Infection In Liver Transplant Patients Research Articles

Clinical course of COVID-19 infection in liver transplant patients

In the presence of chronic liver diseases, the post‑infectious period of COVID‑19 is difficult and potentially mortal. The impact of COVID‑19 on liver transplant patients has not been thoroughly investigated.
 Objective — to study the characteristics of the clinical course of COVID‑19 in liver transplant patients.
 Materials and methods. At the end of December 2014, the first successful liver transplant operation in Georgia was performed at the Batumi Referral Hospital of the Autonomous Republic of Adjara. To date, a total of surgical interventions have been conducted, including 42 surgeries since the beginning of the pandemic. We analysed
 The incidence of COVID‑19 infection in the cohort of 88 patients throughout their hospital stay after liver transplant and at the late postoperative period was analysed, as well as the characteristics of the clinical course of COVID‑19. To prevent COVID‑19 transmission within the hospital, a special protocol been developed: to ensure that the patient is safely isolated from contact with the source of infection. In the postoperative period, all patients received immunosuppressive therapy. To monitor the course of the disease, an interdisciplinary team was created, which consisted of a transplant surgeon, hepatologist, gastroenterologist, infectious disease specialist, therapist, and immunologist. The consultation was held at the place of residence and treatment of a patient.
 Results. No cases of COVID‑19 infection were reported among patients at the hospital where the liver transplant was conducted. In the late period, COVID‑19 was registered in 17 (19.3%) patients, of whom one (5.9%) died from the infection. One patient was infected with COVID‑19 twice. We have identified four variants of the clinical course of COVID‑19: mild (23.5%) — without any symptoms except for mild respiratory symptoms; aggravated (41.2%) — mild respiratory symptoms and dyspeptic symptoms without significant changes in clinical diagnostic parameters; moderate (29.4%) — cough without sputum, hyperthermia for three days, decreased sense of smell, the presence of dyspeptic symptoms, increased average values of biochemical parameters (alanine aminotransferase, aspartate aminotransferase, γ‑glutamyl transpeptidase, alkaline phosphatase, total bilirubin); severe (5.9%) — development of multiple organ failure.
 Conclusions. The implemented set of preventive measures ensured the patient’s protection from COVID‑19 infection in all cases during their hospital stay. In liver transplant patients.

Latent tuberculosis infection in liver transplant patients: a review.

Latent tuberculosis infection in liver transplant patients: a review.

The outcomes of Clostridioides difficile infection in inpatient liver transplant population.

Chronic immunosuppression is a known cause of Clostridioides difficile, which presents with colon infection. It is associated with increased mortality and morbidity. Our aim is to determine the inpatient outcomes of liver transplant patients with Clostridioides difficile infection (CDI) and trends in the last few years. We utilized the national re-admission data (2010-2017) to study the outcomes of CDI in liver transplant patients. Association of C. difficile with re-admission was computed in a multivariable model adjusted for age, sex, gastrointestinal bleeding, hypertension, diabetes, hyperlipidemia, congestive heart failure, cerebrovascular disease, obesity, cancer, insurance, chronic kidney disease, chronic obstructive pulmonary disease, dementia, peripheral vascular disease, smoking, hospital location, and teaching status. During 2010-2017, there were 310222 liver transplant patients hospitalized. Out of these, 9826 had CDI. CDI infection in liver transplant patients was associated with higher 30-day re-admission (14.3% vs. 11.21%, hazard ratio [HR]: 1.14, 95% confidence interval [CI]: 1.01-1.28, p=.02) and in-hospital mortality (odds ratio [OR]: 1.36, 95% CI: 1.14-1.61, p<.001). The most common causes of re-admission in the CDI group were recurrent CDI (41.1%), liver transplant complications (16.5%), and sepsis (11.6%). The median cost for liver transplant patients with C. difficile was significantly higher, $53064 (IQR $24970-$134830) compared to patients that did not have C. difficile, $35703 ($18793-$73871) (p<.001). The median length of stay was also longer for patients with CDI, 6days (4-14) vs. 4days (2-7) (p<.001). CDI in post-liver transplant patients was associated with higher mortality, re-admission, health care cost, and longer length of stay. The most common cause of re-admission was recurrent CDI, which raises the question of the efficacy of standard first-line therapy.

