INFECÇÕES DA CORRENTE SANGUÍNEA NOS PRIMEIROS 180 DIAS APÓS TRANSPLANTE HEPÁTICO: FREQUÊNCIA, ETIOLOGIA E IMPACTO SOBRE A MORTALIDADE

Introdução: As infecções da corrente sanguínea (ICS) são frequentes após transplante hepático, acometendo 19 a 41% dos receptores. Estão associadas a elevadas morbidade e mortalidade, sobretudo quando causadas por bactérias multidroga resistentes (MDR). Métodos: Avaliação retrospectiva de coorte de pacientes submetidos a transplantes de fígado no Hospital Adventista Silvestre entre 2015 e 2020. O diagnóstico de ICS nos primeiros 180 dias pós-transplante foi realizado através de sistemas automatizados de cultivo, com identificação e antibiograma realizados através de metodologia automatizada, com complementação diagnóstica com testes de bancada, conforme a necessidade. A comparação da mortalidade em 1 ano foi calculada por meio do teste de qui quadrado, utilizando o software OpenEpi. Resultados: No período de estudo, foram realizados 564 transplantes em 530 receptores. 53 receptores (10%) apresentaram 72 episódios de ICS nos primeiros 180 dias após o transplante hepático, com mediana de tempo desde o transplante até o diagnóstico de ICS igual a 14 dias. Houve isolamento de 77 microrganismos nos 72 episódios. Houve 5 casos (7%) de infecções polimicrobianas e 9 casos (13%) de bacteremia persistente, definida como isolamento do mesmo microrganismo em hemocultura dentro de 15 dias após a cultura inicial. Em 44 episódios (57%), foram isoladas enterobactérias, com predomínio de Klebsiella pneumoniae (30 episódios; 39%). Nos demais, foram isolados cocos Gram-positivos (n = 19; 25%), bacilos Gram-negativos não fermentadores (n = 11; 14%) e leveduras (n = 3; 4%). Em 27 episódios (38%), houve isolamento de bactéria MDR. A mortalidade em 7 e 30 dias entre pacientes acometidos por ICS, foi de 17% e 44%, respectivamente. Notavelmente, pacientes acometidos por ICS por enterobactérias resistentes aos carbapenêmicos tiveram mortalidade de 71% em 30 dias. Os receptores acometidos por ICS tiveram mortalidade de 62% em 1 ano, enquanto nos não acometidos a mortalidade foi de 20% em 1 ano (p < 0,001, Odds Ratio de 6,60, IC95%: 3,64-12,20). Conclusão: Nesta coorte recente de transplante hepático, a ICS continua sendo complicação frequente, com proporção expressiva causada por bactérias MDR. Sua ocorrência se deu predominantemente no período pós-transplante precoce e esteve associada com elevada mortalidade em 7 e 30 dias, além de ter sido associada com elevação significante de mortalidade em 1 ano, na comparação com pacientes sem diagnóstico de ICS

The influence of carbapenem resistance on mortality in solid organ transplant recipients with <it>Acinetobacter baumannii</it> infection

<p>Abstract</p> <p>Background</p> <p>Infection with carbapenem-resistant <it>Acinetobacter baumannii</it> has been associated with high morbidity and mortality in solid organ transplant recipients. The main objective of this study was to assess the influence of carbapenem resistance and other potential risk factors on the outcome of <it>A. baumannii</it> infection after kidney and liver transplantation.</p> <p>Methods</p> <p>Retrospective study of a case series of <it>A. baumannii</it> infection among liver and renal transplant recipients. The primary outcome was death associated with <it>A. baumannii</it> infection. Multivariate logistic regression was used to assess the influence of carbapenem resistance and other covariates on the outcome.</p> <p>Results</p> <p>Forty-nine cases of <it>A. baumannii</it> infection affecting 24 kidney and 25 liver transplant recipients were studied. Eighteen cases (37%) were caused by carbapenem-resistant isolates. There were 17 (35%) deaths associated with <it>A. baumannii</it> infection. In unadjusted analysis, liver transplantation (p = 0.003), acquisition in intensive care unit (p = 0.001), extra-urinary site of infection (p < 0.001), mechanical ventilation (p = 0.001), use of central venous catheter (p = 0.008) and presentation with septic shock (p = 0.02) were significantly related to a higher risk of mortality associated with <it>A. baumannii</it> infection. The number of deaths associated with <it>A. baumannii</it> infection was higher among patients infected with carbapenem-resistant isolates, but the difference was not significant (p = 0.28). In multivariate analysis, the risk of <it>A. baumannii</it>-associated mortality was higher in patients with infection acquired in the intensive care unit (odds ratio [OR] = 34.8, p = 0.01) and on mechanical ventilation (OR = 15.2, p = 0.04). Appropriate empiric antimicrobial therapy was associated with significantly lower mortality (OR = 0.04, p = 0.03), but carbapenem resistance had no impact on it (OR = 0.73, p = 0.70).</p> <p>Conclusion</p> <p>These findings suggest that <it>A. baumannii</it>-associated mortality among liver and kidney transplant recipients is influenced by baseline clinical severity and by the early start of appropriate therapy, but not by carbapenem resistance.</p

Low-dose aspirin confers protection against acute cellular allograft rejection after primary liver transplantation.

OBJECTIVE To investigate the effect of low-dose aspirin in primary adult liver transplantation LT on acute cellular rejection ACR as well as arterial patency rates. BACKGROUND The use of low-dose aspirin after LT is practiced by many transplant centers to minimize the risk of hepatic artery thrombosis HAT, although solid recommendations do not exist. However, aspirin also possesses potent anti-inflammatory properties and might mitigate inflammatory processes after LT, such as rejection. Therefore, we hypothesized that the use of aspirin after liver transplantation has a protective effect against ACR. METHODS This is an international, multicenter cohort study of primary adult deceased donor LT. The study included 17 high-volume LT centers and covered the 3-year period from 2013 to 2015 to allow a minimum 5-year follow-up. RESULTS In this cohort of 2,365 patients, prophylactic antiplatelet therapy with low-dose aspirin was administered in 1,436 recipients 61%. One-year rejection-free survival rate was 89% in the aspirin group versus 82% in the no-aspirin group HR 0.77, 95% CI 0.63-0.94, p=0.01. One-year primary arterial patency rates were 99% in the aspirin and 96% in the no-aspirin group with a HR of 0.23 95% CI: 0.13-0.40; p<0.001. CONCLUSION Low-dose aspirin was associated with a lower risk of ACR and HAT after LT, especially in the first vulnerable year after transplantation. Therefore, low-dose aspirin use after primary LT should be evaluated to protect the liver graft from ACR and to maintain arterial patency