RESUMEN
Even with appropriate clinical management, complicated methicillin-susceptible Staphylococcus aureus (MSSA) catheter-related bacteremia (CRB) is frequent. We investigated the influence of molecular characteristics of MSSA strains on the risk of complicated bacteremia (CB) in MSSA-CRB. A multicenter prospective study was conducted in Spain between 2011 and 2014 on MSSA-CRB. Optimized protocol-guided clinical management was required. CB included endocarditis, septic thrombophlebitis, persistent bacteremia and/or end-organ hematogenous spread. Molecular typing, agr functionality and DNA microarray analysis of virulence factors were performed in all MSSA isolates. Out of 83 MSSA-CRB episodes included, 26 (31.3%) developed CB. MSSA isolates belonged to 16 clonal complexes (CCs), with CC30 (32.5%), CC5 (15.7%) and CC45 (13.3) being the most common. Comparison between MSSA isolates in episodes with or without CB revealed no differences regarding agr type and functionality. However, our results showed that CC15 and the presence of genes like cna, chp and cap8 were associated with the development of CB. The multivariate analysis highlighted that the presence of cna (Hazard ratio 2.9; 95% CI 1.14-7.6) was associated with the development of CB. Our results suggest that particular CCs and specific genes may influence the outcome of MSSA-CRB.
Asunto(s)
Bacteriemia/patología , Infecciones Relacionadas con Catéteres/patología , Infecciones Estafilocócicas/patología , Staphylococcus aureus/patogenicidad , Factores de Virulencia/análisis , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Análisis por Micromatrices , Persona de Mediana Edad , Tipificación Molecular , Estudios Prospectivos , España , Staphylococcus aureus/genética , Staphylococcus aureus/aislamiento & purificación , Resultado del Tratamiento , Factores de Virulencia/genéticaRESUMEN
Microbiological spectrum and outcome of infectious complications following small bowel transplantation (SBT) have not been thoroughly characterized. We performed a retrospective analysis of all patients undergoing SBT from 2004 to 2013 in Spain. Sixty-nine patients underwent a total of 87 SBT procedures (65 pediatric, 22 adult). The median follow-up was 867 days. Overall, 81 transplant patients (93.1%) developed 263 episodes of infection (incidence rate: 2.81 episodes per 1000 transplant-days), with no significant differences between adult and pediatric populations. Most infections were bacterial (47.5%). Despite universal prophylaxis, 22 transplant patients (25.3%) developed cytomegalovirus disease, mainly in the form of enteritis. Specifically, 54 episodes of opportunistic infection (OI) occurred in 35 transplant patients. Infection was the major cause of mortality (17 of 24 deaths). Multivariate analysis identified retransplantation (hazard ratio [HR]: 2.21; 95% confidence interval [CI]: 1.02-4.80; p = 0.046) and posttransplant renal replacement therapy (RRT; HR: 4.19; 95% CI: 1.40-12.60; p = 0.011) as risk factors for OI. RRT was also a risk factor for invasive fungal disease (IFD; HR: 24.90; 95% CI: 5.35-115.91; p < 0.001). In conclusion, infection is the most frequent complication and the leading cause of death following SBT. Posttransplant RRT and retransplantation identify those recipients at high risk for developing OI and IFD.
Asunto(s)
Rechazo de Injerto/microbiología , Enfermedades Intestinales/cirugía , Intestino Delgado/trasplante , Micosis/microbiología , Infecciones Oportunistas/microbiología , Complicaciones Posoperatorias , Adulto , Niño , Preescolar , Femenino , Estudios de Seguimiento , Rechazo de Injerto/epidemiología , Supervivencia de Injerto , Humanos , Incidencia , Enfermedades Intestinales/complicaciones , Enfermedades Intestinales/microbiología , Masculino , Micosis/epidemiología , Infecciones Oportunistas/epidemiología , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Adulto JovenRESUMEN
The indication for antimicrobial treatment of asymptomatic bacteriuria (AB) after kidney transplantation (KT) remains controversial. Between January 2011 and December 2013, 112 KT recipients that developed one episode or more of AB beyond the second month after transplantation were included in this open-label trial. Participants were randomized (1:1 ratio) to the treatment group (systematic antimicrobial therapy for all episodes of AB occurring ≤24 mo after transplantation [53 patients]) or control group (no antimicrobial therapy [59 patients]). Systematic screening for AB was performed similarly in both groups. The primary outcome was the occurrence of acute pyelonephritis at 24-mo follow-up. Secondary outcomes included lower urinary tract infection, acute rejection, Clostridium difficile infection, colonization or infection by multidrug-resistant bacteria, graft function and all-cause mortality. There were no differences in the primary outcome in the intention-to-treat population (7.5% [4 of 53] in the treatment group vs. 8.4% [5 of 59] in the control group; odds ratio [OR] 0.88, 95% confidence interval [CI] 0.22-3.47) or the per-protocol population (3.8% [1 of 26] in the treatment group vs. 8.0% [4 of 50] in the control group; OR 0.46, 95% CI 0.05-4.34). Moreover, we found no differences in any of the secondary outcomes. In conclusion, systematic screening and treatment of AB beyond the second month after transplantation provided no apparent benefit among KT recipients (NCT02373085).
