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Clinical Spectrum of Fungal Infections After Orthotopic Liver Transplantation

Clinical Spectrum of Fungal Infections After Orthotopic Liver Transplantation Abstract • During a 50-month period, we identified 91 episodes of fungal infection in 72 liver transplant recipients (23.8%). Candida species accounted for 83.5% of cases. Clinical patterns of fungal infections included disseminated infection (19), peritonitis (17), pneumonitis (15), multiple sites of colonization (13), fungemia (11), and other sites (16). The diagnosis of fungal infection was usually made in the first 2 months (84.7% of cases), at a mean time of 16 days after transplantation. Risk factors for fungal infections included retransplantation, Risk score, intraoperative transfusion requirement, urgent status, Roux limb biliary reconstruction (in adults), steroid dose, bacterial infections and antibiotic therapy, and vascular complications. Fungal infections were successfully treated with amphotericin B in 63 cases (74.1%) but were associated with diminished patient survival (50% vs 83.5%). Fungal infection is a frequent source of early morbidity and can be related to well-defined risk factors, suggesting the need for effective prophylaxis. (Arch Surg. 1991;126:149-156) References 1. Schroter GPJ, Hoelscher M, Putnam CW, et al. Fungus infections after liver transplantation . Ann Surg . 1977;186:115-122.Crossref 2. Wajszczuk CP, Dummer JS, Ho M, et al. Fungal infections in liver transplant recipients . Transplantation . 1985;40:347-353.Crossref 3. Kusne S, Dummer JS, Singh N, et al. Infections after liver transplantation: an analysis of 101 consecutive cases . Medicine . 1988;67:132-143.Crossref 4. Colonna JO, Winston DJ, Brill JE, et al. Infectious complications in liver transplantation . Arch Surg . 1988;123:360-364.Crossref 5. Fulginiti VA, Scribner R, Groth CG, et al. Infections in recipients of liver homografts . N Engl J Med . 1968;279:619-626.Crossref 6. Odds FC. Candida and Candidiasis: A Review and Bibliography . 2nd ed. London, England: Bailliere Tindall; 1988. 7. Stone HH, Geheber CE, Kolb LD, Kitchens WR. Alimentary tract colonization by Candida albicans . J Surg Res . 1973;14:273-276.Crossref 8. Stone HH, Kolb LD, Currie CA, Geheber CE. Candida sepsis: pathogenesis and principle . Ann Surg . 1974;179:697-711.Crossref 9. Inoue S, Wirman JA, Alexander JW, et al. Candida albicans translocation across the gut mucosa following burn injury . J Surg Res . 1988;44:479-492.Crossref 10. Ho M. Infections in liver transplant recipients . In: Winter PM, Kang YG, eds. Hepatic Transplantation . New York, NY: Praeger Publishers; 1986: 202-214. 11. Starzl TE, Hakala TR, Shaw BW Jr, et al. A flexible procedure for multiple cadaveric procurement . Surg Gynecol Obstet . 1984;158:223-230. 12. Starzl TE, Iwatsuki SI, Van Thiel DH, et al. Evolution of liver transplantation . Hepatology . 1982;2:614-636.Crossref 13. Shaw BW Jr, Martin DJ, Marquez JM, et al. Venous bypass in clinical liver transplantation . Ann Surg . 1985;200:524-534.Crossref 14. Stratta RJ, Wood RP, Langnas AN, et al. Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation . Surgery . 1989;106:675-684. 15. Wood RP, Shaw BW Jr, Williams L. The use of OKT3 rescue therapy after orthotopic liver transplantation: the University of Nebraska Medical Center experience . Transplant Proc . 1988;20( (suppl 1) ):254-259. 16. Millis JM, McDiarmid SV, Hiatt JR, et al. Randomized prospective trial of OKT3 for early prophylaxis of rejection after liver transplantation . Transplantation . 1989;47:82-88.Crossref 17. Rose HD, Varkey B. Deep mycotic infections in the hospitalized adult: a study of 123 patients . Medicine . 1975;54:499-507.Crossref 18. Hart PD, Russell E, Remington JS. The compromised host and infection, II: deep fungal infection . J Infect Dis . 1969;120:169-191.Crossref 19. Seelig MS. Mechanisms by which antibiotics increase the incidence and severity of candidiasis and alter the immunological defenses . Bacteriol Rev . 1966;30:442-459. 20. Solomkin JS, Simmons RL. Candida infection in surgical patients . World J Surg . 1980;4:381-394.Crossref 21. Cohen R, Roth RJ, Delgado E, et al. Fungal flora of the normal human small and large intestines . N Engl J Med . 1969;280:638-641.Crossref 22. Kusne S, Tobin D, Pasculle W, et al. Candida carriage in the alimentary tract of liver transplant candidates. Transplantation. In press. 23. Rifkind D, Marchioro TL, Schneck SA, Hill RB. Systemic fungal infections complicating renal transplantation and immunosuppressive therapy . Am J Med . 1967;43:28-38.Crossref 24. Markin RS, Stratta RJ, Woods GL. Infection after liver transplantation . Am J Surg Pathol . 1990;14( (suppl 1) ):64-78. 25. Burchard KW, Minor LB, Slotman GJ, Gann DS. Fungal sepsis in surgical patients . Arch Surg . 1983;118:217-221.Crossref 26. Ascher NL, Stock PJ, Bumgardner GL, et al. Infection and rejection of primary hepatic transplant in 93 consecutive patients treated with triple immunosuppressive therapy . Surg Gynecol Obstet . 1988;167:474-484. 27. Paya CV, Hermans PE, Washington JA, et al. Incidence, distribution, and outcome of episodes of infection in 100 orthotopic liver transplantations . Mayo Clin Proc . 1989;64:555-564.Crossref 28. Wiesner RH, Hermans PE, Rakele J, et al. Selective bowel decontamination to decrease gram-negative anaerobic bacterial and Candida colonization and prevent infection after orthotopic liver transplantation . Transplantation . 1988;45:570-574.Crossref 29. Moore FA, Moore EE, Jones TN, McCroskey BL, Peterson VM. TEN versus TPN following major abdominal trauma: reduced septic morbidity . J Trauma . 1989;29:916-923.Crossref 30. Brandell R, Chase SL, Cohn JR. Treatment of oral candidiasis with amphotericin B solution . Clin Pharm . 1988;7:70-72. 31. Slotman GJ, Burchard KW. Ketoconazole prevents Candida sepsis in critically ill surgical patients . Arch Surg . 1987;122:147-151.Crossref 32. Samonis G, Ralston K, Karl C, et al. Prophylaxis of oropharyngeal candidiasis with fluconazole . Rev Infect Dis . 1990;12( (suppl 3) ):S369-S373.Crossref 33. Solomkin JS, Flohr A, Simmons RL. Candida infections in surgical patients: dose requirements and toxicity of amphotericin B . Ann Surg . 1982;195:177-185.Crossref 34. Conti DJ, Tolkoff-Rubin NE, Baker GP, et al. Successful treatment of invasive fungal infection with fluconazole in organ transplant recipients . Transplantation . 1989;48:692-695. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