Successful Treatment of Severe Parainfluenza Pneumonia in a Liver Transplant Recipient with Oral Ribavirin and Intravenous Immunoglobulin

: The most common viruses affecting immunocompromised hosts include cytomegalovirus, herpes simplex virus, varicella-zoster virus, influenza virus, measles virus, and adenovirus. Parainfluenza virus infection is common among human populations. It causes non-specific symptoms in immune-competent hosts; therefore, it may go undiagnosed. However, it is particularly dangerous for immunocompromised patients by presenting a high risk of morbidity and sometimes mortality among them. Patients who have bone marrow or solid organ transplantation need to follow an intense immunosuppressing routine, which leaves them extremely vulnerable to opportunistic agents such as parainfluenza viruses. Several factors determine the severity of parainfluenza virus infections, such as the type of the virus, the level of immunosuppression, and co-infection with other agents. Co-infection is especially important because it makes a correct differential diagnosis difficult. While almost all bodies of influenza infection information in immunocompromised patients are from studies of bone marrow transplant recipients, there are very limited data available on influenza infections in liver transplant patients. We present a liver transplant patient with severe parainfluenza pneumonia that was improved significantly with oral ribavirin and intravenous immunoglobulin. A 23-year-old female patient with a history of liver transplantation from 18 months ago presented with a one-week cough and tachypnea. Chest computed tomography demonstrated ground-glass opacities and diffuse infiltrates throughout both lungs. A multiplex polymerase chain reaction for the detection of respiratory viruses in the nasopharynx was positive for parainfluenza virus type 3 and she was successfully treated with oral ribavirin and intravenous immunoglobulin. Respiratory infection with the parainfluenza virus in immunocompromised adults, including transplant patients, is associated with significant morbidity and mortality, and early treatment with ribavirin and intravenous immunoglobulin may markedly improve their outcomes. To the best of our knowledge, this is the first case report of the successful treatment of parainfluenza infection with ribavirin and intravenous immunoglobulin in a patient with liver transplantation.

S2740 A Case Report in Managing COVID-19 in a Liver Transplant Recipient

INTRODUCTION: Coronavirus Disease 2019 (COVID-19) is a pandemic impacting the entire globe, with over 5.3 million cases worldwide and 1.6 million US cases. Given the scarcity of information on COVID-19 infections in liver transplant patients, this case explores a patient 7 months post-liver transplant on immunosuppression who presented with COVID-19. CASE DESCRIPTION/METHODS: The patient was a 67-year-old female with a past medical history of alpha-1-antitrypsin cirrhosis status post orthotopic liver transplant (OLT) in October 2019, COPD, hypertension, CKD, and insulin-dependent diabetes. She was asymptomatic but tested positive at her nursing home on routine testing. Then lab work showed elevated liver function tests (LFTs)—AST 258, ALT 423, AP 210 from a normal baseline—which prompted the decision to bring her to the hospital. We held her Cellcept and continued her normal tacrolimus and prednisone dosing, 2 mg twice a day and 2.5 mg daily, respectively. We also continued her Mepron and Valcyte prophylaxis. During her 9-day course the only complications she had were fevers day 2–3 and profuse diarrhea day 3–6. Though low suspicion, we treated her empirically for a community-acquired pneumonia and possible C diff. We considered the administration of convalescent plasma but did not since she never became hypoxic. Her transaminitis—a phenomenon seen in 14.8–53% of COVID cases—persistently down-trended thus liver biopsy was not pursued. DISCUSSION: This patient was considered high-risk for decompensation given her age, medical history, and immunosuppression, however her clinical course was mild. Per AASLD guidelines we stopped her Cellcept and continued her tacrolimus and prednisone. We were concerned since kidney transplant patients tended to have poorer outcomes than the general population. The only literature on COVID in OLT patients was a case series from Italy with 6 patients which showed that short-term OLT recipients (<2 years) had better survival rates than long-term recipients (>10 years). The short-term group tended to have significantly higher rates of full immunosuppression, but had lower rates of comorbidities such as diabetes, hypertension, and kidney disease. Although our patient was a short-term recipient on immunosuppression, she was unique in that she had significant comorbidities. Her case demonstrates that OLT patient with a new transaminitis should be considered for COVID-19, and that their immunosuppressive agents may have a protective role against the infection.Table 1.: This table shows the trend of the patient’s LFTs from 1 month prior to admission determined to be her baseline on routine lab work, her admission LFTs (which was her peak), and her LFTs on discharge.

