Clostridium difficile (CD) is one of the most common causes of diarrhea in solid organ transplantation (SOT). Between 1996 and 2005, a total of 2474 solid organ transplants were performed at our ...institution, of which 43 patients developed CD-associated diarrhea. There were 3 lung, 3 heart, 20 liver, 8 kidney-pancreas, 6 kidney, 1 composite tissue, and 2 multivisceral recipients. Onset of CD infection ranged from 5 to 2453 days posttransplant. All patients presented with abdominal pain and watery diarrhea. Toxins A and B were detected using rapid immunoassay or enzyme immunoassay. Treatment consisted of reduction of immunosuppression, fluid and electrolyte replacement, metronidazole (n=20), oral vancomycin (n=20), and a combination of metronidazole and vancomycin (n=2). Toxic megacolon was seen in five patients. Two of them had colonoscopic decompression, and the remaining three required colonic resection. One of these patients died due to multiorgan failure after cured CD enteritis. The remaining patients were discharged with well-functioning grafts and all are currently alive. CD colitis was a rare complication prior to 2000; 38 of the 43 cases occurred thereafter. We conclude that CD colitis represents a severe complication following SOT. Recently, a dramatic increase in the incidence of this complication has been observed. The development of life-threatening toxic megacolon must be considered in solid organ recipients.
The Organ shortage has caused an accumulation of acutely decompensated patients listed as medical urgency code 2 (MUC 2) (United network for Organ Sharing 2) while awaiting liver transplantation. ...Between June 1997 and June 2003, 22 of 360 liver transplantation patients (6%) were listed as MUC 2. Prophylactic immunosuppression consisted of calcineurin inhibitor–based drug therapy, using antithymocyte globulin or interleukin-2 receptor antagonist induction in 64%. The overall perioperative infection rate was 50%, and the rejection rate was 23%. We observed 7 episodes of oral or genital herpes simplex virus lesions; 2 patients (both with cytomegalovirus-mismatched transplants) developed cytomegalovirus disease, and another 5 patients received gancyclovir for preemptive therapy or prophylaxis. Two patients developed pneumonia: 5, sepsis that originated in 4 cases from a contaminated central venous line; and 1 methicillin-resistant endocarditis, which resulted in
Staphylococcus aureus lethal outcome. After a median follow up of 3 years, 1 patient underwent a repeat transplantation procedure and 6 patients had died, 4 of them from infectious complications. Liver transplantation of MUC 2–listed patients may result in acceptable results similar to those of MUC 3 and MUC 4 categories.
Summary
Nocardiosis is a localized or disseminated bacterial infection caused by aerobic Actinomyces that commonly affects immunocompromised hosts. The aim of this study was to retrospectively review ...clinical course and outcome of nocardiosis in solid organ recipients at our centre. Five cases of nocardiosis were identified in a series of more than 4000 consecutive solid organ transplants performed at Innsbruck university hospital during a 25‐year period. Of the five patients with nocardiosis, two had undergone multivisceral, one liver, one kidney and one lung transplantation. Three patients with Nocardia asteroides infection were treated successfully and recovered from their infectious disease, however, one lost his renal graft following withdrawal of immunosuppression. The lung recipient recovered from nocardiosis but died later on from Pseudomonas pneumonia. One multivisceral recipient died from Nocardia farcinica‐disseminated infection. Nocardiosis is a rare, difficult‐to‐diagnose‐and‐treat complication following solid organ transplantation. Intestinal recipients might be at increased risk to develop this infection.
Summary
Group milleri streptococci (GMS) comprise a heterogeneous group of streptococci including the species intermedius, constellatus and anginosus. They may cause chronic intra‐abdominal and ...intrathoracic abscesses, which are difficult to treat. This is a retrospective analysis including 45 transplant recipients in whom GMS were isolated. The epidemiology, clinical significance and the impact on the outcome in all transplant patients with infections caused by GMS during a 4‐year period (2001–2004) was evaluated. The 45 solid organ recipients (88 isolates) included 34 liver‐, four kidney/pancreas‐, one kidney‐, two small bowel‐, three combined liver/kidney‐ and one combined kidney/small bowel transplant recipient. In 42 cases GMS caused intra‐abdominal infection, in two cases pleural empyema and in one case soft tissue infection. Only a single isolate of GMS was cultured from blood. In 54 of the 88 specimens (61%), which grew GMS, other pathogens were also isolated. GMS frequently caused recurrent cholangitis (n = 17) associated with anastomotic and nonanastomotic biliary strictures. These cases were managed by repeated stenting or surgical intervention and prolonged antibiotic therapy. No patient died directly related to GMS infection and all except one case responded to combined surgical/antibiotic treatment. One pancreas graft was lost because of erosion haemorrhage associated with an abscess. GMS were susceptible to penicillin G, carbapenems and clindamycin, whereas cephalosporins and quinolones showed intermediate activity or resistance in some cases, and GMS in general were found resistant to aminoglycosides. GMS may cause serious infections in transplant recipients which are difficult to treat. Their prevalence in transplant surgical site infections thus far may have been underestimated.