Asunto(s)
Antibacterianos/uso terapéutico , Bacteriuria/tratamiento farmacológico , Rechazo de Injerto/tratamiento farmacológico , Fallo Renal Crónico/cirugía , Trasplante de Riñón/efectos adversos , Pielonefritis/prevención & control , Bacterias/efectos de los fármacos , Bacteriuria/complicaciones , Bacteriuria/microbiología , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular , Rechazo de Injerto/etiología , Supervivencia de Injerto/efectos de los fármacos , Humanos , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Pronóstico , Pielonefritis/etiología , Factores de RiesgoRESUMEN
The optimal approach following the isolation of Staphylococcus aureus from an intravascular catheter tip in the absence of concomitant bacteremia remains unclear. We aimed to determine the rate of delayed complications in these patients. We performed a retrospective observational study (during the period 2002-2012) including patients with a catheter tip culture yielding S. aureus. Patients were followed up for ≥6 months. The primary endpoint was the occurrence of delayed staphylococcal complications (either bacteremia and/or metastatic distant infections). A total of 113 patients were included (75 % male, median age 61 years): 46 and 67 with negative and positive blood cultures, respectively. We found a lower rate of delayed staphylococcal complications in cases with no bacteremia within 48 h since catheter removal than in cases of confirmed S. aureus catheter-related bacteremia (0.0 % vs. 25.4 %; p-value < 0.001). In the group without bacteremia, there was a subgroup of 15 patients (32.6 %) who did not receive antimicrobial treatment. Again, delayed complications occurred less commonly in this subgroup of patients without bacteremia (0.0 % vs. 25.4 %; p-value = 0.033). In contrast to patients with S. aureus catheter-related bacteremia, no delayed infectious complications were observed in patients with an isolated catheter tip culture yielding S. aureus and negative blood cultures within 48 h of catheter removal. Futures studies are needed to assess if the therapeutic approach could be different for this group of patients.
Asunto(s)
Bacteriemia/etiología , Catéteres Venosos Centrales/microbiología , Infección Hospitalaria/etiología , Infecciones Estafilocócicas/etiología , Staphylococcus aureus/aislamiento & purificación , Anciano , Bacteriemia/epidemiología , Infección Hospitalaria/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Infecciones Estafilocócicas/epidemiologíaRESUMEN
BACKGROUND: Recent studies suggest that Epstein-Barr virus DNAemia (EBVd) may act as a surrogate marker of post-transplant immunosuppression. This hypothesis has not been tested so far in lung transplant (LT) recipients. METHODS: We included 63 patients undergoing lung transplantation at our center between October 2008 and May 2013. Whole blood EBVd was systematically assessed by real-time polymerase chain reaction assay on a quarterly basis. The occurrence of late complications (overall and opportunistic infection [OI] and chronic lung allograft dysfunction [CLAD]) was analyzed according to the detection of EBVd within the first 6 months post transplantation. RESULTS: Any EBVd was detected in 30 (47.6%) patients. Peak EBVd was higher in patients with late overall infection (2.23 vs. 1.73 log10 copies/mL; P = 0.026) and late OI (2.39 vs. 1.74 log10 copies/mL; P = 0.004). The areas under receiver operating characteristic curves for predicting both events were 0.806 and 0.871 respectively. The presence of an EBVd ≥2 log10 copies/mL during the first 6 months post transplantation was associated with a higher risk of late OI (adjusted hazard ratio [aHR] 7.92; 95% confidence interval [CI] 2.10-29.85; P = 0.002). Patients with detectable EBVd during the first 6 months also had lower CLAD-free survival (P = 0.035), although this association did not remain statistically significant in the multivariate analysis (aHR 1.26; 95% CI 0.87-5.29; P = 0.099). CONCLUSIONS: Although preliminary in nature, our results suggest that the detection of EBVd within the first 6 months after transplantation is associated with the subsequent occurrence of late OI in LT recipients.
