Abu-Elmagd, K

Fung, J

Furukawa, H

Irish, W

Kusne, S

Rakela, J

Starzl, TE

Todo, S

English

PubMed

Name not available

Infectious complications after small bowel transplantation in adults: an update

D-Scholarship@Pitt

". K~ ~ ... _----_ ... _--- --~-Infectious Complications After Small Bowel Transplantation in Adults: an Update S. Kusne, H. Furukawa, K. Abu-Elmagd, W. Irish, J. Rakela, J. Fung, T.E. Starzl, and S. Todo WE have reported our experience with the first 21 adult patients after small bowel transplantation (Tx) on tacrolimus immunosuppression regimen in the Paris meet-ing.1 The present report represents an update of the infectious complications that occurred in this patient pop-ulation. METHODS Patient Population Between May 1990 and February 1995,29 adult patients underwent small bowel Tx in the Transplantation Institute, University of Pittsburgh. Fifteen patients underwent small bowel transplant (SBTx),8 had small bowel together with liver transplant (SBTx/L), and 6 patients underwent multi-visceral Tx (MY), which included SBTx/L together with other organs. In 11 patients (8 SBTx, 3 MY) Tx of the bowel included also colonic segment. Patients were prospectively followed for infectious complications using previous definitions of infection.2 Immunosuppression Tacrolimus was given intravenol.lsly at 0.1 mglkg/day and later orally at 0.15 mglkg every 12 hours. Steroid induction was given with 1 gm methylprednisolone and steroid maintenance with 20 mg prednisone. Acute rejection was treated with a "bolus" or "recycle" of methylprednisolone. Steroid resistant rejection was treated with OKT3 monoclonal antibody. Prophylaxis Antimicrobial prophylaxis included intravenous ccfotaximc and ampicillin 4 gld for 3 days, oral nystatin 2 million units a day, intravenous ganciclovir IO/mg/kg/d, oral trimethoprim/sulfame-thoxazule HO mgl400 mg a day, and selective bowel decontamina-tion with colistin. gentamicin. and nystatin. RESULTS Twenty-nine adult patients underwent small bowel Tx and were prospectively followed for infectious complications. The median follow up was 643 days (Range 21 days to 4.7 years). The mean age was 33 years (Range 19 to 58 years), and the Female/Male ratio was 1.2/1.0. The Kaplan-Meier I-year patient survival was 68% :!:: 9%. and overall mortality was 55% (16/29). Twenty-eight of 29 (97%) patients had at least one infectious episode. and the median number of infectious episodes was 5 per infected patient (Range I to 11). The percentage of patients with bacterial infection was 93%. viral infection 69%. and fungal infection 59%. The median number of episodes per infected patient in the three transplant types. SBTx. SBTxJL. MV. was 3.5. 5.0. and 6.5. respectively (P = .056. Kruskal-Wallis Test). The percent-age of SBTx patients with hacterial infection at the first 3 months after Tx with and without colonic segments was 87% (7/8), and 43% (317), respectively (P = .20, Fisher Exact Test). There were total of 140 episodes of infection and their occurrence at 1 to 3 months, 4 to 6 months, and later than 6 months following Tx was 40%, 16%, and 44%, respec-tively. These included: bacterial (90): line infection (25), peritonitis (12), abdominal abscess (11), primary bactere-mia (11), pneumonia (8), wound infection (8), Oostridium difficile colitis (6), others (9); viral (26): CMV (19), EBV (3), HSV (1). hepatitis C (3); fungal (20): candidiasis (16), aspergillosis (1), coccidioidomycosis (1), others (2); bacte-riallfungal (4). Twenty-one of 29 (72%) patients had at least one episode of bacteremia or fungemia, and the median number of episodes was 2.0 (Range 1.0 to 7.0). The source of infection for these episodes of positive blood culture was: intravascular line (43%), abdomen (19%), others (11%). and unknown source (28%). There were total of 54 positive blood cultures which included: aerobic gram positive organ-isms in 62%, aerobic gram negative organisms in 28%, anaerobic organisms in 2%, and candida species in 9%. Sixteen of 29 (55%) patients developed symptomatic CMV infection. Of these, 10 patients had primary infection, and 6 patients had reactivation. These infections included: gastro-enteritis (90%), hepatitis (5%), and retinitis (5%). DISCUSSION We reported in the past our experience with the first 21 patients who underwent small bowel Tx at the University of Pittsburgh.' In this report we were able to summarize our experience in a larger group of patients with a longer follow-up. The rate of infectious complication after small bowel Tx is very high, and the risk of infection is still relatively high more than 6 months after Tx. There was a trend for a higher rate of infection in patients who underwent MV compared to patients who underwent SBTx or SBTxJL. There was also a trend of higher rate of early bacterial infections in patients From the Departments of Surgery and Medicine and the Division of Transplantation Medicine, University of Pittsburgh, Pennsylvania. Supported by research grants from the Veterans Administra-tion and Project Grant No DK 29961 from the National Institutes of Health. Bethesda. Maryland. Address reprint requests to Shimon Kusne, MD. Transplanta-tion Institute, 3601 Fifth Ave. 4C Falk, Pittsburgh, Pennsylvania 15213. @ 1996 by Appleton & Lange 0041-1345/96/$3.001 + 0 Transplantation Proceedings, Vol 28. No 5 (October), 1996: pp 2761-2762 2761 2762 with SBTx with a colonic segment. Symptomatic CMV infection and bacteremia/fungemia were the most frequent infections. We have identified the vulnerability of the transplant gut to CMV, and its association with higher amounts of tacrolimus and steroids. 3.4 The high rate of bacteremiaJfungemia is mostly due to infection of central lines and abdomen. Bacterial translocation from the gut may explain in part those episodes of bacteremia with "unknown" source, and early bacterial infections in SBTx with colonic segment. Reduced infectious complications after small bowel transplantation is a very important goal. Possible strategies for the future are: preemptive therapy and limitation of transplant of CMV seronegative recipients with seroposi-KUSNE, FURUKAWA, ABU-ELMAGO ET AL tive organs, limitation of colonic segment transplant, paying special attention to management and maintenance of cen-tral lines. and innovative strategies in immunosuppression therapy. REFERENCES 1. Kusne S. Manez R, Bonet H. et al: Transplant Proc 26:1682, 1994 2. Kusne S, Dummer 1S, Singh N, et al: Medicine 67:132, 1988 3. Manez R. Kusne S, Green M, et al: Transplantation 59:1010, 1995 4. Furukawa H, Manez R, Kusne S, et al: Transplant Proc 27:1357, 1995 

Infectious complications after small bowel transplantation in adults: An update

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Infectious complications after small bowel transplantation in adults: An update

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