Dauber J H, Paradis I L, Dummer J S
Division of Pulmonary and Critical Care Medicine, University of Pittsburgh School of Medicine, Pennsylvania.
Clin Chest Med. 1990 Jun;11(2):291-308.
This article has outlined the features of the major types of infections encountered in pulmonary allograft recipients. Virtually any pathogen can cause infection in these immunocompromised subjects, and there is a distinct propensity for these organisms to invade the transplanted lung. As is the case with other major organ recipients, there is a temporal sequence in the types of infection lung allograft recipients contract. Bacteria are the most frequent cause of pneumonia in the first postoperative month. After this period, infection with CMV, particularly CMV pneumonitis, becomes most common. Following the "window" for CMV infection, the risk for infestation with P. carinii becomes the primary concern. The latter two types of infection pose a double risk for the recipient: (1) morbidity and mortality from the infection itself and (2) chronic rejection following on the heels of these infections and producing morbidity and mortality on its own. Pulmonary allograft recipients are also susceptible to fungi, particularly C. albicans. Although these infections rarely produce an overwhelming pneumonia, they nonetheless carry a grave prognosis because they usually become widely disseminated. Better selection of donor lungs and prophylactic measures such as the use of broad-spectrum antibiotics and amphotericin B in the early postoperative period, the use of CMV-negative blood products in seronegative recipients, and the chronic administration of trimethoprim-sulfamethoxazole have reduced the rate of infection with bacteria, fungi, CMV (primary infections only), and P. carinii, respectively. Despite these relative successes, however, the risk for infection of the allograft remains high because the defense mechanisms in the lung allograft are breached by the effects of surgery, the "allogeneic environment" in the allograft and systemic immunosuppression, and the fact that chronic rejection causes structural changes that predispose to bacterial colonization of the airways and the need for increased levels of immunosuppression. Despite the formidable barrier that infection of the lung allograft poses, the procedure of pulmonary transplantation clearly holds sufficient promise that all efforts possible should be made to hurdle this barrier. Achieving such a goal would ensure a place for pulmonary transplantation in the armamentarium of treatment for irreversible pulmonary disease.
本文概述了肺移植受者中常见的主要感染类型的特点。实际上，任何病原体都可在这些免疫功能低下的个体中引发感染，且这些病原体具有侵袭移植肺的明显倾向。与其他主要器官移植受者一样，肺移植受者感染的类型存在一定的时间顺序。细菌是术后第一个月内肺炎最常见的病因。在此之后，巨细胞病毒（CMV）感染，尤其是CMV肺炎，变得最为常见。在CMV感染的“窗口期”过后，卡氏肺孢子虫感染的风险成为主要关注点。后两种感染类型给受者带来双重风险：（1）感染本身导致的发病和死亡；（2）这些感染之后继发慢性排斥反应，并自身导致发病和死亡。肺移植受者也易感染真菌，尤其是白色念珠菌。尽管这些感染很少引发严重的肺炎，但预后严重，因为它们通常会广泛播散。更好地选择供肺以及采取预防性措施，如术后早期使用广谱抗生素和两性霉素B、血清学阴性受者使用CMV阴性血液制品以及长期服用甲氧苄啶-磺胺甲恶唑，分别降低了细菌、真菌、CMV（仅原发性感染）和卡氏肺孢子虫的感染率。然而，尽管取得了这些相对的成功，移植肺的感染风险仍然很高，因为手术的影响、移植肺内的“同种异体环境”和全身免疫抑制破坏了移植肺的防御机制，而且慢性排斥反应导致结构改变，易引发气道细菌定植，进而需要提高免疫抑制水平。尽管肺移植感染构成了巨大障碍，但肺移植手术显然具有足够的前景，应尽一切可能努力跨越这一障碍。实现这一目标将确保肺移植在不可逆肺部疾病的治疗手段中占有一席之地。