Asunto(s)
Infecciones por Virus de Epstein-Barr/diagnóstico , Herpesvirus Humano 4/aislamiento & purificación , Trasplante de Pulmón/efectos adversos , Infecciones Oportunistas/etiología , Complicaciones Posoperatorias/etiología , Adulto , Anciano , Biomarcadores/sangre , Estudios de Cohortes , ADN Viral/sangre , Infecciones por Virus de Epstein-Barr/virología , Femenino , Estudios de Seguimiento , Herpesvirus Humano 4/genética , Humanos , Terapia de Inmunosupresión , Incidencia , Masculino , Persona de Mediana Edad , Reacción en Cadena en Tiempo Real de la Polimerasa , Estudios Retrospectivos , ViremiaRESUMEN
BACKGROUND: Antibiotic resistance is an emerging phenomenon in kidney transplantation (KT). METHODS: We compared species distribution and antimicrobial susceptibility patterns in 1052 isolates from urine cultures obtained in 2 different cohorts of kidney transplant recipients in a single center (Cohort A: 189 patients undergoing KT between January 2002 and December 2004 [336 isolates]; Cohort B: 115 patients undergoing KT between January 2011 and December 2013 [716 isolates]). RESULTS: Asymptomatic bacteriuria accounted for most of the isolates (86.9% in Cohort A and 92.3% in Cohort B). Klebsiella pneumoniae (9.5% vs. 15.6%), Pseudomonas aeruginosa (1.8% vs. 7.9%), and Enterobacter cloacae (0.6% vs. 3.1%) were significantly more common in Cohort B. The isolation of K. pneumoniae in Cohort B was associated with the occurrence of acute pyelonephritis (9.8% of all K. pneumoniae isolates vs. 2.8% of the remaining uropathogens; P = 0.001). Non-susceptibility rates among Enterobacteriaceae in Cohort B were higher for every class of antibiotics (P ≤ 0.003) with the exception of fosfomycin. Compared to Cohort A, significant increases were seen in isolates from Cohort B for multidrug-resistant (MDR) (43.9% vs. 67.8%, respectively; P = 0.001), extended-spectrum beta-lactamase (ESBL)-producing (6.6% vs. 26.1%; P = 0.001), and carbapenemase-producing Enterobacteriaceae strains (0.0% vs. 5.0%; P = 0.001). Such differences were mostly attributable to K. pneumoniae (as 54.5% and 13.4% of isolates in Cohort B were ESBL-producing and carbapenemase-producing, respectively). MDR isolates were responsible for 69.1% of episodes of symptomatic urinary tract infection in Cohort B. CONCLUSION: The increase in resistance rates among Enterobacteriaceae uropathogens is significant and may have an effect on KT programs.
Asunto(s)
Antibacterianos/farmacología , Farmacorresistencia Bacteriana , Enterobacter cloacae/efectos de los fármacos , Infecciones por Enterobacteriaceae/microbiología , Trasplante de Riñón/efectos adversos , Infecciones Urinarias/microbiología , Adulto , Anciano , Antibacterianos/administración & dosificación , Antibacterianos/uso terapéutico , Infecciones Asintomáticas , Proteínas Bacterianas/metabolismo , Enterobacter cloacae/enzimología , Enterobacter cloacae/aislamiento & purificación , Infecciones por Enterobacteriaceae/tratamiento farmacológico , Infecciones por Enterobacteriaceae/orina , Femenino , Fosfomicina/administración & dosificación , Fosfomicina/farmacología , Fosfomicina/uso terapéutico , Humanos , Infecciones por Klebsiella/microbiología , Infecciones por Klebsiella/orina , Klebsiella pneumoniae/aislamiento & purificación , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Infecciones por Pseudomonas/microbiología , Infecciones por Pseudomonas/orina , Pseudomonas aeruginosa/aislamiento & purificación , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Retrospectivos , Infecciones Urinarias/tratamiento farmacológico , Infecciones Urinarias/orina , beta-Lactamasas/metabolismoRESUMEN
BACKGROUND: Monitoring of peripheral blood lymphocyte subpopulation (PBLS) counts might be useful for estimating the risk of infection after liver transplantation (LT). METHODS: We prospectively measured total lymphocyte and PBLS counts at baseline and post-transplant months 1 and 6 in 92 LT recipients. PBLS were enumerated by single-platform 6-color flow cytometry technology. Areas under receiver operating characteristic (ROC) curves were used to evaluate the accuracy of different PBLS for predicting cytomegalovirus (CMV) disease and overall opportunistic infection (OI). Adjusted hazard ratios (aHRs) for both outcomes were estimated by Cox regression. RESULTS: After a median follow-up of 730.0 days, 29 patients (31.5%) developed 38 episodes of OI (including 22 episodes of CMV disease). The counts of CD3(+) , CD4(+) , and CD8(+) T cells, and CD56(+) CD16(+) natural killer (NK) cells at month 1 were significantly lower in patients subsequently developing OI. The NK cell count was the best predictive parameter (area under ROC curve for predicting CMV disease: 0.78; P-value = 0.001). Patients with an NK cell count <0.050 × 10(3) cells/µL had higher cumulative incidences of CMV disease (P-value = 0.001) and overall OI (P-value <0.001). In the multivariate models, an NK cell count <0.050 × 10(3) cells/µL at month 1 post transplantation remained as an independent risk factor for CMV disease (aHR: 5.54; P-value = 0.003) and overall OI (aHR: 7.56; P-value <0.001). CONCLUSION: Post-transplant kinetics of NK cell counts may be used as a simple and affordable proxy to the cell-mediated immunity status in LT recipients and to their associated risk of OI.