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Publisher
American Medical Association
Copyright
Copyright © 1991 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1991.01410260033005
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Abstract

Abstract • During a 50-month period, we identified 91 episodes of fungal infection in 72 liver transplant recipients (23.8%). Candida species accounted for 83.5% of cases. Clinical patterns of fungal infections included disseminated infection (19), peritonitis (17), pneumonitis (15), multiple sites of colonization (13), fungemia (11), and other sites (16). The diagnosis of fungal infection was usually made in the first 2 months (84.7% of cases), at a mean time of 16 days after transplantation. Risk factors for fungal infections included retransplantation, Risk score, intraoperative transfusion requirement, urgent status, Roux limb biliary reconstruction (in adults), steroid dose, bacterial infections and antibiotic therapy, and vascular complications. Fungal infections were successfully treated with amphotericin B in 63 cases (74.1%) but were associated with diminished patient survival (50% vs 83.5%). Fungal infection is a frequent source of early morbidity and can be related to well-defined risk factors, suggesting the need for effective prophylaxis. (Arch Surg. 1991;126:149-156) References 1. Schroter GPJ, Hoelscher M, Putnam CW, et al. Fungus infections after liver transplantation . Ann Surg . 1977;186:115-122.Crossref 2. Wajszczuk CP, Dummer JS, Ho M, et al. Fungal infections in liver transplant recipients . Transplantation . 1985;40:347-353.Crossref 3. Kusne S, Dummer JS, Singh N, et al. Infections after liver transplantation: an analysis of 101 consecutive cases . Medicine . 1988;67:132-143.Crossref 4. Colonna JO, Winston DJ, Brill JE, et al. Infectious complications in liver transplantation . Arch Surg . 1988;123:360-364.Crossref 5. Fulginiti VA, Scribner R, Groth CG, et al. Infections in recipients of liver homografts . N Engl J Med . 1968;279:619-626.Crossref 6. Odds FC. Candida and Candidiasis: A Review and Bibliography . 2nd ed. London, England: Bailliere Tindall; 1988. 7. Stone HH, Geheber CE, Kolb LD, Kitchens WR. Alimentary tract colonization by Candida albicans . J Surg Res . 1973;14:273-276.Crossref 8. Stone HH, Kolb LD, Currie CA, Geheber CE. Candida sepsis: pathogenesis and principle . Ann Surg . 1974;179:697-711.Crossref 9. Inoue S, Wirman JA, Alexander JW, et al. Candida albicans translocation across the gut mucosa following burn injury . J Surg Res . 1988;44:479-492.Crossref 10. Ho M. Infections in liver transplant recipients . In: Winter PM, Kang YG, eds. Hepatic Transplantation . New York, NY: Praeger Publishers; 1986: 202-214. 11. Starzl TE, Hakala TR, Shaw BW Jr, et al. A flexible procedure for multiple cadaveric procurement . Surg Gynecol Obstet . 1984;158:223-230. 12. Starzl TE, Iwatsuki SI, Van Thiel DH, et al. Evolution of liver transplantation . Hepatology . 1982;2:614-636.Crossref 13. Shaw BW Jr, Martin DJ, Marquez JM, et al. Venous bypass in clinical liver transplantation . Ann Surg . 1985;200:524-534.Crossref 14. Stratta RJ, Wood RP, Langnas AN, et al. Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation . Surgery . 1989;106:675-684. 