Surgical Site Infections in Liver Transplant Patients: A Single-Center Experience

AimThe aim of the study was a single-center assessment of occurrence of surgical site infections (SSI) in patients after liver transplantation and an attempt to determine factors that may contribute to this complication. Patients and methodsAnalysis of medical records of 60 adult patients, who underwent first transplantation in 2016 and 2017 was conducted. Selected pre-, intra-, and postoperative factors were assessed. Statistical analysis was performed with StatSoft Statistica 13.1 PL package. ResultsSSI occurred in 25% of liver recipients, with average timing of diagnosis on the 14th day after surgery. Mean duration of hospitalization was significantly longer in patients who experienced SSI than in patients without this complication (35.8 ± 8.9 days vs 25.2 ± 6 days, P < .0001). SSI occurred a little more frequently in men and older recipients, as well as in overweight and underweight patients (not significant). An indication for transplantation did not have an impact on SSI occurrence. The complication was more likely in patients with diabetes and renal failure prior to transplantation (P > .05). Duration of the procedure, blood loss and prolonged drainage did not have any impact on SSIs. SSI was significantly more common in recipients with lower total protein value (P < .0002) and anemia (P < .0002) in early postoperative period. ConclusionAmong the studied population, a high incidence of SSI was noted, and that some of the identified risk factors differ from those described in the literature.

No evidence of occult hepatitis C or E virus infections in liver-transplant patients with sustained virological response after therapy with direct acting agents.

It has been recently suggested that occult hepatitis C virus (HCV) infection and hepatitis E virus (HEV) reactivation might occur after direct acting antiviral agent-induced (DAA-induced) sustained virological response (SVR). The aim of our study was to identify occult HCV and HEV infection in a cohort of organ transplant patients who had achieved SVR and had persistent elevation in liver-enzyme levels. Sixty-six liver and/or kidney transplant patients were treated with DAAs. All but one achieved SVR12. Twenty-nine (8-39) months post-SVR12, 8 of the 65 patients (12.3%) who achieved SVR12 had persistently elevated liver enzyme levels. In 1 patient, this was related to hepatitis B virus reactivation. In the 7 remaining patients, blood samples (n=7), liver biopsies (n=4), and peripheral blood mononuclear cells (PBMCs) (n=7) were collected simultaneously in order to identify occult HCV or HEV infection. Hepatitis C virus RNA and HEV RNA were not detected in serum, liver tissues, or PBMCs. No HEV reactivation was observed after HCV clearance in patients who had anti-HEV IgG. Our study suggests that there is no occult HCV or HEV infection in transplant patients after successful treatment of HCV infection with DAAs, even in patients with a persistent elevation of liver enzyme levels. However, due to the small number of patients included in our study, this finding should be confirmed in a larger cohort.

A Practical Review of Cytomegalovirus in Gastroenterology and Hepatology.

