Singh N, Gayowski T, Wagener M, Marino I R, Yu V L
Infectious Disease Section, VA Medical Center, Pittsburgh, Pennsylvania 15240, USA.
Transplantation. 1996 Feb 15;61(3):396-401. doi: 10.1097/00007890-199602150-00013.
Pulmonary infections are a significant cause of morbidity after liver transplantation; Gram-negative bacilli, cytomegalovirus, and Pneumocystis carinii were the usual pulmonary pathogens in the earlier studies in liver transplant recipients receiving cyclosporine. We prospectively assessed the impact of pulmonary infection in 101 consecutive liver transplant recipients receiving the new immunosuppressive agent tacrolimus (FK506). Fifteen percent (15/101) of the patients had 19 episodes of pneumonia; 58% (11/19) of the pneumonias were bacterial, 37% (7/19) were fungal, and 5% (1/19) were protozoal (Toxoplasma gondii). Twenty-seven percent of the bacterial pneumonias were due to Legionella. None of the patients had cytomegalovirus or P carinii pneumonia. Seven percent (7/10) of the study patients had fungal pneumonitis; 4% had invasive aspergillosis and 3% had cryptococcosis. Mortality was significantly higher (53%, 8/15) for patients with pneumonia than for patients without pneumonia (10%, 9/86, P = 0.0004). Only fungal pneumonias were the direct cause of death; 63% (5/8) of the deaths were in patients with fungal pneumonitis. Our data suggest a changing pattern of microbial etiologies of pneumonitis in the era of modern immunosuppressive agents. We show that P carinii pneumonia and cytomegalovirus can be effectively curtailed with appropriate prophylaxis. Fungal infections, on the contrary, not only constituted a major proportion of the pneumonia, but also carried the highest pneumonia-associated mortality. Legionella infections can be overlooked unless specialized laboratory methodology (cultured on selective media, urinary antigen) are applied routinely on all cases of pneumonia. We recommend routine culture on the water supply for Legionella in all transplant centers.
肺部感染是肝移植后发病的一个重要原因；在早期接受环孢素治疗的肝移植受者研究中，革兰氏阴性杆菌、巨细胞病毒和卡氏肺孢子虫是常见的肺部病原体。我们前瞻性评估了101例连续接受新型免疫抑制剂他克莫司（FK506）治疗的肝移植受者肺部感染的影响。15%（15/101）的患者发生了19次肺炎；58%（11/19）的肺炎为细菌性，37%（7/19）为真菌性，5%（1/19）为原虫性（弓形虫）。27%的细菌性肺炎由军团菌引起。所有患者均未发生巨细胞病毒或卡氏肺孢子虫肺炎。7%（7/10）的研究患者发生真菌性肺炎；4%为侵袭性曲霉病，3%为隐球菌病。肺炎患者的死亡率（53%，8/15）显著高于无肺炎患者（10%，9/86，P = 0.0004）。只有真菌性肺炎是直接死因；63%（5/8）的死亡患者患有真菌性肺炎。我们的数据表明，在现代免疫抑制剂时代，肺炎的微生物病因模式正在发生变化。我们表明，通过适当的预防措施，卡氏肺孢子虫肺炎和巨细胞病毒可以得到有效控制。相反，真菌感染不仅在肺炎中占很大比例，而且与肺炎相关的死亡率最高。除非对所有肺炎病例常规应用专门的实验室方法（在选择性培养基上培养、尿抗原检测），否则军团菌感染可能被忽视。我们建议所有移植中心对供水系统进行军团菌常规培养。
