Summary of treatment experience of carbapenem-resistant Klebsiella pneumoniae infection after renal transplantation in DCD era
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摘要:
目的 总结心脏死亡器官捐献(DCD)时代肾移植术后耐碳青霉烯类肺炎克雷伯菌(CRKP)感染的临床治疗经验。 方法 回顾性分析2015年1月至2019年1月行DCD供肾移植术后CRKP感染的17例受者和10例供者临床资料。供、受者均行细菌培养和药敏试验; 记录CRKP感染受者的临床表现、治疗及转归情况。 结果 7例供者感染CRKP,对其预处理后,2例供者CRKP转阴,5例供者CRKP未转阴。所有供肾均接受替加环素+美罗培南+伏立康唑灌洗预防感染。17例CRKP感染的受者中,包括11例血培养阳性、10例尿培养阳性、3例痰培养阳性、3例切口分泌物阳性、3例腹膜后引流液阳性; 其临床表现包括发热8例、移植肾动脉破裂出血7例或移植肾动脉内血栓形成1例、膀胱刺激征3例、咳砖红色胶冻样痰1例。接受替加环素+美罗培南治疗5例,移植肾丢失1例,受者死亡4例; 接受头孢他啶-阿维巴坦+美罗培南治疗12例,移植肾丢失3例,受者死亡1例。 结论 CRKP感染供者并非肾移植的绝对禁忌证,提前处理供者感染,受者术后早期给予足量敏感抗生素可以治愈感染,改善肾移植受者预后。 Abstract:Objective To summarize the clinical treatment experience of carbapenem-resistant Klebsiella pneumoniae (CRKP) infection after renal transplantation in donation after cardiac death (DCD) era. Methods Clinical data of 10 donors and 17 recipients with CRKP infection after DCD renal transplantation from January 2015 to January 2019 were retrospectively analyzed. Both donors and recipients received bacterial culture and drug sensitivity test. Clinical manifestations, treatment and outcome of CRKP-infected recipients were recorded. Results Seven donors were infected with CRKP. After pretreatment, CRKP in 2 cases turned negative, CRKP in 5 donors did not turn negative. All renal grafts were treated with tigecycline+meropenem+voriconazole lavage to prevent infection. Among 17 recipients with CRKP infection, 11 cases were positive for blood culture, 10 positive for urine culture, 3 positive for sputum culture, 3 positive for incisional secretion and 3 positive for retroperitoneal drainage. Clinical manifestations included fever in 8 cases, rupture and hemorrhage of the transplant renal artery in 7 cases or thrombosis in the transplant renal artery in 1 case, bladder irritation sign in 3 cases and cough with brick red jelly-like sputum in 1 case, respectively. Five patients were treated with tigecycline+meropenem, 1 patient suffered from renal graft loss and 4 recipients died. Twelve patients were treated with ceftazidime-avibactam +meropenem, 3 patients presented with renal graft loss and 1 recipient died. Conclusions CRKP-infected donor is not the absolute contraindication of renal transplantation. Pretreatment of donor infection and early administration of sufficient sensitive antibiotics can cure CRKP infection and improve the clinical prognosis of renal transplant recipients. -
表 1 CRKP感染供者细菌培养结果、预处理情况
Table 1. Bacterial culture result and pretreatment situation of CRKP infected donors
供者例序 培养标本 供者预处理措施 供者预处理结果 血 尿 痰液 供肾灌洗液 1 (-) (+) (-) (+) 替加环素+美罗培南 未转阴 2 (-) (-) (+) (-) 无 误以为假阳性 3 (-) (-) (-) (+) 无 误以为真阴性 4 (-) (+) (-) (-) 头孢他啶-阿维巴坦+美罗培南 转阴 5 (+) (+) (-) (-) 头孢他啶-阿维巴坦+美罗培南 转阴 6 (-) (+) (-) (+) 头孢他啶-阿维巴坦+美罗培南 未转阴 7 (-) (+) (-) (+) 头孢他啶-阿维巴坦+美罗培南 未转阴 表 2 CRKP感染受者的临床表现、治疗及转归情况
Table 2. Clinical manifestation, treatment and outcome of CRKP infected recipients