Asunto(s)
Infecciones por Citomegalovirus/sangre , Células Asesinas Naturales/inmunología , Trasplante de Hígado/efectos adversos , Subgrupos Linfocitarios/inmunología , Monitorización Inmunológica/métodos , Infecciones Oportunistas/sangre , Anciano , Citomegalovirus/aislamiento & purificación , Infecciones por Citomegalovirus/epidemiología , Infecciones por Citomegalovirus/inmunología , Infecciones por Citomegalovirus/virología , Femenino , Citometría de Flujo , Estudios de Seguimiento , Humanos , Inmunidad Celular , Recuento de Linfocitos/economía , Masculino , Persona de Mediana Edad , Infecciones Oportunistas/epidemiología , Infecciones Oportunistas/inmunología , Infecciones Oportunistas/microbiología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores de RiesgoRESUMEN
Infections produced by Mycobacterium abscessus are emerging in immunosuppressed patients, such as solid organ transplant recipients. We report the first case, to our knowledge, of a vertebral osteomyelitis caused by M. abscessus in a heart transplant recipient, and review the risk factors, manifestations, and therapeutic approaches to this uncommon disease.
Asunto(s)
Trasplante de Corazón/efectos adversos , Mycobacterium/aislamiento & purificación , Osteomielitis/complicaciones , Infecciones del Sistema Respiratorio/complicaciones , Anciano , Antibacterianos/uso terapéutico , Claritromicina/uso terapéutico , Femenino , Humanos , Huésped Inmunocomprometido , Mycobacterium/clasificación , Osteomielitis/diagnóstico por imagen , Osteomielitis/tratamiento farmacológico , Osteomielitis/microbiología , Infecciones del Sistema Respiratorio/diagnóstico por imagen , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Infecciones del Sistema Respiratorio/microbiología , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: This study aimed to characterize the dynamics of acquisition of cytomegalovirus (CMV)-specific cell-mediated immunity (CMI) in CMV donor positive/recipient negative solid organ transplant (SOT) patients receiving long-term antiviral prophylaxis, and to determine whether development of CMI confers protection against CMV disease. METHODS: A prospective multicenter study was conducted in Spain from September 2009 to September 2012. Whole blood specimens were prospectively collected at 30, 90, 120, 200, and 365 days after SOT, and CMI was determined by enumeration of CMV pp65 and IE-1-specific CD69(+) /interferon-γ-producing CD8(+) and CD4(+) T cells by flow cytometry for intracellular cytokine staining. As part of a simultaneous clinical trial, patients received either early prophylaxis (in the first 3 days after transplantation) in the first period of the study or delayed prophylaxis (initiated at day 14) during the second period of the study. The impact of the dynamics of acquisition of CMV-specific CMI on the incidence of CMV disease was evaluated by Kaplan-Meier survival analysis. RESULTS: A total of 95 SOT recipients were recruited. CMV infection and disease occurred in 38 (40%) and 26 (27.4%) patients, respectively. The proportion of patients achieving any detectable CMV-specific CMI response at each of the different monitoring points was higher in liver transplant recipients, as compared to kidney or heart transplant recipients. The presence of any detectable response at day 120 or 200 was protective against the development of CMV disease (positive predictive values 92% and 93%, respectively). CONCLUSIONS: The rate of acquisition of CMV-specific CMI in SOT recipients undergoing antiviral prophylaxis differed significantly between different SOT populations. Patients developing any detectable CMI response were protected against the occurrence of CMV disease.
