sepsis in post transplant patients
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SEPSIS IN POST TRANSPLANT PATIENTS
Dr.Hina Aamir AbbasiSIUT
Case
47 yrs old male patient Renal transplant 6 months ago Presented with complain of… Fever Cough Shortness of breath Confusion Fatigue Weight loss for the last two weeks
Patient was a case of End stage renal disease secondary to glomerulonephritis and was dialysis dependant prior to renal transplant
Donor was his healthy elder brother. Post transplant 6 months were
uneventful.
Drug history
Post Transplant, patient had been on immunosuppressive drugs ;
Azathioprine Tacrolimus Prednisolone
Contd..
Patient was febrile 100F fever, H/R 104b/m, R/R 40 br/min B.P100/60 and decreased urine output and GCS 12/15
Patient admitted in Transplant ICU and put on ventilatory support as his ABG’s showed picture of severe acidosis and hypoxemia.
Diagnosis..
Sepsis or acute cellular rejection??
Graft biopsy
Renal biopsy graft was sent which showed normal cellular infiltration and no rejection…
Differential diagnosis
Disseminated tuberculousis Pneumocystitis carnii pneumonia Interstitial pneumonia Klebsiella pneumonia Cytomegalovirus infection MRSA
Haematological investigations
Hb- 11.4 TLC 2900 Platelet 145 Na 135 K 3.8 HCO3 15 Cl 111 FBS 127 Urea 54 Cr 1.40
Investigations
Blood culture Viral serology for CMV, EBV Tracheal culture and BAL Stool D/R Urine C/S Sputum AFB & C/S Xray chest CT scan chest
Xray chest
CT scan chest
Results
Patient’s x ray showed diffuse interstitial infiltrates….suggestive of atypical pneumonia …
Tracheal C/S were negative
Cultures from Broncho Alveolar Lavage were positive for Pneumocystits Carnii
Treatment
Septran DS (sulfamethoxazole/trimethoprim).
Vancomycin Acyclovir Hydrocortisone Tacrolimus Omeprazole
Management
Chest physiotherapy Nebulisation Ventilator bundles DVT prophylaxis Stress ulcer prophylaxis Fluid management and TPN of the
patient continued as per hospital protocol
Initially patient showed improvement but after 10 days his GCS began to drop
His MRI brain was done and CSF culture sent
MRI and CSF cultures
MRI brain showed multiple abnormal and intensify areas in b/l basal ganglia brain stem with post contrast enhancement seen, like infective in nature.
CSF culture was positive for CMV
Patient had superimposed CMV infection and was given Ganciclovir for 14 days and showed improvement
He was extubated and later on shifted to ward after 45 days of admission in Transplant ICU
Case discussion
As immunosupressive agents and graft survival have improved , infectious complications have become a major obstacle to infection free survival
The net state of Immunosuppressi
on
Epidemiologicalexposures
Challenges
Identification of infection in transplant recipients is difficult , as inflamatory response are blunted by immunosupression
Fever may have no infectious etiology and in fact may be an early signs of rejection.
Even if source of infection identified then balance to be kept between transplant rejection and modification of immune supression
Antibiotics chosen carefully as many are toxic to allografts.
Post transplant sepsis risk factors
Co-morbid (DM, immunosuppression) Malnutrition Unrecognised or undertreated infections Colonisation by resistant organisms
(MRSA , Pseudomonas ,enterobacter) Prolong surgery Infected graft Multiple blood transfusion Graft injury; prolong ischemia
Data shows…
Infection affects all kidney transplant recipients, in one form or another.
Over 50 percent of transplant patients have at least one infection in the first year following transplantation.
If the patient’s graft is working well more than six months post-transplant, they donot require additional immunosuppression to combat rejection, he or she is primarily at risk for infections encountered by the general population such as pneumonias and urinary tract infections.
Etiololgy
Pneumonia Urosepsis Wound infection Cellulitus Viral…...CMV, PCP, EBV, Polyoma
virus Fungal…Mucormycosis, Aspergillus, Candida Tuberculosis
Miscellaneous causes of fever
Underlying malignancy Superimposed infections Febrile neutropenia Endocarditis Meningitis Drug induced Thromboembolic phenomenon
Incidence
bacteriatuberculosisviralfungalmeningitisendocarditis5
Underlying cause
Over immunosuppression Potent immunosuppressive agents
Approach to post transplant septic patient
Think of a wider horizon….
Empirical therapy includes ……. Broad spectrum antibiotics Antivirals Antifungals Septran (trimethoprin and sulfamethoxazole) Continue immunosuppressive drugs
General principles of management Low threshold for imaging as lack of clinical
manifestation of infection
Invasive diagnostic approach is required for culture and histology
Pancultures (sputum, stool, urine, wound,CSF ) including virology and fungal cultures
Medication level (azathioprine, cyclosporine)
Considerations
Epidemiological exposures Patient’s net state of immune Time from transplantation Type of transplantation Immune response is blunted, sign and
symptoms are altered Anticipate possible organism Early treatment Cover for the right agent
Thankyou