Page 1588 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 115: The Transplant Patient 1107

started empirically on this population of patients posttransplant. In the
TABLE 115-18 Prophylaxis Posttransplant
dire situation of multidrug resistant organisms, synergy antimicrobial
Lung Liver Heart sensitivity testing is performed to determine which optimal combina-
CMV CMV positivity or mismatch CMV positivity or CMV positivity or tion of antimicrobials would have the greatest impact on suppression of
mismatch mismatch these organisms in the posttransplant period.
PJP All recipients All recipients All recipients Liver Transplant–Specific Infectious Considerations: Intra-abdominal infec-
Bacterial Empiric broad spectrum until Routine surgical Routine surgical tions ranging from local abscess formation to overt peritonitis can occur
cultures from transplant prophylaxis prophylaxis; if donor following liver transplantation. Development of these complications
(CF: based on previous + for infection, should always lead the clinician to suspect that a leak has occurred from
colonizing organisms and then pathogen- the biliary anastomosis or from the jejunojejunostomy; correction of these
resistance specific empiric problems will often require laparotomy and surgical repair. However,
patterns) coverage; if chroni- abscesses usually can be treated with CT-guided drainage and subsequent
cally infected device serial CT scans to ensure that the collection has been adequately drained.
pretransplant, Transient biliary tree infection and subsequent bacteremia may occur
empiric coverage following biliary tree manipulation (T-tube manipulation, cholangi-
based on pathogen ography, etc). This has prompted many experts to advocate the use of
preemptive systemic antibiotics around the time of such procedures. 143
Fungal If previously colonized Consider if risk factors a Oral candida Early fungal infections, such as disseminated Candida, are not uncom-
Oral candida prophylaxis Oral candida prophylaxis prophylaxis
mon after liver transplant as they are commensal organisms of the
a Risk factors: >2 OR, retransplant, renal failure, large number of blood product (>40 units). gastrointestinal tract. The incidence has been reported between 7% and
42% with Candida species and Aspergillus species as the most responsible
empiric broad-spectrum antimicrobials based on their center’s micro- pathogens. Overgrowth and translocation of these as well as gram-
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biological resistance patterns. These empiric antibiotics are intended negative organisms can result in admission to the intensive care unit and
to reduce the development of a donor-associated infection/pneumonia. necessitate surgical exploration. The risk of fungal infections increases
Once the donor bronchoalveolar lavage reveals either a negative culture after therapy with broad-spectrum antibiotics, central venous catheters,
or a particular organism, the antibiotics can be stopped if negative or treatment of rejection with intensification of immunosuppression and
tailored appropriately if positive. steroid regimens, and duration of antibiotics. Some centers administer
Cytomegalovirus (CMV) infection of the graft can cause significant antifungal prophylaxis to adult liver transplant recipients at high risk for
morbidity and can increase transplant-related mortality (see the section developing invasive candidiasis such as those with at least two or more
“Infections due to Cytomegalovirus”). The reported incidence of invasive of any of the following: prolonged or repeat operations, retransplanta-
aspergillosis in the lung transplant recipient ranges from 4% to 23%. tion, renal failure, high transfusion requirement (≥40 units of cellular
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Risk factors for infection include anastomotic ischemia, single lung trans- blood products including platelets, red blood cells, and autotransfusion),
plant, CMV infection, and pretransplant colonization with Aspergillus. choledochojejunostomy, and Candida colonization preoperatively.
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In addition, the presence of immunosuppression, broad-spectrum antibi- Duration varies from center to center; however, up to 4 weeks or during
otics, cold exposure, and impaired mucociliary clearance create an envi- the duration that the risk factors are present is reasonable according to
ronment for Aspergillus to seed and flourish. The bronchial anastomosis some infectious disease experts. Recent evidence demonstrates that
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is particularly vulnerable to infection with this organism, though the mortality due to fungal infections and episodes of fungal infections can
airways may become more diffusely affected, and mucosal edema, ulcer- be reduced significantly with antifungal prophylaxis. 165
ation, and formation of pseudomembranes may occur. Mortality varies
from 23% in those with local disease to up to 82% in those with invasive Infectious Issues Specific to Heart Transplant: Infective endocarditis is an
pulmonary disease. Recent antifungals have been developed that have infrequent complication following heart transplantation. When it occurs,
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potent anti-Aspergillus activity with better side-effect profiles than older it often develops along the supravalvular suture line. Antibiotic prophy-
therapies. Newer triazoles such as voriconazole have been shown to be laxis is generally recommended for heart transplant recipients prior to
more effective than previous antifungals. One study has shown that vori- dental, gastrointestinal, or genitourinary tract surgery. Hearts from
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conazole provided greater survival and fewer significant adverse events donors with infection are occasionally transplanted; however, it is rec-
compared to the more traditional amphotericin B for the treatment of ommended that the repeat cultures prior to organ retrieval are negative,
invasive aspergillosis. Multiple subsequent trials have supported this antimicrobials were administered to the donor and there is no evidence
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finding and voriconazole is considered the drug of choice for the primary of infective endocarditis. If transplanted, pathogen-specific antimicrobial
treatment of invasive aspergillosis in all organ transplant recipients. 161 therapy should be administered to the recipient and surveillance blood
Patients with septic lung disease (cystic fibrosis or bronchiectasis) cultures should be obtained. If a chronically infected device is present
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have a very high risk of early infection as these patients’ upper airways prior to transplant, antimicrobial coverage should be tailored to include
are typically highly colonized prior to transplant. Despite efforts to steril- those organisms posttransplant.
ize the trachea and major bronchi in the perioperative period, secretions
originating from these recipients’ upper airways and proximal lower CONCLUSION
airways likely contaminate the transplanted lungs. Consequently most
centers employ an antimicrobial strategy to deal with these colonizing The role of the intensivist in the management of the transplant recipi-
organisms, which are typically Staphylococcus aureus, nontuberculosis ent has allowed for marked improved early survival of this population.
mycobacteria, Pseudomonas species, enteric gram-negative bacilli, or Advances in donor management and preservation, bridging modalities
Aspergillus. Owing to long-standing antibiotic pressure these organisms for end-stage organ disease, transplant technique, immunosuppres-
are often highly resistant to first-line agents, and can be difficult to treat sion regimens, and antimicrobials have enabled transplant to be a life-
if an infection becomes established. In particular, Burkholderia cepacia prolonging option for a subset of patients that were previously deemed
is a dreaded colonizer that represents a major threat for some centers palliative. For the patient who presents with an acute and fulminant
caring for cystic fibrosis patients. Indeed, patients with cystic fibrosis form of end-stage organ disease, knowledge of which center has new
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complicated by B cepacia infection have a worse outcome than their bridging modalities available is key to supporting and opening up trans-
counterparts without this infection. 163,164 At our center, preestablished plant as an option to a critically ill subset of patients. Optimization of
antimicrobial regimens based on the patients’ previous cultures are postoperative management and knowledge of potential complications

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