific stewardship programs to avoid the overuse of antibiotics and antifungal drugs, are essential steps to reduce the impact of post transplant infections on allograft and patient outcomes.

Predictors of shock and mortality in solid organ transplant recipients with bacteremia caused by non-lactose-fermenting gram-negative bacilli

BACKGROUND

More data on bacteremia due to non-lactose fermenting gram-negative bacilli (NLF GNB) in solid organ transplant (SOT) recipients are needed. We aimed to investigate the epidemiology, microbiology, and risk factors for mortality and septic shock due to NLF GNB bacteremia in SOT recipients.

METHODS

We performed a retrospective, double-center study over a 12-year study period. The risk factors for mortality and septic shock in SOT recipients with NLF GNB bacteremia were assessed with multivariate logistic regression analysis.

RESULTS

A total of 230 episodes of bloodstream infections (BSIs) occurred in 159 SOT recipients. Fifty episodes of NLF GNB bacteremia were detected in 47 SOT recipients, with a predominance of Acinetobacter baumanii (27 isolates, 54.0%). The antibiotic resistance rate of all NLF GNB to 10 of 12 antibiotics investigated was more than 50%. The independent risk factors associated with septic shock were platelet count < 50 000/mm(3) (odds ratio (OR) = 14.41, 95% confidence interval (CI) = 2.64-78.71, p = 0.002) and late-onset bacteremia (time of onset more than 2 months post-transplant) (OR = 10.87, 95% CI = 1.79-65.89, p = 0.009). Lung focus (OR = 32.91, 95% CI = 2.56-423.18, p = 0.007) and septic shock (OR = 70.38, 95% CI = 4.21-1176.21, p = 0.003) were risk factors for bacteremia-related mortality.

CONCLUSIONS

The drug resistance of the pathogens and the morbidity and mortality rates of NLF GNB bacteremia were high in SOT recipients. For septic shock, associated risk factors were thrombocytopenia and late-onset bacteremia. The risk factors significantly associated with mortality were lung focus and septic shock.

Death and kidney allograft dysfunction after bacteremia

BACKGROUND

Some studies have reported causal associations between bacteremia and mortality or allograft loss in kidney transplant recipients (KTR). However, few studies have assessed the clinical course of kidney function and the risk of acute allograft rejection after bacteremia.

METHODS

We retrospectively reviewed 902 kidney transplants performed at Nagoya Daini Red Cross Hospital between January 1, 2002 and March 31, 2014. Forty-five living donor kidney transplant recipients with single bacteremia were included. We analyzed death, change in kidney function, and development of acute allograft rejection 12 months after bacteremia according to the following groups: primary source of bacteremia (urinary tract or other sources), site of acquisition (community acquired or nosocomial), severity (not meeting the systemic inflammatory response syndrome criteria and sepsis or severe sepsis and septic shock), empiric antibiotic use (appropriate or inappropriate), and baseline kidney function (estimated glomerular filtration rate ≤44.7 or ≥44.8 ml/min).

RESULTS

Urinary tract infection (UTI) was the leading cause of bacteremia (68.9 %), and Escherichia coli was the most common pathogen. Three cases (6.7 %) died of infection that caused bacteremia within 12 months. Pneumonia accounted for two-thirds. Kidney function declined 1 week after bacteremia (P < 0.05), particularly in severe cases. Thereafter, kidney function was comparable to baseline level in each group (P ≥ 0.05). Severe UTI was associated with subsequent acute allograft rejection (P = 0.03).

CONCLUSIONS

Pneumonia in KTR should be managed with caution. Kidney function generally returned to baseline level after bacteremia. However, severe UTI may be associated with subsequent acute allograft rejection.

[Infectious complications after kindred kidney allotransplantation]

It was analyzed the medical records of 231 patients who underwent living kindred donor kidney transplantation. Early postoperative complications were observed in 51 (22%) patients including infectious events in 30 cases namely pyelonephritis (13), pneumonia (6), sepsis (5), wound infection (3), pulmonary tuberculosis (2) and esophageal mycosis (1). Microflora investigation revealed predominantly gram-negative bacteria including enterobacteriaceae (K. pneumoniae, E. coli and E. cloacae) and nonfermentable bacteria (P. aeruginosa, Acinetobacter spp.). Analysis of 7-year antibiotic susceptibility showed that polymyxin, imipenem, cefoperazone/sulbactam and amikacin preserve their activity against enterobacteriaceae and pseudomonas; linezolid, vancomycinum and moxifloxacin--against staphylococcus; voriconazole, amphotericinum B and fluconazole--against Candida spp. These medicines are preferred for antibiotic prevention of perioperative and early postoperative infectious complications.

Factors influencing mortality in solid organ transplant recipients with bloodstream infection

Although bloodstream infection (BSI) is a major cause of mortality after solid organ transplantation, information regarding its prognostic factors is scarce. To identify risk factors for 30-day mortality in solid organ transplant (SOT) recipients with BSI, we prospectively recorded all episodes of BSI occurring in adult SOT recipients from January 2007 to October 2014 at a university hospital. We identified 361 consecutive episodes of BSI involving 246 patients. The 30-day case-fatality rate from the onset of BSI was 11.4%. Factors independently associated with 30-day mortality in a logistic regression analysis were shock at presentation (OR 13.658; 95% CI 5.985-31.168), acute graft rejection in the previous 6 months (OR 3.681; 95% CI 1.059-12.795), and a platelet count of <50,000 × 10(9)/L (OR 3.070; 95% CI 1.173-8.038). Kidney recipients were the patients with the best prognosis (OR 0.375; 95% CI 0.156-0.900). Our findings may help to identify SOT recipients with BSI who are at the highest risk of death.