Asunto(s)
Antivirales/uso terapéutico , Infecciones por Citomegalovirus/prevención & control , Citomegalovirus/inmunología , Ganciclovir/análogos & derivados , Inmunidad Celular , Trasplante de Órganos , Complicaciones Posoperatorias/prevención & control , Adulto , Anciano , Infecciones por Citomegalovirus/etiología , Infecciones por Citomegalovirus/inmunología , Infecciones por Citomegalovirus/virología , Femenino , Estudios de Seguimiento , Ganciclovir/uso terapéutico , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios/métodos , Complicaciones Posoperatorias/inmunología , Complicaciones Posoperatorias/virología , Estudios Prospectivos , Resultado del Tratamiento , ValganciclovirRESUMEN
The usefulness of monitoring of complement levels in predicting the occurrence of infection in kidney transplant (KT) recipients remains largely unknown. We prospectively assessed serum complement levels (C3 and C4) at baseline and at months 1 and 6 in 270 patients undergoing KT. Adjusted hazard ratios (aHRs) for infection in each posttransplant period were estimated by Cox regression. The prevalence of C3 hypocomplementemia progressively decreased from 21.5% at baseline to 11.6% at month 6 (p = 0.017), whereas the prevalence of C4 hypocomplementemia rose from 3.7% at baseline to 9.2% at month 1 (p = 0.004). Patients with C3 hypocomplementemia at month 1 had higher incidences of overall (p = 0.002), bacterial (p = 0.004) and fungal infection (p = 0.019) in the intermediate period (months 1-6). On multivariate analysis C3 hypocomplementemia at month 1 emerged as a risk factor for overall (aHR 1.911; p = 0.009) and bacterial infection (aHR 2.130; p = 0.014) during the intermediate period, whereas C3 hypocomplementemia at month 6 predicted the occurrence of bacterial infection (aHR 3.347; p = 0.039) in the late period (>6 month). A simple monitoring strategy of serum C3 levels predicts the risk of posttransplant infectious complications in KT recipients.
Asunto(s)
Complemento C3/deficiencia , Rechazo de Injerto/etiología , Infecciones/etiología , Enfermedades Renales/complicaciones , Trasplante de Riñón/efectos adversos , Complicaciones Posoperatorias , Femenino , Rechazo de Injerto/mortalidad , Supervivencia de Injerto , Humanos , Infecciones/mortalidad , Enfermedades Renales/cirugía , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Tasa de Supervivencia , Centros de Atención TerciariaRESUMEN
BACKGROUND: The impact of iron metabolism on the risk of infectious complications has been demonstrated in various immunosuppressed populations. However, no previous studies have assessed this potential association in kidney transplant (KT) recipients. METHODS: We prospectively analyzed 228 patients undergoing KT at our institution from November 2008 to February 2011. Serum iron parameters (iron level, ferritin, total iron-binding capacity, unsaturated iron-binding capacity, transferrin, and transferrin saturation) were assessed within the first 2 weeks after transplantation (median interval, 3 days; interquartile [Q1 -Q3 ] range, 1-6 days), and before the occurrence of the first infectious episode (median interval, 26 days; Q1 -Q3 range, 11-76 days). Primary outcome was the occurrence of any episode of infection during the first year. Multivariate-adjusted hazard ratios (aHRs) were estimated by Cox regression models. RESULTS: Patients with ferritin level ≥ 500 ng/mL had higher incidence rates (per 1000 transplant-days) of overall infection (P = 0.017), bacterial infection (P = 0.002), and bloodstream infection (P = 0.011) during the first post-transplant year. One-year infection-free survival rate was lower in these recipients (26% vs. 41%; P = 0.004). On multivariate analysis, after adjusting for potential confounders, ferritin emerged as an independent predictor of overall infection (aHR [per unitary increment], 1.001; P = 0.006), and bacterial infection (aHR [per unitary increment], 1.001; P = 0.020). CONCLUSION: Monitoring of serum iron parameters in the early post-transplant period may be useful in predicting the occurrence of infection in KT recipients, although further studies should be carried out to confirm this preliminary finding.
