Kaviani Aaron, Ince Dilek, Axelrod David A
1Organ Transplant Center, Department of Surgery, University of Iowa Hospitals & Clinics, 200 Hawkins Drive, Iowa City, IA 52242 USA.
2Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Hospitals & Clinics, Iowa City, USA.
Curr Transplant Rep. 2020;7(1):1-11. doi: 10.1007/s40472-020-00268-0. Epub 2020 Jan 24.
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.
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 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.
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.
在器官移植患者术前及术后的管理中，早期诊断感染并立即开始使用适当的抗菌药物至关重要。我们回顾了该领域的最新文献和指南，并整理了针对重症器官移植受者护理的医疗保健专业人员的当前建议。
多重耐药菌的发生率正在上升。多重耐药革兰氏阴性菌约占所有菌株的14%。耐万古霉素肠球菌血流感染也在增加，因为现在20.5%的医院内肠球菌对万古霉素耐药，这改变了经验性抗生素的选择。耐氟康唑菌种在住院患者念珠菌血症病例中占比高达46%。因此，新指南建议对患有中重度疾病的念珠菌血症患者首选棘白菌素类药物。最后，患者中出现耐更昔洛韦巨细胞病毒感染的发生率为5%-12%，如果对治疗反应不佳，需要早期识别并改用替代治疗方案。
血流感染是实体器官移植中死亡和发病的主要原因。据报道，脓毒症和脓毒性休克的死亡率分别高达24%和50%。因此，应迅速诊断血流感染并立即开始静脉使用抗生素。应进行适当的复苏，并减少免疫抑制药物的数量和/或剂量。还必须通过适当的放射引流或手术干预实现适当的源头控制。这些患者的初始抗生素治疗应覆盖革兰氏阳性菌，尤其是存在血管内导管的情况下，以及革兰氏阴性菌。特别是在重症患者中，尤其是如果患者接受了全胃肠外营养或使用了广谱抗生素，也应考虑使用卡泊芬净等棘白菌素类药物。
