Pasteurella multocida septic shock following liver transplantation treated with drotrecogin alfa (activated)

Pasteurella bacteraemia: Impact of comorbidities on outcome, based on a case series and literature review

OBJECTIVES

Pasteurella bacteraemia is rare, but has been associated with a high mortality rate. The aim of this study was to estimate the impact of comorbidities on patients with Pasteurella bacteraemia.

METHODS

All cases of Pasteurella bacteraemia in adults treated in our centre between January 2008 and December 2017 were included retrospectively and compared with cases identified in a systematic review of the literature via MEDLINE covering the years 1951-2017. The epidemiological, bacteriological, and clinical data were collected, as well as the instances of death after 30 days.

RESULTS

Twenty cases of Pasteurella bacteraemia identified in our centre and 99 cases from the literature review were included. A major comorbidity was found in 80/119 (67.2%) patients. The death rate at 30 days was 31.1%. The most common comorbidities were cirrhosis, immunosuppressive therapy, and malignant diseases. Age was not associated with mortality. On multivariate analysis, the only factor associated with mortality was a major comorbidity (odds ratio 2.78, 95% confidence interval 1.01-7.70; p = 0.04).

CONCLUSIONS

This study confirms the high mortality rate and highlights the importance of the host background, independent of age, in Pasteurella bacteraemia. Clinicians should be aware of the comorbidities in cases of Pasteurella infection, due to the poor prognosis of bacteraemia.

Pseudoaneurysm formation after Pasteurella multocida lower extremity vascular bypass graft infection

Prosthetic vascular bypass graft infection is a rare complication requiring prompt identification and isolation of the organism. A 66-year-old woman developed left lower extremity pain and a pulsatile pseudoaneurysm 7 months after left common femoral to peroneal artery bypass with prosthetic polytetrafluoroethylene graft, requiring re-exploration and a jump graft. Pasteurella multocida was isolated from blood and tissue culture specimens, and the patient admitted to a new kitten that frequently bit her lower extremities. Treatment included intravenous administration of ertapenem for 6 weeks followed by lifelong oral antibiotic suppression, which may offer the best chance for limb salvage when total graft explantation would result in amputation.

[Infections in organ transplantations]

Infections play a crucial role in organ transplantations as possible complications. Viruses, bacteria, fungi and parasites are potential agents. The relevance of individual diseases depends on the organ transplanted. Morphology of the inflammatory reaction is given by the agent involved, but often several reactions can be caused by the same agent and different agents can also lead to the same reaction. Histology therefore provides concrete identification of the causal agent only in some cases, such that additional microbiological diagnostics are necessary. Results from these investigations should be transferred to the pathologist to distinguish between infection-associated changes and transplant rejection.

The use of recombinant human activated protein C (drotrecogin alpha) in solid organ transplant recipients: case series and review of the literature

Septic shock occurs frequently in solid organ transplant (SOT) recipients. Standard therapy includes fluid resuscitation, the administration of antimicrobials, and source control of the infection. Adjunctive therapy with recombinant human activated protein C (rhaPC), also called drotrecogin alpha, is another treatment that is used in patients but has not been studied in SOT patients. Concerns regarding the use of this drug in this patient population include the risk of bleeding and the potential to adversely affect graft survival. Here we report the largest case series of SOT recipients with septic shock who received rhaPC. This was a retrospective chart review that looked at the impact of this drug in the SOT population. In this single-center study, we identified 17 patients with a SOT and septic shock who received rhaPC. Six of the patients underwent kidney transplants, 5 received lung transplants, 4 received cadaveric liver transplants, and 2 received combined kidney/pancreas transplants. The average APACHE II score was 26.6 ± 5.5; all patients were undergoing mechanical ventilation and receiving vasopressors at the time of rhaPC administration. Overall mortality in the group was 23.5% (4/17) at 28 days post infusion. All of the deaths were due to complications of septic shock. Allograft survival was present in 13/17 (76.5%) of the patients at 28 days. Bleeding occurred in 17.6% of patients (3/17). The use of rhaPC appears to be associated with a favorable effect on mortality, with the potential for increased risk of bleeding. Clinicians must balance this risk with the potential benefit of this drug until further research can be conducted.

The use of drotrecogin alfa (activated) in solid organ transplant patients: a case series

BACKGROUND

Drotrecogin alfa (activated) (DAA), a recombinant human activated protein C, is indicated for the reduction of mortality in patients with severe sepsis who have a high risk of death. In the initial trial, DAA demonstrated a significant reduction in mortality at 28 days for patients treated with DAA in comparison with standard supportive treatment (placebo). However, solid organ transplant recipients were excluded from the study. Transplant recipients are at an increased risk for sepsis and there is minimal literature describing the safety and efficacy of DAA in the transplant population.

METHODS

Thirteen solid organ transplant recipients who received DAA between November 2001 and January 2004 were included in this case series. Patients were prospectively identified and data collection occurred concurrently and by retrospective chart review. All patients met the DAA use criteria based on the institutional standard protocol.

RESULTS

We report the outcomes of the 13 adult transplant patients who received a total of 14 courses of DAA for severe sepsis. At the time of DAA initiation, all patients required mechanical ventilation, 86% necessitated vasopressor support, and had a median of 3 dysfunctional organs. The median Acute Physiology and Chronic Health Evaluation (APACHE) II score at initiation was 30. Overall, hemodynamic stability and APACHE II score improved at the end of DAA infusion. Causes of early discontinuation were bleeding (57%), scheduled procedure (14%), increased international normalized ratio (14%), and death (14%). In-hospital, 28-day, and 1-year mortality was 69%, 62%, and 83%, respectively.

CONCLUSION

DAA appears to be safe with appropriate monitoring. However, transplant recipients had a higher incidence of bleeding events leading to early discontinuation of DAA. Efficacy is difficult to assess without an appropriate control group for comparison.

Use of activated protein C in liver transplantation patients with septic shock

Recombinant human activated protein C (rhAPC) has been approved for use in patients with severe sepsis at high risk of death. Because of the high risk of bleeding, liver transplantation (LT) patients have been excluded from the randomized control trials that evaluated efficacy and safety of rhAPC and, thus, few data are available on the use of this drug in LT patients with severe sepsis. We describe our experience with 5 LT recipients treated for septic shock with the best conventional therapy and rhAPC. Before rhAPC therapy, all the patients showed septic shock, with > or =3 organ dysfunctions and thrombocytopenia with impairment of coagulation. rhAPC therapy started within 30 hours after septic shock onset in all the patients who recovered from sepsis-induced circulatory failure, improved organ dysfunction, and completed the 96 hours of rhAPC therapy. During rhAPC infusion, 4 patients received fresh frozen plasma and/or platelet concentrates because of thrombocytopenia and severe hemostasis dysfunction. No major bleeding occurred and only 1 patient presented with minor bleeding events.