Asunto(s)
Infecciones Bacterianas/epidemiología , Ferritinas/sangre , Hierro/sangre , Trasplante de Riñón/efectos adversos , Sepsis/epidemiología , Transferrina/metabolismo , Adulto , Anciano , Infecciones Bacterianas/sangre , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores de Riesgo , Sepsis/sangreRESUMEN
INTRODUCTION: Severity of recurrent hepatitis C virus (HCV) infection in liver transplant recipients (LTR) is variable and the influence of different factors, including the administration of antiviral therapy in the long-term outcome is controversial. METHODS: We analyzed the outcome of a cohort of HCV-infected LTR who were transplanted in our institution. Patients were divided into 2 groups (severe and non-severe HCV disease) depending on the presence of a fibrosis score of F ≥ 2 in the Scheuer index and/or fibrosing cholestasic hepatitis (FCH) in a graft biopsy. Risk factors were studied using logistic regression analysis. Survival of patients was estimated using Kaplan-Meier plots. A total of 146 patients were followed for a mean of 58 months. RESULTS: Fifty-six (34%) patients developed severe HCV disease and showed shorter survival (P < 0.024). Donor age (odds ratio [OR]: 1.04; 95% confidence interval [CI]: 1.02-1.06) and pre-transplant viral load (VL) >10(6) UI/mL (OR: 3.5; 95% CI: 1.42-10.61) were the only factors associated with severe HCV infection. Over-immunosuppression (OR: 2.3; 95% CI: 1.2-4.41) was specifically associated with the development of FCH. Overall, patient survival in recipients who received a full course of anti-HCV therapy was higher than in patients who did not complete antiviral therapy (P = 0.004) or received no treatment (P = 0.007). Patients with non-severe HCV infection have a higher probability of receiving a full course of antiviral therapy (P = 0.033). CONCLUSION: In conclusion, donor age, pre-transplant VL, and over-immunosuppression were associated with the long-term development of severe HCV recurrence in liver grafts. Administration of a full course of antiviral therapy was associated with better survival.
Asunto(s)
Antivirales/uso terapéutico , Hepatitis C/tratamiento farmacológico , Trasplante de Hígado/efectos adversos , Adulto , Femenino , Hepacivirus/efectos de los fármacos , Hepatitis C/mortalidad , Hepatitis C/patología , Hepatitis C/virología , Humanos , Cirrosis Hepática/tratamiento farmacológico , Cirrosis Hepática/mortalidad , Cirrosis Hepática/patología , Cirrosis Hepática/virología , Masculino , Persona de Mediana Edad , Recurrencia , Factores de Riesgo , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
We aimed to analyze the incidence, risk factors and impact of hypogammaglobulinemia (HGG) in 226 kidney transplant (KT) recipients in which serum immunoglobulin (Ig) levels were prospectively assessed at baseline, month 1 (T(1) ), and month 6 (T(6) ). The prevalence of IgG HGG increased from 6.6% (baseline) to 52.0% (T(1) ) and subsequently decreased to 31.4% (T(6) ) (p < 0.001). The presence of IgG HGG at baseline (odds ratio [OR] 26.9; p = 0.012) and a positive anti-HCV status (OR 0.17; p = 0.023) emerged as risk factors for the occurrence of posttransplant IgG HGG. Patients with HGG of any class at T(1) had higher incidences of overall (p = 0.018) and bacterial infection (p = 0.004), bacteremia (p = 0.054) and acute pyelonephritis (p = 0.003) in the intermediate period (months 1-6). Patients with HGG at T(6) had higher incidences of overall (p = 0.004) and bacterial infection (p < 0.001) in the late period (>6 month). A complementary log-log model identified posttransplant HGG as an independent risk factor for overall (hazard ratio [HR] 2.03; p < 0.001) and bacterial infection (HR 2.68; p < 0.0001). Monitoring of humoral immunity identifies KT recipients at high risk of infection, offering the opportunity for preemptive immunoglobulin replacement therapy.
Asunto(s)
Inmunoglobulinas/sangre , Infecciones/etiología , Trasplante de Riñón/efectos adversos , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de RiesgoRESUMEN
Long-term prophylaxis against cytomegalovirus (CMV) started immediately after transplantation in (D+/R-) poses a higher risk of late-onset CMV disease. Delayed CMV prophylaxis could allow a transitory exposure of the immune system to CMV, which would let the immune system mount an adequate CMV-specific cytotoxic response in (D+/R-) patients and confer protection against CMV disease. We included all (D+/R-) solid organ transplant recipients (SOT) performed at our institution (January 3/October 6) who received CMV prophylaxis (mainly with oral valganciclovir) during 100 d. In the first period (until December 4), prophylaxis was initiated immediately after transplantation (conventional prophylaxis: CP). Since January 5, it was initiated after 14 d (delayed prophylaxis: DP). Incidence and severity of CMV disease was compared between both groups. A total of 44 SOT recipients were included (CP: 26 and DP: 18). CMV disease was diagnosed in eight patients (18%), seven of 26 (27%) in the CP group, and one of 18 (5.5%) in the DP group (p = 0.07). CMV colitis was reported in five of 26 patients in the CP group (19%), whereas there were no cases of visceral CMV disease in the DP group (p = 0.048). A 14-d delay in the beginning of long-term prophylaxis against CMV in (D+/R-) is safe and could prevent the onset of late-CMV disease.
