Managing Post-Transplant Infections by ProQuest


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                                                                                    DECEMBER 2008         Renal & Urology News 31

       Managing Post-Transplant Infections
       Among other challenges, clinicians have to deal with new multidrug-resistant bacterial infections
       BY WAYNE KUZNAR                             Rare but dangerous                          In the first month post-transplant,     ing urinary tract infection. Otherwise
       CLEVELAND—A three-part para-                “In recent years, we’ve had a num-        the usual standard postoperative in-      the patient may come back uro-
       digm of infection following organ           ber of very-high-profile transmis-        fections are the rule rather than         septic, and it turns out [to be]
       transplantation should guide the ne-        sions in the news,” Dr. Avery added.      opportunistic infections. These con-      ciprofloxacin-resistant,” she said.
       phrologist in assessing the risk and in-    These infections include seronega-        sist of line, lung, and wound infec-        ICUs are frequently encountering
       stituting appropriate prophylaxis and       tive HIV transmission, seronegative       tions. “Some are related to technical     carbapenem-resistant Acinetobacter
       treatment of infection following kid-       hepatitis C transmission, West Nile       issues with the surgery itself, and       and carbapenem-resistant Klebsiella
       ney transplant, Robin Avery, MD, said       virus, and, lastly, lymphocytic chorio-   some have to do with early reacti-        (also known as carbapenemase-
       at the Nephrology Update 2008 here.         meningitis (LCM) virus.                   vation of herpes simplex virus (HSV)      producing Klebsiella [KPC]), “which
         A factor complicating the manage-           “Thankfully these complications         or yeast. [Occasionally, these infec-
       ment of these infections, however, is       are quite rare. Unfortunately when        tions involve] bacteremia or other
       the emergence of unusual organisms          they do occur in patients, they are       unsuspected pathogens in the              CMV and BK virus
       and resistant organisms that are sus-       often associated with high morbidity      donor,” she said.
       ceptible to fewer antimicrobials, ne-       and mortality,” she said. Therefore,
                                                                                                                                       are among the
       cessitating more frequent use of drugs      they prompt discussion about the          Rise of multidrug resistance              pathogens that may
       of last resort.                             appropriate level of screening for          The rise of multidrug-resistant bac-
         The classic timetable of infection        pathogens in donors.                      teria has complicated the manage-         affect outcomes.
       following organ transplantation, as           The answers are not always clear,       ment of post-transplant infection.
       articulated by Dr. Robert Rubin over        Dr. Avery said. “For example, [in]        “Methicillin-resistant Staphylococcus     means resistance to imipenem and all
       two decades ago, can be divided             the lymphocytic choriomeningitis          aureus and vancomycin-resistant           standard antibiotics.” This means
       into three main periods: first month        situation…the donor’s family mem-         Enterococcus, traditionally bad bugs,     that these pathogens would respond
       post-transplant, months 1 to 6, and         ber, hamster, and recipient all tested    seem tame compared [with] some of         only to amikacin, if that, or IV co-
       after month 6. At any time, the risk        positive for LCM virus, but the           the ones we’re dealing with now,”         listin or tigecycline, and some of these
       can be deduced from knowing the             donor’s serology itself was negative,”    she said.                                 are nephrotoxic.
       time post-transplant, the prophylaxis       she noted. Additions to the current         Infection with quinolone-resistant         Imipenem has traditionally been a
       administered, environmental expo-           screening panel of pathogens in           Escherichia coli or other gram-           fallback to treat extended-spectrum
       sures, and the net state of immuno-         donors would be costly, and false         negative bacteria is becoming more        beta-lactamase-producing E. coli and
       suppression, commented Dr. Avery,           positives may exclude some indivi-        common, and “therefore it’s impor-        Klebsiella, but these organisms are
       section head, Transplant Infectious         duals who otherwise are appropri-         tant to get microbiologic confirma-       now becoming resistant to imipenem.
       Disease, Cleveland Clinic.                  ate donors.                               tion and susceptibilities when treat-                         continued on page 32

       Age Alone Should Not Deter ADT Use in Men
       With radiotherapy, it benefits high-risk PCa patients older than 70
       BOSTON—Age alone should not                 and 15% vs. 32% in men older than         98% and 80%, respectively. In this
       matter when deciding whether to             70 years). The five-year incidence of     group, shorter duration of ADT was
       combine long-term androgen depri-           distant metastases in men aged 70         associated with an 80% increased
       vation therapy (ADT) and radiation          and younger was significantly lower       risk of all-cause mortality, the re-
       therapy in men with high-risk pros-         in ADT patients (3.7% vs. 11.8%); in      searchers noted.
       tate cancer, a study found.                 men older than 70, the incidence was        “We know the risks of distant
         In a retrospective study, researchers     similar in the ADT and no-ADT             metastasis, recurrence, and death are
       identified 530 men (median age 69           groups. This translated into a five-      higher when androgen deprivation
       years; range 45-89 years) who had           year overall survival advantage in        therapy is not part of radiation treat-
       clinically localized prostate cancer with   men aged 70 years and younger (96%        ment,” said study investigator Joshua
       clinical signs of high-risk disease: pre-  
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