Human cytomegalovirus (CMV) is a ubiquitous Herpesviridae virus with a wide spectrum of pathology in humans. Host immunity is a major determinant of the clinical manifestation of CMV and can vary widely in the gastroenterology and hepatology practice setting. Immunocompetent patients generally develop a benign, self-limited mononucleosis-like syndrome whereas gastrointestinal tissue-invasive disease is more frequently seen in immunocompromised and inflammatory bowel disease patients. Additionally, liver allograft dysfunction is a significant consequence of CMV infection in liver transplant patients. While polymerase chain reaction and immunohistochemistry techniques allow for the reliable and accurate detection of CMV in the human host, the diagnostic value of different serologic, endoscopic, and histologic tests depends on a variety of factors. Similarly, latent CMV, CMV infection, and CMV disease carry different significance depending on the patient population, and the decision to initiate antiviral therapy can be complex and patient-specific. This review will focus on the pathophysiology, diagnosis, and management of CMV in patient populations relevant to the practice of gastroenterology and hepatology—liver transplant recipients, inflammatory bowel disease patients, and otherwise immunocompetent patients.

Disseminated Adenovirus Infection in an Adult Orthotopic Liver Transplant Recipient

Adenovirus infections in liver transplant patients are important cause or morbidity and mortality. Our understanding of the adenovirus pathogenesis and management approach are limited. We present a rare case of self resolving disseminated adenovirus infection in a liver transplant recipient. A 60-year-old male with a history of orthotopic liver transplant 2010 for alcoholic cirrhosis and RNY hepaticojejunostomy 2011 for anastomotic stricture on cyclosporine 175 mg daily presented with fatigue, severe headache, bilateral eye pain with redness and light sensitivity for 3 weeks and fevers up to 104 F for one week. On examination left eye was swollen shut and painful to touch with minor dried blood on outside. Laboratory findings on admission were notable for ALP of 514, AST/ALT 206/237, total bilirubin 1.2, lipase 1674, amylase 201, APAP level < 2.0. Routine blood and urine cultures, serum CMV PCR, and serum cryptococcal antigen were negative. Nasopharyngeal respiratory virus panel was positive for adenovirus PCR but CXR did not show pneumonitis. Serum adenovirus PCR was strongly positive at 347014 copies/ml. Ophthalmology recommended supportive care for his acute hemorrhagic conjunctivitis likely from adenovirus. MRCP was performed and ruled out choledocholithiasis, biliary dilation, biloma or abscess of transplant liver. Since the patient did not have abdominal symptoms and his conjunctivitis improved, it was decided to manage the patient conservatively without using potentially toxic cidofovir. He was discharged 3 days later. Follow up serum adenovirus PCR showed decreasing viral load. Disseminated adenovirus infection is defined as documented disease in >= end organs and viremia is present in most but not all patients. Manifestations include hepatitis, pneumonia, pancreatitis, enterocolitis, hemorrhagic cystitis and nephritis. A high degree of clinical suspicion should be maintained for prompt diagnosis as standard diagnostic tests like blood and urine cultures do not yield adenovirus. Positive PCR (in serum or other body fluids or tissue) may suggest invasive disease in the appropriate context. Serial quantitative serum viral load is used for preemptive treatment in high risk allogeneic hematopoetic cell transplant recipients and also acts as a surrogate for clinical response to therapy. We believe that our patient probably had tissue invasive hepatitis, pancreatitis and conjunctivitis with an upper respiratory infection (without pneumonitis) along with significant adenoviremia. Interestingly, despite disseminated tissue invasive disease, the patient recovered without specific adenoviral therapy. There is no well-defined treatment for adenovirus infection. Management from limited clinical information for disseminated infections supports use of cidofovir. Unfortunately it is fraught with nephrotoxicity. A novel lipid formulation of cidofovir (brincidofovir) offers some hope as it seems to be kidney friendly. There are no good data on ribavirin and immunoglobulins, but adenovirus specific T cell therapy has occasionally been used successfully in recalcitrant disease. Our case illustrates that although disseminated adenovirus infection can be life threatening and has limited effective treatment options, it can occasionally resolve spontaneously.