Asunto(s)
Antivirales/uso terapéutico , Infecciones por Citomegalovirus/prevención & control , Citomegalovirus/patogenicidad , Ganciclovir/análogos & derivados , Rechazo de Injerto/inmunología , Trasplante de Órganos , Inmunología del Trasplante , Adulto , Infecciones por Citomegalovirus/virología , Ganciclovir/uso terapéutico , Humanos , Pronóstico , Factores de Riesgo , Tasa de Supervivencia , Resultado del Tratamiento , ValganciclovirRESUMEN
INTRODUCTION: Mycobacterium bovis is an infrequent cause of central nervous system tuberculosis in Spain, with few cases described in the literature. Since compulsory pasteurization of milk and implementation of eradication programs on infected cattle, human sporadic illness with this organism has dramatically declined in developed countries. CASE REPORT: A 71-year-old immunocompromised male, who presented a calvarial lytic lesion. A craniotomy for the total resection of the lesion was performed and the microbiology results were positive for M. bovis, therefore antituberculous therapy was initiated. Despite of the correct treatment, the patient developed a tuberculous abscess that required an aggressive surgical management followed by a suppurative fistula. Based on the treatment of tuberculous lymphadenitis, we decided to perform a conservative management with antituberculous therapy (isoniazid + rifampicin + ethambutol + moxifloxacin + steroids during 12 months) and avoided new surgical cleanings of the surgical bed obtaining a good response and a good clinical evolution. CONCLUSIONS: As far as we know, this is the first case reported of a suppurative fistula after the resection of a cerebral abscess caused by M. bovis, therefore, there is no report in the literature about the treatment of this complication.
TITLE: Caso insólito de absceso cerebral por Mycobacterium bovis complicado con fístula supurativa y revisión de la bibliografía.Introducción. Mycobacterium bovis es una causa infrecuente de tuberculosis del sistema nervioso central en España, del cual existen pocos casos descritos en la bibliografía. Desde la pasteurización obligatoria de la leche y la implementación de programas de erradicación del ganado infectado, la enfermedad esporádica humana con este organismo ha disminuido drásticamente en los países desarrollados. Caso clínico. Varón inmunoafectado de 71 años, que presentaba una lesión lítica esporádica en la calota. Se realizó una craneotomía de la lesión y los resultados de microbiología fueron positivos para M. bovis, por lo que se inició tratamiento con terapia antituberculosa. A pesar del tratamiento correcto, el paciente desarrolló un absceso tuberculoso, que requirió un tratamiento quirúrgico agresivo, seguido de una complicación con una fístula supurativa. Sobre la base del tratamiento descrito para la linfadenitis tuberculosa, se decidió realizar un tratamiento conservador de la fístula supurativa, sin realizar nuevas limpiezas del lecho quirúrgico, y mantener de manera prolongada la terapia antituberculosa (isoniacida + rifampicina + etambutol + moxifloxacino + esteroides durante 12 meses), con lo que presentó una buena evolución clínica. Conclusiones. Hasta la fecha, éste es el primer caso descrito de una fístula supurativa después de la resección de un absceso cerebral causado por M. bovis, por lo que no existe en la bibliografía artículo alguno que describa el tratamiento adecuado de esta complicación.
Asunto(s)
Absceso Encefálico/complicaciones , Fístula/etiología , Mycobacterium bovis , Complicaciones Posoperatorias/etiología , Tuberculosis del Sistema Nervioso Central/complicaciones , Anciano , Absceso Encefálico/terapia , Fístula/terapia , Humanos , Masculino , Complicaciones Posoperatorias/terapia , España , Tuberculosis del Sistema Nervioso Central/terapiaRESUMEN
OBJECTIVE: Previous studies on monitoring of post-transplant cytomegalovirus (CMV)-specific cell-mediated immunity (CMI) are limited by single-centre designs and disparate risk categories. We aimed to assess the clinical value of a regular monitoring strategy in a large multicentre cohort of intermediate-risk kidney transplant (KT) recipients. METHODS: We recruited 124 CMV-seropositive KT recipients with no T-cell-depleting induction pre-emptively managed at four Spanish institutions. CMV-specific interferon-γ-producing CD4+ and CD8+ T cells were counted through the first post-transplant year by intracellular cytokine staining after stimulation with pp65 and immediate early-1 peptides (mean of six measurements per patient). The primary outcome was the occurrence of any CMV event (asymptomatic infection and/or disease). Optimal cut-off values for CMV-specific T cells were calculated at baseline and day 15. RESULTS: Twelve-month cumulative incidence of CMV infection and/or disease was 47.6%. Patients with pre-transplant CMV-specific CD8+ T-cell count <1.0 cells/µL had greater risk of CMV events (adjusted hazard ratio (aHR) 2.84; p 0.054). When the CMI assessment was performed in the immediate post-transplant period (day 15), the presence of <2.0 CD8+ T cells/µL (aHR 2.18; p 0.034) or <1.0 CD4+ T cells/µL (aHR 2.43; p 0.016) also predicted the subsequent development of a CMV event. In addition, lower counts of CMV-specific CD4+ (but not CD8+) T cells at days 60 and 180 were associated with a higher incidence of late-onset events. CONCLUSIONS: Monitoring for CMV-specific CMI in intermediate-risk KT recipients must be regular to reflect dynamic changes in overall immunosuppression and individual susceptibility. The early assessment at post-transplant day 15 remains particularly informative.
