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Age Alone Should Not Deter ADT Use in Men


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