Incidence of cross infection in liver transplant patients. Risk factors and role of nursing

ObjectiveTo determine the incidence and risk factors of infection in liver transplant recipients immediately post-transplant, during admission to a liver transplant unit during the immediate post-transplant admission. MethodologyDescriptive, prospective study performed in the Liver Transplant Unit of Hospital Clínic, Barcelona. All liver transplant recipients between January 2012 and August 2015 (n=241) were included. Statistical analysis was performed with R Commander. Variables were compared with Chi-square and Student's t-test. A value of p≤.05 was considered significant. ResultsThe incidence of infection was 34.8%. The most frequent infections were bacterial (75.3%), particularly urinary infections (34.6%) caused by Escherichia coli and Klebsiella pneumoniae. Independent risk factors for the development of bacterial infections according to multivariate analysis were sex, age and length of hospital stay. ConclusionsInfections are a significant problem in the early post-transplant period, and are associated with longer hospitalisation periods. The role of nursing in preventing infections, by identifying risk factors, correctly applying nursing protocols in insertion, maintenance and early withdrawal of medical devices and fulfilling hand hygiene, is essential.

HHV-6 in liver transplantation: A literature review.

Human herpesvirus 6 (HHV-6A and HHV-6B) can cause primary infection or reactivate from latency in liver transplant recipients, which can result in a variety of clinical syndromes, including fever, hepatitis, encephalitis and higher rates of graft dysfunction as well as indirect effects including increased risks of mortality, CMV disease, hepatitis C progression and greater fibrosis scores. Although HHV-6 infection is currently diagnosed by quantifying viral DNA in plasma or blood, biopsy to demonstrate histopathological effects of HHV-6 remains the gold standard for diagnosis of end-organ disease. HHV-6 reactivation may be restricted to the infected organ with no evidence of active infection in the blood. HHV-6 infections in liver transplant patients are mostly asymptomatic, but clinically significant tissue-invasive infections have been treated successfully with ganciclovir, foscarnet or cidofovir. Inherited chromosomally integrated HHV-6 (ciHHV-6), in either the recipient or the donor organ, may create confusion about systemic HHV-6 infection. Recipients with inherited ciHHV-6 may have an increased risk of opportunistic infection and graft rejection. This article reviews the current scientific data on the clinical effects, risk factors, pathogenesis, diagnosis and treatment of HHV-6 infections in liver transplant recipients.

Carbapenem-Resistant Klebsiella pneumoniae influences the outcome of early infections in liver transplant recipients.

BackgroundInfections remain a leading cause of morbidity and mortality among liver transplant (LT) recipients. The aim of our study was to define the factors associated with outcome of early bacterial and fungal infections in a cohort of patients who underwent LT at the University Hospital of Ancona over a nine year period.MethodsAll consecutive patients who underwent LT in our center were considered. An early infection was defined as occurring in the first month post-transplantation.ResultsAmong 330 patients who underwent LT from August 2005 to October 2014, 88 (27 %) had at least one infection documented within 30 days after transplantation. In 54 cases only one site was involved, in 34 cases ≥2 sites. There were 43 (30 %) pneumonia, 40 (27 %) surgical site infections, 31 (22 %) blood stream infections, and 30 (21 %) urinary tract infections. Gram-negative bacteria accounted for 64 % of the culture-positive cases, followed by Gram-positive bacteria (30 %) and fungi (6 %). A high proportion of drug-resistant strains was found within either Gram-negative (79 %) or Gram-positive (81 %) bacteria. There were 27 out 88 patients (31 %) who died within 180 days from the transplant. Factors independently associated with a higher risk of mortality were: renal replacement therapy (HR 11.797 [CI95 % 3.082–45.152], p < 0.0001), multisite infections (HR 4.865 [CI95 % 1.417–16.700], p = 0.012) and being infected with carbapenem-resistant Klebsiella pneumoniae (CRKP; HR 5.562 [CI95 % 1.186–26.088], p = 0.030).ConclusionsOverall, these data indicate that early infections in LT patients are characterized by significant mortality. In particular, an early infection caused by CRKP has an adverse impact on survival in these patients suggesting an urgent need for adopting preventive measures to avoiding this complication.

