B a c t e r e m i a in t r a.n. .s. .p. l a n t . r e c ,"p ,"e n t s . • A prospective study of demographics) etiologic agents, risk factors, and outcomes Marilyn M. Wagener, MPH Victor L. Yu, MD Pittsburgh, Pennsylvania
Background: Bacteremic infections are a major cause of death among organ transplant
recipients. We sought to identify the risk factors associated with death and examine the timing of the bacteremic episode after operation to recognize patients who may benefit from perioperafive prophylactic antibiotic therapy. Methods: A total of 125 episodes of bacteremia or fungemia in 16 heart, 26 kidney, and 70 liver recipients were monitored prospectively in 1 year. Results: The urinary tract was the most frequent portal for kidney recipients, the gastrointestinal and biliary tracts were frequent for liver recipients, and the lung was frequent in heart recipients. Heart and liver recipients were more severely ill at the time of bacteremia and had bacteremia sooner after operation. Death at 14 days after onset of bacteremia was 33% in heart recipients, 24% in liver recipients, and 11% in kidney recipients. Risk of death was associated with the severity of the underlying condition of the transplant recipient, the source of the bacteremia, and the microbial agent. Pseudomonas aeruginosa and Enterobacter species had fatality rates of 47% and 63%, respectively. P. aeruginosa and Enterobacter were also most commonly associated with failures of perioperative antibiotic prophylaxis. Conclusions: There are distinct clinical patterns of bacteremia in transplant recipients. The emergence of P. aeruginosa and Enterobacter species in the immediate postoperative period appeared to be a significant cause of morbidity and death among transplant recipients. (AJIC AM J INFECTCONTROL1992;20:239-47)
I n f e c t i o n r e m a i n s a m a j o r c a u s e of m o r b i d i t y a n d d e a t h a m o n g o r g a n t r a n s p l a n t r e c i p i e n t s . 1-a Bacteremia has been associated with an especially h i g h m o r t a l i t y r a t e in this p a t i e n t p o p u l a t i o n . 4 W e p r o s p e c t i v e l y t r a c k e d all b a c t e r e m i a s in o u r p o p u l a t i o n of t r a n s p l a n t r e c i p i e n t s to define this p a t i e n t p o p u l a t i o n a n d t h e i r r i s k f a c t o r s f o r death. We f u r t h e r a n a l y z e d the m i c r o b i a l o r i g i n s o f the b a c t e r e m i c e p i s o d e s w i t h r e s p e c t to the t i m e of o n s e t of b a c t e r e m i a a n d the p o s s i b i l i t y t h a t the bacteremia might have been prevented by postoperative prophylactic antibiotic therapy) From the Division of Infectious Disease, University of Pittsburgh School of Medicine, Pittsburgh, Pa. Reprint requests: Victor L. Yu, MD, University of Pittsburgh School of Medicine, Scaife 968, Pittsburgh, PA 15261.
17/46/36079
METHODS Study population All t r a n s p l a n t r e c i p i e n t s w h o w e r e h o s p i t a l i z e d with blood cultures positive for pathogens during a 1 - y e a r p e r i o d (19 8 7) w e r e p r o s p e c t i v e l y t r a c k e d until d i s c h a r g e o r death. The s i g n i f i c a n c e o f a p o s i t i v e b l o o d c u l t u r e w a s b a s e d o n the clinical j u d g m e n t of the i n f e c t i o u s d i s e a s e a n d s u r g i c a l t r a n s p l a n t services. All p a tients w h o r e c e i v e d specific a n t i b i o t i c t h e r a p y f o r the b a c t e r e m i a w e r e i n c l u d e d in the study. Additional cultures positive for the same organism w i t h i n a 3 - d a y p e r i o d w e r e c o n s i d e r e d to r e p r e sent the same episode.
