Bloodstream infection following 217 consecutive systemic-enteric drained pancreas transplants

Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.

Risk factors for surgical site infection after kidney and pancreas transplantation

OBJECTIVE

To evaluate the incidence of surgical site infection (SSI) in a cohort of pancreas transplant recipients and assess predisposing risk factors for SSI DESIGN: Retrospective cohort study SETTING: Single transplant center in CanadaPatientsPatients who underwent any simultaneous pancreas and kidney (SPK) or pancreas after kidney (PAK) transplant procedures between January 2000 and December 2015 METHODS: In this retrospective cohort evaluation of SPK or PAK recipients, we assessed the incidence of SSI and risk factors associated with superficial, deep, and organ/space SSI. Multivariate logistic regression was used to identify independent risk factors for SSI in SPK and PAK recipients.

RESULTS

In total, 445 adult transplant recipients were enrolled. The median age of these patients was 51 years (range, 19-71 years), and 64.9% were men. SSIs were documented in 108 patients (24.3%). Organ/space SSIs predominated (59 patients, 54.6%), followed by superficial SSIs (47 patients, 43.5%) and deep SSIs (3 patients, 2.8%). Factors predictive of SSIs in the multivariate analysis were cold pancreas ischemic time (odds ratio [OR], 1.002; P=.019) and SPK transplant (compared to PAK transplant recipients; OR, 2.38; P=.038). Patients with SSIs developed graft loss more frequently (OR, 16.99; P<.001).

CONCLUSIONS

Organ/space SSIs remain a serious and common complication after SPK and PAK. Prolonged cold ischemic time and SPK transplant were the risk factors predictive of SSIs. Appropriate perioperative prophylaxis in high-risk patients targeting the potential pathogens producing SSIs in kidney and/or pancreas transplant recipients and a reduction in cold ischemia may prove beneficial in reducing these SSIs.

Nosocomial bloodstream infections in a nationwide study: comparison between solid organ transplant patients and the general population

BACKGROUND

The incidence of bloodstream infection (BSI) varies according to the transplanted organ. Mortality can be as high as 24%, with a significant impact on graft survival. Transplantation is a risk factor for multidrug-resistant (MDR) organisms, but comparison with a non-transplanted population in a single large cohort has not been described.

METHODS

This is a prospective nationwide study (16 centers) reporting data on 2364 monomicrobial nosocomial BSIs, comparing 83 episodes in solid organ transplant patients with 2447 BSIs occurring in the general hospital population.

RESULTS

The prevalence of groups of infecting organisms (gram-positive, gram-negative, and fungi) was similar between transplant patients and the general population and a similar crude mortality rate was observed (34.9% in transplant vs. 43.3% in non-transplant patients). Staphylococcus aureus was the single most frequently isolated organism in both groups, and Acinetobacter species was more frequently isolated in the general population. Regarding MDR organisms, Klebsiella species, and Enterobacter species resistant to cefepime, as well as Acinetobacter species resistant to meropenem, were significantly more frequent in transplant patients.

CONCLUSION

Antimicrobial resistance is higher, particularly among gram-negative bacteria in the transplant population, although the overall mortality rate between transplant and non-transplant patients with nosocomial BSI is similar.

Bacterial and fungal infections in the early post-transplantation period after simultaneous pancreas-kidney transplantation: etiological agents and their susceptibility

OBJECTIVE

This study aims to evaluate the frequency of microbial isolates and their susceptibility profiles cultured from clinical samples obtained from 26 simultaneous pancreas-kidney transplant (SPK) recipients suspected of infections during the early post-transplantation period.

PATIENTS AND METHODS

Data on microbiologic culture of 26 adult patients undergoing SPK were collected prospectively from 2001 to the end of 2006. Isolation and identification of cultured micro-organisms were performed according to standard microbiological procedures and commercially available tests. Susceptibility of the strains to antibacterial agents was made by the Clinical and Laboratory Standards Institute guidelines.

RESULTS

All the patients were followed prospectively for the first 4 weeks after surgery. In total, 263 samples from clinical materials obtained from 26 SPK recipients were cultured. Bacterial cultures were positive in 29.3% (n = 77) clinical samples. Of these, 219 microbial strains were cultured. Gram-positive bacteria were found in 64% (n = 140), Gram-negative bacteria in 22.8% (n = 50), and fungal strains were isolated in 13.2% (n = 29). Incidence rate values for subsequent isolation of micro-organisms in the sub-periods of time for decreasing the SPK were Gram-positive bacteria (102.3-18.7; I versus IV), growing the Gram-negative bacteria (14-46.1 I versus III) IV were 14, decreasing to fungi (22.1-1.6, I versus IV). Until now this early post-transplantation period was considered homogeneous time after transplantation. This study shows that this period is actually heterogenous, with statistically significant differences being observed between results obtained in consecutive 4 weeks after transplantation.

CONCLUSIONS

The results of this study show that the incidence rate was elevated with increasing age in the SPK group of patients. In the SPK group, our data showed the highest rate of isolation of micro-organisms compared with recipients of kidneys or liver.