Acute cytomegalovirus (CMV) disease and indirect effects caused by the virus alter the outcome after solid organ transplantation. Long-term results after 54 lung and 139 cardiac transplants at a ...single center have been retrospectively analyzed with regard to CMV status. Standard CMV prophylaxis consisted of ganciclovir for 100 days. Lung recipients were pretransplant CMV negative in 32 per cent as compared to heart recipients with 23 per cent. Patient survival after mismatch transplants (donor positive, recipient negative) was significantly reduced as compared to the other match groups (42% vs 76% at five years, P = 0.01). In heart recipients, CMV positive patients receiving a CMV negative graft showed best survival, whereas in the group of lung recipients negative/negative matched transplants produced best results. In both groups, CMV negative grafts had a better outcome than CMV positive grafts, and a survival difference between heart and lung recipients was only observed in recipients of a CMV positive grafts. Despite ganciclovir prophylaxis, CMV match remains an important factor for survival follwing heart and, even more profoundly, lung transplantation. Because survival was least favorable in the mismatched group, prophylactic regimens warrant improvement. For CMV negative lung recipients, CMV matching might be considered.
Summary
BACKGROUND: Infection of alloplastic material is usually caused by staphylococci. Enterococci rarely have been implicated in infections after osteosynthesis.
Enterococcus faecium
is resistant ...to most antibiotics with glycopeptides being considered the treatment of choice. METHODS: We describe the case of a 41-year-old male, who sustained a trauma during a working accident with multiple open fractures of the right femur, tibia, food and toes. RESULTS: Initial treatment included stabilizing the fractures using external fixation and debridement of wounds with the application of a vacuum assisted device. On the third day post trauma, the fracture was stabilized by osteosynthesis with LISS lateral and of the median condyle. Repeatedly, soft tissue necroses were debrided and the VAC-system changed and after four weeks the skin was covered with a MESH graft. During the seventh week the patient got a fracture of the LISS and a new system had to be implanted.
Enterococcus faecium
was isolated and treatment was started with Vancomycin. The patient underwent another two surgical interventions with debridement of necroses and implantation of autologous spongiosa and BMP 7. External fixation was removed and moderate mechanical stress was tolerated. Antibiotic therapy was switched to oral linezolid for another six weeks. Nine weeks later, CT scan showed a regenerated femur and ankle joint. Six months following the complicated trauma, the patient was able to walk again. CONCLUSIONS: Multimodal approach with stepwise reconstruction of the severely traumatized tissue allowed recovery from this injury with a good functional result. Linezolid proved useful in the oral therapy of this severe enterococcal infection.
Meningitis is a rare complication following organ and stem-cell transplantation and can be caused by a variety of microorganisms.
To retrospectively review the clinical course and outcome of five ...cases of listeriosis in four organ recipients and one stem-cell recipient during a seven-year period.
Patient records for more than 3500 patients undergoing organ or stem-cell transplantation at the university hospital of Innsbruck during a 27-year period were evaluated. Standard immunosuppression consisted of calcineurin inhibitor-based triple drug therapy with or without ATG or IL2 receptor antagonist induction.
The first case affected a 35-year-old woman who received an allogenic bone marrow transplant for advanced breast cancer. Cases two and three related to two male heart recipients. Cases four and five were diagnosed in one male and one female renal recipient. Listeria monocytogenes was isolated from blood in two cases and from cerebrospinal fluid in three. Treatment consisted of ampicillin in all cases with the addition of tobramycin (1), TMPS (1), meropenem (2) or imipenem/cilastatin (1). The deaths of two patients were directly related to L. monocytogenes.
Although listeriosis is a rare complication following transplantation, this infection should be ruled out in individuals presenting with neurological symptoms and fever.
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