Staphylococcus aureus isolates colonizing and infecting cirrhotic and liver-transplantation patients: comparison of molecular typing and virulence factors

BackgroundS. aureus is an important agent of colonization and infection in liver transplant patients. It harbors several virulence factors that can increase its pathogenicity. However, studies of virulence and molecular typing of MRSA in cirrhotic and liver transplantation patients are scarce.ResultsHere we use SCCmec, PFGE, spa typing, MLST and virulence factors to characterize MRSA isolates in pre and post liver transplantation patients. Sixteen (13 %) of 126 cirrhotic and 15 of the 64 liver-transplanted patients (23 %) were colonized by MRSA (p = 0.091). SCCmec types I, II and III that are generally associated with nosocomial infections were identified in 91 % of the isolates. None of the isolates carried PVL, adhesion factors and fib gene. Only three MRSA colonized isolates carried tst gene and were characterized as SCCmec type I and t149. Ten spa types and five STs were identified; t002 and ST105 were the most frequent profiles. Spa types and ST1510 never described in Brazil and a new spa type t14789 were identified. Nineteen PFGE subtypes were found and grouped into nine types. There was a predominant cluster, which was related to the New York/Japanese epidemic clone and harboured SCCmec type II identified in both cirrhotic and post-transplantation patients. Based on SCCmec and virulence factors the MRSA isolates belonged to NY/Jpn clone seen be more similar to the USA100 MRSA isolates.ConclusionsAlthough without significance, liver-transplantation was more frequently colonized by MRSA than cirrhotic patients. The most frequent SCCmec was type II, and the predominant cluster was related to the New York/Japanese clone. A new spa t14789, and ST1510 never reported in Brazil were identified.

Mycophenolic Acid Metabolites Acyl-Glucuronide and Glucoside Affect the Occurrence of Infectious Complications and Bone Marrow Dysfunction in Liver Transplant Recipients.

BACKGROUND Mycophenolic acid (MPA) prodrugs are anti-proliferative immunosuppressive agents commonly used after organ transplantation. Although they are generally well tolerated by patients, adverse effects may occur. It is postulated that MPA metabolites could also contribute to these adverse effects. MATERIAL AND METHODS The objective of this study was the assessment of concentrations of total MPA and its metabolites, phenyl glucuronide (MPAG), acyl glucuronide (AcMPAG) and glucoside (GluMPA), using liquid chromatography combined with mass spectrometry (LC/MS/MS) in two groups: kidney transplant recipients and liver transplant patients. Associations of MPA and its metabolites with adverse effects were analyzed. RESULTS The study group consisted of 211 recipients of liver or kidney transplants who received immunosuppressive therapy, including MPA prodrugs. Multivariant analysis showed a positive influence of MPA on gastroenterotoxicity in kidney transplant recipients. In liver patients, gastroenterotoxicity was associated with lower MPAG concentrations. A positive influence of AcMPAG on bacterial infections in liver transplant patients was observed. In liver transplant recipients, a positive influence of MPA and a negative influence of GluMPA levels on the PLT count were revealed. MPA and its metabolites did not influence the hemoglobin levels in both groups. There were no significant relationships among MPA, its metabolites and WBC counts. CONCLUSIONS In kidney transplant recipients, total MPA trough concentration is associated with gastroenterotoxicity and its monitoring could have important role in management of gastrointestinal complications. The quantification of AcMPAG in liver recipients receiving MPA may be helpful in avoiding bacterial infections. GluMPA seems to have a toxic effect on thrombopoiesis.

Occult hepatitis B virus infection in liver transplant patients in a Brazilian referral center

Estimates of occult hepatitis B virus (HBV) infection prevalence varies among different studies depending on the prevalence of HBV infection in the study population and on the sensitivity of the assay used to detect HBV DNA. We investigated the prevalence of occult HBV infection in cirrhotic patients undergoing liver transplantation in a Brazilian referral center. Frozen liver samples from 68 adults were analyzed using a nested polymerase chain reaction assay for HBV DNA. The specificity of the amplified HBV sequences was confirmed by direct sequencing of the amplicons. The patient population comprised 49 (72.1%) males and 19 (27.9%) females with a median age of 53 years (range=18-67 years). Occult HBV infection was diagnosed in three (4.4%) patients. The etiologies of the underlying chronic liver disease in these cases were alcohol abuse, HBV infection, and cryptogenic cirrhosis. Two of the patients with cryptic HBV infection also presented hepatocellular carcinoma. Markers of previous HBV infection were available in two patients with occult HBV infection and were negative in both. In conclusion, using a sensitive nested polymerase chain reaction assay to detect HBV DNA in frozen liver tissue, we found a low prevalence of occult HBV infection in cirrhotic patients undergoing liver transplant, probably due to the low prevalence of HBV infection in our population.