Canadian clinical practice guidelines for invasive candidiasis in adults

Candidemia and invasive candidiasis (C/IC) are life-threatening opportunistic infections that add excess morbidity, mortality and cost to the management of patients with a range of potentially curable underlying conditions. The Association of Medical Microbiology and Infectious Disease Canada developed evidence-based guidelines for the approach to the diagnosis and management of these infections in the ever-increasing population of at-risk adult patients in the health care system. Over the past few years, a new and broader understanding of the epidemiology and pathogenesis of C/IC has emerged and has been coupled with the availability of new antifungal agents and defined strategies for targeting groups at risk including, but not limited to, acute leukemia patients, hematopoietic stem cell transplants and solid organ transplants, and critical care unit patients. Accordingly, these guidelines have focused on patients at risk for C/IC, and on approaches of prevention, early therapy for suspected but unproven infection, and targeted therapy for probable and proven infection.

Prevention and treatment of complications after pancreas transplantation

With the development of new organ preservation solutions, the application of new immunosuppressive drugs and the improvement of intensive postoperative care, pancreas transplantation has become an ideal treatment for diabetic patients with uremia. According to the International Pancreas Transplant Registry (IPTR) latest statistics, over 30 000 cases of pancreas transplantation have been carried out in the world from 1966 to the end of 2008, of which more than 22 000 cases were implemented in the United States. Complications after pancreas transplantation have been recognized since 1966 when a patient died of rejection and sepsis two months after the first case of pancreas-kidney transplantation. With the extensive development of pancreas transplantation, a better understanding of complications after pancreas transplantation is needed.

Epidemiology of infections requiring hospitalization during long-term follow-up of pancreas transplantation

BACKGROUND.: Pancreas transplantation (PT) provides the best glycemic control option for diabetes mellitus but is associated with significant morbidities related to infectious disease. METHODS.: We performed a retrospective study of a cohort of consecutive PT recipients in whom PT was performed from 1998 to 2006 (n=216) and followed up them until July 2008. Data regarding infections, rejection, infection chemoprophylaxis, graft failure, absolute lymphocyte counts (ALCs), and mortalities were collected. RESULTS.: Simultaneous pancreas and kidney, pancreas transplantation alone, and pancreas after kidney (PAK) transplantations were performed in 42, 67, and 107 patients, with a mean (standard deviation) age at transplantation of 46.8 (8.03), 40.6 (10.1), and 43.7 (8.19) years. Of the simultaneous pancreas and kidney, pancreas transplantation alone, and PAK transplant recipients, 54.7%, 37.3%, and 58.8% were men. Overall, 63% developed a serious infection during the median follow-up of 6.4 years. Mean (range) number of infectious episodes was 2.3 (1-12), with mostly bacterial infections both within (68%) and after 1 year (78%). Incidence of bacterial and viral infections was greatest in the first 3 months after transplantation. Fungal infections were more constant. Bladder exocrine drainage was associated with higher risk of infection (hazard ratio=2.5, P<0.001). Infection within the first 3 months after transplantation was related to higher mortality after the first 3 months (hazard ratio=3.19). ALC was associated with the risk of first infections (P=0.005) and bacterial infections (P<0.001). CONCLUSIONS.: Incidence of infections after PT was 63% and mostly bacterial. Bladder drainage increases infection risk and low ALC partially predicts episodes. Limitations include retrospective design, unequal composition of PT groups, and lack of data between kidney and PT for PAK.

Prevention and management of hyperglycemia after pancreas transplantation

PURPOSE OF REVIEW

Pancreas transplantation is considered the optimal therapy for patients with insulin-dependent diabetes. Successful pancreas transplantation achieves euglycemia and allows freedom from insulin therapy. Long-term allograft success may be limited by the development of impaired glucose metabolism. The objectives of the present review are to summarize the possible reasons for endocrine pancreatic dysfunction and to focus on its prevention and management and emphasize the role of immunosuppression.

RECENT FINDINGS

The diabetogenic effects of current immunosuppressive agents have been well established. Regimens without corticosteroids and calcineurin-inhibitor minimization or avoidance have been promoted. Recent studies have revisited the pathogenesis of type I and type II diabetes and demonstrated common pathways, including apoptosis induction, for the exhaustion and destruction of the pancreatic islets.

SUMMARY

The immunosuppressive regimens in pancreatic transplantation should be designed and appropriately modified according to the graft immunological and metabolic conditions. New molecules that are able to preserve islet function and maintain optimal insulin secretion should be considered for pancreas transplant recipients.

Clonal heterogeneity of clinical isolates of vancomycin-resistant Enterococcus faecium with unique vanS

OBJECTIVE

To examine the clonal diversity of vancomycin-resistant enterococci (VRE).

METHODS

A total of 900 clinical isolates of enterococci were obtained, and VRE isolates were subjected to antimicrobial susceptibility tests, biochemical fingerprinting with the PhPlate system (PhP), ribotyping and pulsed-field gel electrophoresis (PFGE) typing.

RESULTS

Forty-nine of all enterococcal isolates were resistant to high levels of vancomycin (MIC >or= 128) and identified as Enterococcus faecium. Biochemical fingerprinting with PhP showed that the VRE isolates were highly diverse (diversity index, D(i) = 0.93) and belonged to 24 PhP-types. The VRE could be separated into 34 and 27 types with PFGE and ribotyping, giving diversity indices of 0.98 and 0.97, respectively. The PFGE method was more discriminatory than ribotyping and PhP system for E. faecium isolates. A combination of either of the two typing methods resulted in at least 44 types. Furthermore, sequencing analysis of vanS of Tn1546 showed one nucleotide mutation (C-->A) at position 5727 in comparison with the prototype BM4147, which was found to be unique in all Iranian VRE isolates.

CONCLUSION

The isolated clinical VRE strains were highly diverse in Tehran.