供者例序 供者感染 受者例序 术后感染时间(d) 临床症状 术后并发症 治疗 存活情况 肾 人 1 (+) 1 14 发热、血栓、出血 无 替加环素+美罗培南 存活 死亡 2 14 发热、出血 切口及肺部感染 替加环素+美罗培南 存活 死亡 2 (+) 3 9 出血 DGF① 头孢他啶-阿维巴坦+美罗培南 切肾 存活 4 7 出血 肺部感染、CRKP复发 头孢他啶-阿维巴坦+美罗培南 切肾 存活 3 (+) 5 14 出血 DGF、胰腺炎 替加环素+美罗培南+磷霉素 存活 死亡 6 14 发热、膀胱刺激征、出血 切口感染 替加环素+美罗培南 切肾 存活 4 (+) 7 14 发热、出血 无 头孢他啶-阿维巴坦+美罗培南 切肾 存活 8 14 无 无 头孢他啶-阿维巴坦+美罗培南 存活 存活 5 (+) 9 30 发热、膀胱刺激征 无 头孢他啶-阿维巴坦+美罗培南 存活 存活 10 无 无 无 头孢他啶-阿维巴坦+美罗培南 存活 存活 6 (+) 11 无 无 无 头孢他啶-阿维巴坦+美罗培南 存活 存活 12 无 无 无 头孢他啶-阿维巴坦+美罗培南 存活 存活 7 (+) 13 无 无 无 头孢他啶-阿维巴坦+美罗培南 存活 存活 14 无 无 无 头孢他啶-阿维巴坦+美罗培南 存活 存活 8 (-) 15 91 发热、咳痰 呼吸衰竭 替加环素+美罗培南 存活 死亡 9 (-) 16 262 发热、膀胱刺激征 CRKP复发、排斥反应 头孢他啶-阿维巴坦+美罗培南 存活 存活 10 (-) 17 186 发热、膀胱刺激征 肺部感染、精神病 头孢他啶-阿维巴坦+美罗培南 存活 死亡 注:①DGF为移植物功能延迟恢复。 -
[1] XU L, SUN X, MA X. Systematic review and Meta-analysis of mortality of patients infected with carbapenem-resistant Klebsiella pneumoniae[J]. Ann Clin Microbiol Antimicrob, 2017, 16(1):18. DOI: 10.1186/s12941-017-0191-3. [2] YIGIT H, QUEENAN AM, ANDERSON GJ, et al. Novel carbapenem-hydrolyzing beta-lactamase, KPC-1, from a carbapenem-resistant strain of Klebsiella pneumoniae[J]. Antimicrob Agents Chemother, 2001, 45(4):1151-1161. doi: 10.1128/AAC.45.4.1151-1161.2001 [3] 范鹏飞, 张玮晔.心脏死亡器官捐献供肝功能维护的研究进展[J/CD].实用器官移植电子杂志, 2016, 4(5): 311-314. DOI: 10.3969/j.issn.2095-5332.2016.05.012.FAN PF, ZHANG WY. Research progress on the maintenance of liver function from cardiac death organ donation[J/CD]. Pract J Organ Transplant (Electr Vers), 2016, 4(5): 311-314. DOI: 10.3969/j.issn.2095-5332.2016.05.012. [4] HU FP, GUO Y, ZHU DM, et al. Resistance trends among clinical isolates in China reported from CHINET surveillance of bacterial resistance, 2005-2014[J]. Clin Microbiol Infect, 2016, 22(Suppl 1):S9-S14. DOI: 10.1016/j.cmi.2016.01.001. [5] 李智斌, 张更, 刘克普, 等.公民逝世后器官捐献肾移植早期多重耐药菌感染的临床研究[J].器官移植, 2017, 8(5):386-391. DOI: 10.3969/j.issn.1674-7445.2017.05.010.LI ZB, ZHANG G, LIU KP, et al. Clinical study of early infection of multi-drug resistant organisms after renal transplantation from organ donation after citizen's death[J]. Organ Transplant, 2017, 8(5):386-391. DOI: 10.3969/j.issn.1674-7445.2017.05.010. [6] 王长希, 邓荣海.公民逝世后器官捐献感染性供者的移植应用[J/CD].中华移植杂志(电子版), 2016, 10(1): 24-28.DOI: 10.3877/cma.j.issn.1674-3903.2016.01.004.WANG CX, DENG RH. Organ transplantation of infected donors derived from donation after citizen death[J/CD]. Chin J Transplant (Electr Vers), 2016, 10(1): 24-28. DOI: 10.3877/cma.j.issn.1674-3903.2016.01.004. [7] 许名杰, 谢续标, 彭龙开, 等.肾移植后感染性移植肾动脉破裂五例临床分析[J].中华器官移植杂志, 2017, 38(4):211-217.DOI:10.3760/cma.j.issn.0254-1785. 2017.04.004.XU MJ, XIE XB, PENG LK, et al. Clinical analysis of 5 cases of infectious renal artery rupture after renal transplantation[J]. Chin J Organ Transplant, 2017, 38(4):211-217. DOI: 10.3760/cma.j.issn.0254-1785.2017.04.004. [8] 王全楚, 朱晓红, 唐中雷.高致病性肺炎克雷伯杆菌导致的社区获得性肺炎死亡1例[J].中华危重病急救医学, 2017, 29(1):84.DOI:10.3760/cma.j.issn.2095-4352. 2017.01.018.WANG QC, ZHU XH, TANG ZL. A dead case of severe community-acquired pneumonia caused by highly pathogenic Klebsiella pneumoniae[J]. Chin Crit Care Med, 2017, 29(1):84. DOI:10.3760/cma.j.issn.2095-4352. 