Probiotic use in preventing postoperative infection in liver transplant patients.

Although liver transplantation has been widely practised, post-operative bacterial infection is still a frequent complication which contributed to an increased risk of fatality. There were studies on preoperative use of probiotics for liver transplant patients and acquired reduction in postoperative sepsis and wound infection, but the relevant clinical experience with pre- and probiotics is still limited. This study is to assess fibre and probiotic use aimed at preventing bacterial sepsis and wound complications in patients undergoing liver transplantation. There were a total of sixty-seven adult patients scheduled for liver transplantation were included in a public teaching hospital. From January to December 2011, 34 continuous patients following liver transplantation were put on fibre + probiotics. In retrospectively, from January to December 2010, 33 continuous patients were collected as a control group and they were only received fibre post operation. The incidence of bacterial infections was compared in patients receiving either fibre and lactobacillus or fibre only. Statistical analysis was performed using SPSS 15. The t test, fisher's and chi- square test was used to compare discrete variables. In summary, in the analysis of 67 liver transplant recipients, 8.8% group A patients developed infections compared to 30.3% group B patients. The difference between groups A and B was statistically significant in both cases. In addition, the duration of antibiotic therapy was significantly shorter in the lactobacillus-group. Wound infection was the most frequent infections and enterococci the most frequently isolated bacteria. Fibre and lactobacilli were well tolerated in most cases. The operating time, amount of intra- and post-operatively transfused units of blood, fresh frozen plasma and albumin did not differ significantly between the groups. Combined fibre and probiotics could lower the incidence of bacterial infections and shorten the duration of antibiotic therapy following liver transplantation in comparison to conventional nutrition. In contrast to antibiotics, it is relatively cheap and does not cause resistant strains or serious side effects.

Humans as donors and producers of biological material: some ethical considerations on a thin red line.

The donation of blood, organs, cells and tissues in accordance with the relevant regulations is an act of great generosity and altruism [1].Human blood can be processed to produce plasma-derived medicines such as albumin, factor VIII and immmunoglobulin, which are precious therapeutic tools [2]. Human hepatitis B immunoglobulin (HBIg), for example, is used for both preventive and therapeutic purposes. It can be administered either intramuscularly or intravenously and is effective in a number of circumstances such as, in particular: for the prevention of post-surgery infections in liver transplant patients; as prophylaxis in persons exposed to the hepatitis B virus (HBV) either accidentally (through contact with infected blood) or through sexual contact; in paediatrics (in the treatment of children born to HbsAg-positive mothers and immunocompromised children) [3]. Several nations have put in place schemes to collect so-called “hyperimmune” plasma from donors [4]: this is obtained from healthy donors who have been vaccinated against HBV and are then given an additional booster in order to produce a high plasma antibody count. The resulting hyperimmune plasma is collected

Anidulafungin—A New Therapeutic Option for Candida Infections in Liver Transplantation

