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Post trans1208.qxp 1/5/09 12:08 PM Page 1 www.renalandurologynews.com 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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