Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University, Stanford, California 94305, USA.
J Heart Lung Transplant. 2010 Mar;29(3):306-15. doi: 10.1016/j.healun.2009.08.018. Epub 2009 Oct 22.
During the past 25 years, advances in immunosuppression and the use of selective anti-microbial prophylaxis have progressively reduced the risk of infection after heart transplantation. This study presents a historical perspective of the changing trends of infectious disease after heart transplantation.
Infectious complications in 4 representative eras of immunosuppression and anti-microbial prophylaxis were analyzed: (1) 38 in the pre-cyclosporine era (1978-1980), (2) 72 in the early cyclosporine era (1982-1984), where maintenance immunosuppression included high-dose cyclosporine and corticosteroid therapy; (3) 395 in the cyclosporine era (1988-1997), where maintenance immunosuppression included cyclosporine, azathioprine, and lower corticosteroid doses; and (4) 167 in the more recent era (2002-2005), where maintenance immunosuppression included cyclosporine and mycophenolate mofetil.
The overall incidence of infections decreased in the 4 cohorts from 3.35 episodes/patient to 2.03, 1.35, and 0.60 in the more recent cohorts (p < 0.001). Gram-positive bacteria are emerging as the predominant cause of bacterial infections (28.6%, 31.4%, 51.0%, 67.6%, p = 0.001). Cytomegalovirus infections have significantly decreased in incidence and occur later after transplantation (88 +/- 77 days, pre-cyclosporine era; 304 +/- 238 days, recent cohort; p < 0.001). Fungal infections also decreased, from an incidence of 0.29/patient in the pre-cyclosporine era to 0.08 in the most recent era. A major decrease in Pneumocystis jiroveci and Nocardia infections has also occurred.
The overall incidence and mortality associated with infections continues to decrease in heart transplantation and coincides with advances in immunosuppression, the use of selective anti-microbial prophylaxis, and more effective treatment regimens.
在过去的 25 年中，免疫抑制和选择性抗微生物预防的进步逐渐降低了心脏移植后的感染风险。本研究从历史角度展示了心脏移植后传染病变化趋势。
分析了免疫抑制和抗微生物预防的 4 个代表性时期的感染并发症：（1）环孢素前时代（1978-1980 年）的 38 例，（2）环孢素早期时代（1982-1984 年）的 72 例，其中维持免疫抑制包括高剂量环孢素和皮质类固醇治疗；（3）环孢素时代（1988-1997 年）的 395 例，其中维持免疫抑制包括环孢素、硫唑嘌呤和较低剂量的皮质类固醇；（4）较近期时代（2002-2005 年）的 167 例，其中维持免疫抑制包括环孢素和霉酚酸酯。
4 个队列中感染的总发生率从 3.35 例/患者降至 2.03、1.35 和 0.60 例/患者（p<0.001）。革兰氏阳性菌成为细菌性感染的主要原因（28.6%、31.4%、51.0%、67.6%，p=0.001）。巨细胞病毒感染的发生率显著降低，且发生在移植后较晚（88±77 天，环孢素前时代；304±238 天，最近队列；p<0.001）。真菌感染也有所减少，从环孢素前时代的 0.29 例/患者降至最近时代的 0.08 例/患者。卡氏肺孢子虫和诺卡氏菌感染也大幅减少。
心脏移植后与感染相关的总发病率和死亡率继续下降，这与免疫抑制、选择性抗微生物预防和更有效的治疗方案的进步相符。