IntroductionIn the last years, the incidence of Candida infections in liver transplant recipients has increased with still higher morbidity and mortality. Anidulafungin, a new echinocandin that does not interfere with cytochrome p450, shows no need for dosage adjustment based upon renal or hepatic function or weight. AimTo analyze tolerance to and microbiologic and clinical efficacy of Anidulafungin to treat Candida infections in liver transplant patients. Materials and MethodsThis phase 3b, prospective, open-label, single-center study focused on liver transplant patients with a suspected and/or diagnosed Candida infection. The patients received Anidulafungin intravenously, optionally followed by oral therapy with azoles. The primary endpoint was the global response at the end of therapy; secondary endpoints were the efficacy of intravenous therapy, 90-day survival, as well as tolerance for and interaction with immunosuppresants. ResultsWe considered 42 consecutive liver recipients transplanted between 2009 and 2010 among whom 13 (31%) were recruited for the study and four patients were treated with Anidulafungin as empirical therapy, six as preemptive therapy, and three as targeted treatment for documented candidemia (7.1%). The immunosuppressive regimen consisted of tacrolimus and low dose of steroids. The Candida species were: C albicans (50%), C glabrata (12.5%), C parapsilosis (12.5%), C krusei (12.5%), C lusitaniae (6.2%), C tropicalis (6.2%), and multiple others (25%). The principle site of isolation was the bile (53.8%), followed by the bloodstream (23.1%), central venous catheters (15.4%), bronchoalveolar lavage (15.4%), peritoneum (7.7%), and other locations (7.7%). Two patients (15.4%) died of severe sepsis with multiple organ failure. There was no alteration of hepatic enzymes, indices of cholestasis or changes in immunosuppressant drug levels. ConclusionAnidulafungin was an effective, safe, and well-tolerated drug. There were neither toxic effects to the grafts or adverse interactions with immunosuppresants.

Incidence and risk factors for infections after liver transplant: single‐center experience at the University Hospital Fundación Santa Fe de Bogotá, Colombia

The incidence of infections in liver transplant patients is higher compared with recipients of other organs, and infections are one of the major complications after transplantation. The aim of our study was to evaluate the incidence, presentation and risk factors of infections in liver transplant recipients in a Latin-American population, and to compare the results with data worldwide. We performed a retrospective analysis of 94 consecutive patients undergoing liver transplantation between 2004 and 2008 at the University Hospital Fundación Santa Fe de Bogotá, Colombia. The patients contributed a total of 64.4 person years (PY). Fifty-two patients (55.3%) developed one or more infections, in total 83 events (128.9 infections/100 PY). Bacterial infections represented the most frequent event (71.1%), followed by viral (19.3%) and fungal infections (8.4%). In 1%, no causative organism was identified. More than one-third of infections (37%) occurred during the first 30 days, whereas 83% of all events were seen during the first 6 months. The most common site of pathogen localization was the bloodstream (25.3%), followed by the urinary tract (15.7%), liver with bile tract (14.5%), abdomen (10.8%), surgical site (7.2%), and lungs (9.6%). The overall mortality after 1 year was 14.9%, and 57.1% of the deaths were attributed to infections. We found that risk factors significantly associated with increased incidence rate ratio for infection were prolonged stay at the intensive care unit, the need for parenteral nutrition, and blood transfusion requirement. Our data provide additional information about etiology and epidemiology of infections after liver transplantation.

Fulminant septic shock due to Clostridium perfringens skin and soft tissue infection eight years after liver transplantation

Bacterial and fungal infections are the main cause of death within the first year after liver transplantation. Clostridium perfringens is the most common germ causing gas gangrene. Infections with Clostridium perfringens may present in a variety of clinical manifestations, reaching from asymptomatic infections to massive intravascular haemolysis and multiple organ failure due to septic shock. We here report on a 55-year old male liver transplant patient suffering from skin and soft tissue infection eight years after liver transplantation. The patient was referred to our department from a community hospital. Upon admission in our department the infection had been ongoing for at least three days. Laboratory analyses demonstrated severe infection and impaired liver function. Tomogram and computed tomography scan of his right limb showed typical images of gas gangrene. The patient was immediately scheduled for surgical debridement. During surgery the patient developed septic shock with severe coagulopathy and died six hours after the operation due to uncontrolled septic shock. The histopathological and microbiologic work-up of the resected skin and soft tissue showed necrotic areas infiltrated with Clostridium perfringens. Even long-term survivors of liver transplantation are at major risk for life-threatening infections. The reported clinical scenario of Clostridium perfringens infection indicates the narrow therapeutic window. Clostridium perfringens should always be considered as a cause of infection in liver transplant patients.