Asunto(s)
Infecciones por Citomegalovirus/inmunología , Citomegalovirus/inmunología , Trasplante de Riñón , Monitorización Inmunológica/métodos , Linfocitos T/inmunología , Anciano , Femenino , Humanos , Inmunidad Celular , Interferón gamma/metabolismo , Recuento de Linfocitos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Factores de Riesgo , Linfocitos T/citología , Linfocitos T/metabolismo , Receptores de TrasplantesRESUMEN
BACKGROUND: Corynebacterium urealyticum is a cause of urinary tract infection and encrusting cystitis or pyelitis. Information about this infection in renal transplant recipients is based on case reports. We communicate the first prospective epidemiological study for this population. METHODS: We selected a cohort of 163 renal transplant recipients who were screened for urinary tract infection due to C. urealyticum. Long-term incubation and special media were used for culture of C. urealyticum. The cohort was observed for a mean of 26.2 months (standard deviation, 8.7; range, 1-36 months). Risk factors and outcomes were assessed. RESULTS: At baseline, 16 (9.8%) of 163 patients had C. urealyticum bacteriuria (6 were asymptomatic, 9 had acute cystitis, and 1 had encrusting pyelitis). Independent risk factors (assessed by multivariate analysis) for urinary tract C. urealyticum infection were: antibiotic administration during the previous month (odds ratio, 8.04; 95% confidence interval, 1.57-41.06; P = .012), history of nephrostomy (odds ratio, 51.59; 95% confidence interval, 3.62-736.06; P = .004), and skin colonization (odds ratio, 208.35; 95% confidence interval, 21.54-2015.22; P< .001). Presence of urinary tract infection symptoms for >1 month (odds ratio, 27.7; 95% confidence interval, 2.55-300.5; P = .006) and obstructive uropathy (odds ratio 25.9; 95% confidence interval, 4.43-152.31; P < .001) were more frequent during follow-up in patients with C. urealyticum bacteriuria. CONCLUSIONS: When specifically tested for, C. urealyticum bacteriuria is more prevalent than previously thought in renal transplant recipients, and it is closely related to obstructive uropathy. Future studies are necessary to establish the relevance of treating the infection during follow-up after renal transplantation.
Asunto(s)
Infecciones por Corynebacterium , Corynebacterium/aislamiento & purificación , Rechazo de Injerto/microbiología , Enfermedades Renales/microbiología , Trasplante de Riñón/efectos adversos , Infecciones Urinarias , Adolescente , Adulto , Anciano , Bacteriuria/epidemiología , Bacteriuria/microbiología , Estudios de Cohortes , Corynebacterium/clasificación , Infecciones por Corynebacterium/complicaciones , Infecciones por Corynebacterium/epidemiología , Infecciones por Corynebacterium/microbiología , Cistitis/epidemiología , Cistitis/microbiología , Femenino , Rechazo de Injerto/epidemiología , Humanos , Enfermedades Renales/epidemiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Pielitis/epidemiología , Pielitis/microbiología , Factores de Riesgo , Infecciones Urinarias/complicaciones , Infecciones Urinarias/epidemiología , Infecciones Urinarias/microbiologíaRESUMEN
Transmission of infection from donor to recipient is a potential complication of transplantation. More data on this issue are needed to expand the insufficient donor pool. This study evaluates the incidence of donor nonviral infection, transmission from infected donors and the effect of donor infection on 30-day recipient survival. Data from 211 infected donors contributing to 292 (8.8%) of 3322 consecutive transplant procedures within RESITRA (Spanish Research Network for the Study of Infection in Transplantation) were prospectively compiled and analyzed. Lung was the most likely transplanted organ carried out with an infected donor and Staphylococcus aureus was the most commonly isolated microorganism. In more than a half of donors, the lung was the site of infection. Donor-to-host transmission was documented in 5 patients out of 292 (1.71%), 2 of whom died of the acquired infection (40%). Nonetheless, there was no difference in 30-day patient survival when comparing transplant procedures performed with organs from infected or uninfected donors. In conclusion, donor infection is not an infrequent event, but transmission to the recipient is quite low. Hence, with careful microbiological surveillance and treatment, the number of organs available for transplantation may be increased.