15. Wood RP, Shaw BW Jr, Williams L. The use of OKT3 rescue therapy after orthotopic liver transplantation: the University of Nebraska Medical Center experience . Transplant Proc . 1988;20( (suppl 1) ):254-259. 16. Millis JM, McDiarmid SV, Hiatt JR, et al. Randomized prospective trial of OKT3 for early prophylaxis of rejection after liver transplantation . Transplantation . 1989;47:82-88.Crossref 17. Rose HD, Varkey B. Deep mycotic infections in the hospitalized adult: a study of 123 patients . Medicine . 1975;54:499-507.Crossref 18. Hart PD, Russell E, Remington JS. The compromised host and infection, II: deep fungal infection . J Infect Dis . 1969;120:169-191.Crossref 19. Seelig MS. Mechanisms by which antibiotics increase the incidence and severity of candidiasis and alter the immunological defenses . Bacteriol Rev . 1966;30:442-459. 20. Solomkin JS, Simmons RL. Candida infection in surgical patients . World J Surg . 1980;4:381-394.Crossref 21. Cohen R, Roth RJ, Delgado E, et al. Fungal flora of the normal human small and large intestines . N Engl J Med . 1969;280:638-641.Crossref 22. Kusne S, Tobin D, Pasculle W, et al. Candida carriage in the alimentary tract of liver transplant candidates. Transplantation. In press. 23. Rifkind D, Marchioro TL, Schneck SA, Hill RB. Systemic fungal infections complicating renal transplantation and immunosuppressive therapy . Am J Med . 1967;43:28-38.Crossref 24. Markin RS, Stratta RJ, Woods GL. Infection after liver transplantation . Am J Surg Pathol . 1990;14( (suppl 1) ):64-78. 25. Burchard KW, Minor LB, Slotman GJ, Gann DS. Fungal sepsis in surgical patients . Arch Surg . 1983;118:217-221.Crossref 26. Ascher NL, Stock PJ, Bumgardner GL, et al. Infection and rejection of primary hepatic transplant in 93 consecutive patients treated with triple immunosuppressive therapy . Surg Gynecol Obstet . 1988;167:474-484. 27. Paya CV, Hermans PE, Washington JA, et al. Incidence, distribution, and outcome of episodes of infection in 100 orthotopic liver transplantations . Mayo Clin Proc . 1989;64:555-564.Crossref 28. Wiesner RH, Hermans PE, Rakele J, et al. Selective bowel decontamination to decrease gram-negative anaerobic bacterial and Candida colonization and prevent infection after orthotopic liver transplantation . Transplantation . 1988;45:570-574.Crossref 29. Moore FA, Moore EE, Jones TN, McCroskey BL, Peterson VM. TEN versus TPN following major abdominal trauma: reduced septic morbidity . J Trauma . 1989;29:916-923.Crossref 30. Brandell R, Chase SL, Cohn JR. Treatment of oral candidiasis with amphotericin B solution . Clin Pharm . 1988;7:70-72. 31. Slotman GJ, Burchard KW. Ketoconazole prevents Candida sepsis in critically ill surgical patients . Arch Surg . 1987;122:147-151.Crossref 32. Samonis G, Ralston K, Karl C, et al. Prophylaxis of oropharyngeal candidiasis with fluconazole . Rev Infect Dis . 1990;12( (suppl 3) ):S369-S373.Crossref 33. Solomkin JS, Flohr A, Simmons RL. Candida infections in surgical patients: dose requirements and toxicity of amphotericin B . Ann Surg . 1982;195:177-185.Crossref 34. Conti DJ, Tolkoff-Rubin NE, Baker GP, et al. Successful treatment of invasive fungal infection with fluconazole in organ transplant recipients . Transplantation . 1989;48:692-695.

Journal

Archives of SurgeryAmerican Medical Association

Published: Feb 1, 1991

References