Study definitions and procedures The s t a n d a r d p e r i o p e r a t i v e p r o p h y l a c t i c a n t i b i otic r e g i m e n s w e r e as follows: k i d n e y r e c i p i e n t s , 239
A,.c
Wagener and Yu
240 Table
October 1992
1. Demographics of bacteremic transplant recipients Parameter
Heart recipients
Incidence during study 11% (11/98) Age (yr) Mean 48,7 Range 16-63 Male 67% (12/18) White 100% (18/18) WBC (1000 cells/ram 3) Mean 15.0 Range 0.5-38
Background: Bacteremic infections are a major cause of death among organ transplant
recipients. We sought to identify the risk factors associated with death and examine the timing of the bacteremic episode after operation to recognize patients who may benefit from perioperafive prophylactic antibiotic therapy. Methods: A total of 125 episodes of bacteremia or fungemia in 16 heart, 26 kidney, and 70 liver recipients were monitored prospectively in 1 year. Results: The urinary tract was the most frequent portal for kidney recipients, the gastrointestinal and biliary tracts were frequent for liver recipients, and the lung was frequent in heart recipients. Heart and liver recipients were more severely ill at the time of bacteremia and had bacteremia sooner after operation. Death at 14 days after onset of bacteremia was 33% in heart recipients, 24% in liver recipients, and 11% in kidney recipients. Risk of death was associated with the severity of the underlying condition of the transplant recipient, the source of the bacteremia, and the microbial agent. Pseudomonas aeruginosa and Enterobacter species had fatality rates of 47% and 63%, respectively. P. aeruginosa and Enterobacter were also most commonly associated with failures of perioperative antibiotic prophylaxis. Conclusions: There are distinct clinical patterns of bacteremia in transplant recipients. The emergence of P. aeruginosa and Enterobacter species in the immediate postoperative period appeared to be a significant cause of morbidity and death among transplant recipients. (AJIC AM J INFECTCONTROL1992;20:239-47)
I n f e c t i o n r e m a i n s a m a j o r c a u s e of m o r b i d i t y a n d d e a t h a m o n g o r g a n t r a n s p l a n t r e c i p i e n t s . 1-a Bacteremia has been associated with an especially h i g h m o r t a l i t y r a t e in this p a t i e n t p o p u l a t i o n . 4 W e p r o s p e c t i v e l y t r a c k e d all b a c t e r e m i a s in o u r p o p u l a t i o n of t r a n s p l a n t r e c i p i e n t s to define this p a t i e n t p o p u l a t i o n a n d t h e i r r i s k f a c t o r s f o r death. We f u r t h e r a n a l y z e d the m i c r o b i a l o r i g i n s o f the b a c t e r e m i c e p i s o d e s w i t h r e s p e c t to the t i m e of o n s e t of b a c t e r e m i a a n d the p o s s i b i l i t y t h a t the bacteremia might have been prevented by postoperative prophylactic antibiotic therapy) From the Division of Infectious Disease, University of Pittsburgh School of Medicine, Pittsburgh, Pa. Reprint requests: Victor L. Yu, MD, University of Pittsburgh School of Medicine, Scaife 968, Pittsburgh, PA 15261.
17/46/36079
METHODS Study population All t r a n s p l a n t r e c i p i e n t s w h o w e r e h o s p i t a l i z e d with blood cultures positive for pathogens during a 1 - y e a r p e r i o d (19 8 7) w e r e p r o s p e c t i v e l y t r a c k e d until d i s c h a r g e o r death. The s i g n i f i c a n c e o f a p o s i t i v e b l o o d c u l t u r e w a s b a s e d o n the clinical j u d g m e n t of the i n f e c t i o u s d i s e a s e a n d s u r g i c a l t r a n s p l a n t services. All p a tients w h o r e c e i v e d specific a n t i b i o t i c t h e r a p y f o r the b a c t e r e m i a w e r e i n c l u d e d in the study. Additional cultures positive for the same organism w i t h i n a 3 - d a y p e r i o d w e r e c o n s i d e r e d to r e p r e sent the same episode.
Study definitions and procedures The s t a n d a r d p e r i o p e r a t i v e p r o p h y l a c t i c a n t i b i otic r e g i m e n s w e r e as follows: k i d n e y r e c i p i e n t s , 239
A,.c
Wagener and Yu
240 Table
October 1992
1. Demographics of bacteremic transplant recipients Parameter
Heart recipients
Incidence during study 11% (11/98) Age (yr) Mean 48,7 Range 16-63 Male 67% (12/18) White 100% (18/18) WBC (1000 cells/ram 3) Mean 15.0 Range 0.5-38
