Infectious Diseases II
Consider dual gram-negative therapy (fluoroquinolone or aminoglycosides) in patients with shock or if
antimicrobial resistance is suspected.
Consider adding vancomycin to gram-negative therapy in patients with shock, suspected catheter-related
infection, skin and soft tissue infection, pneumonia, and/or hemodynamic instability. Gram-positive
therapy can be discontinued in 48–72 hours if no evidence of gram-positive infections is discovered.
Modifications to initial antibiotic choices should be considered for patients with worsening clinical
status or if patients’ microbiological data warrant change.
Unexplained persistent fever in an otherwise clinically stable patient rarely warrants an escalation in
therapy. Persistent fevers for 4–7 days after initiation of antibacterial agents should warrant consideration
for empiric antifungal coverage in those who have persistent neutropenia.
Initial antimicrobials should be de-escalated or escalated in documented infections depending on in
vitro susceptibility. Treatment of febrile neutropenia is necessary until the patient is afebrile for at least
48 hours, is hemodynamically stable with resolution of neutropenia (ANC greater than 500 cells/mm3),
and has negative blood cultures. For patients with documented infections, the treatment duration is
decided by the organism and infection site; treatment should always continue until neutrophil resolution
(ANC greater than 500 cells/mm3).
Patients with hemodynamic instability should have their initial antibiotic regimen escalated to include
coverage for resistant bacteria and fungi.
use of hematopoietic growth factors should be considered for patients with a high anticipated risk of
febrile neutropenia (20% or greater).
Epidemiology
Hospital-acquired bacterial infections are the most common types of infections in SOT recipients.
50%–75% of SOT recipients will experience an infection within the first year after transplantation.
Posttransplant infections may contribute to graft dysfunction and reduce long-term survival, and
they have been associated with prolonged LOS and cost of care.
| d. | An analysis of 60,000 renal transplant recipients found that infections were the second leading |
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cause of death.
Excessive use of antibiotics before transplantation: With the use of prophylactic antimicrobials in
the pretransplant period, many transplant recipients are experiencing resistant pathogens in the
posttransplant period.
Infections are most common in the first 6 months after transplantation, with different pathogens
presenting after various durations of immunosuppression. See Figure 3. OIs are rare in the first
month after transplantation because the full effects of immunosuppression are not yet present.
Fungal and viral infections experienced during the first month after transplantation are usually
donor derived.
Duration of hospitalization after transplantation
| d. | Renal dysfunction |
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Several acute rejection episodes
General clinical approach for infectious diseases issues in critically ill SOT recipients
Be cognizant of the patient’s transplant timeline, particularly with respect to possible OIs,
pretransplant risk factors, immune status, intensity of immunosuppressive therapy, prophylactic
regimens, and recent treatments of rejection.
Have a high clinical suspicion for OIs.