2017.01.018. [9] 韩环立, 张明满, 郭春宝, 等.胆道闭锁患儿肝移植术后并发症分析[J].临床肝胆病杂志, 2017, 33(2):316-319. DOI: 10.3969/j.issn.1001-5256.2017.02.024.HAN HL, ZHANG MM, GUO CB, et al. An analysisof postoperative complications in children with biliaryatresia after liver transplantation[J]. J Clin Hepatol, 2017, 33(2):316-319. DOI: 10.3969/j.issn.1001-5256.2017.02.024. [10] LEWIS JD, SIFRI CD. Multidrug-resistant bacterial donor-derived infections in solid organ transplantation[J]. Curr Infect Dis Rep, 2016, 18(6):18. DOI: 10.1007/s11908-016-0526-9. [11] 张鹏亮, 徐修礼, 白露.医院感染大肠埃希菌及肺炎克雷伯菌的产酶率与耐药性分析[J].中华医院感染学杂志, 2015, 23(3):508-510.DOI: 10.11816/cn.ni.2015-124964.ZHANG PL, XU XL, BAI L. Analysis of drug resistance and enzyme production rate of Escherichia coli and Klebsiella pneumoniae in hospital infections[J]. ChinJ Nosocom, 2015, 23(3):508-510. DOI: 10.11816/cn.ni.2015-124964. [12] 李凤林, 马振广, 夏红强.肺炎克雷伯杆菌致血流感染1例分析[J].实用检验医师杂志, 2016, 8(3):188-190. DOI: 10.3969/j.issn.1674-7151.2016.03.019.LI FL, MA ZG, XIA HQ. Analysis of 1 case of bloodstream infection caused by Klebsiella pneumoniae[J]. Chin JLabor Path, 2016, 8(3):188-190. DOI: 10.3969/j.issn.1674-7151.2016.03.019. [13] TAMINATO M, FRAM D, PEREIRA RRF, et al. Infection related to Klebsiella pneumoniae producing carbapenemase in renal transplant patients[J]. Rev Bras Enferm, 2019, 72(3):760-766. DOI: 10.1590/0034-7167-2019-0009. [14] BERGAMASCO MD, BARROSO BARBOSA M, DE OLIVEIRA GARCIA D, et al. Infection with Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae in solid organ transplantation[J]. Transpl Infect Dis, 2012, 14(2):198-205. DOI: 10.1111/j.1399-3062.2011.00688.x. [15] 唐小红, 朱卫民.肺炎克雷伯菌耐碳青霉烯类抗菌药的研究进展[J].国外医药(抗生素分册), 2014, 35(3):115-118, 122.DOI: 10.3969/j.issn.1001-8751.2014.03.004.TANG XH, ZHU WM. Progress about carbapenem resistant of Klebsiella pneumoniae[J]. World Not Antibio, 2014, 35(3):115-118, 122.DOI:10.3969/j.issn. 1001-8751.2014.03.004. [16] HIRSCH EB, TAM VH. Detection and treatment options for Klebsiella pneumoniae carbapenemases (KPCs): an emerging cause of multidrug-resistant infection[J]. J Antimicrob Chemother, 2010, 65(6):1119-1125. DOI: 10.1093/jac/dkq108. [17] CICORA F, MOS F, ROBERTI J. Kidney transplant recipients infected with blaKPC-2-producing Klebsiella pneumoniae[J]. Nefrologia, 2015, 35(3):340-343. DOI: 10.1016/j.nefro.2015.02.002. [18] DENG M, ZHU MH, LI JJ, et al. Molecular epidemiology and mechanisms of tigecycline resistance in clinical isolates of acinetobacter baumannii from a Chinese university hospital[J]. Antimicrob Agents Chemother, 2014, 58(1):297-303. DOI: 10.1128/AAC.01727-13. [19] SPANU T, DE ANGELIS G, CIPRIANI M, et al. In vivo emergence of tigecycline resistance in multidrug-resistant Klebsiella pneumoniae and Escherichia coli[J]. Antimicrob Agents Chemother, 2012, 56(8):4516-4518. DOI: 10.1128/AAC.00234-12. [20] LEVASSEUR P, GIRARD AM, CLAUDON M, et al. In vitro antibacterial activity of the ceftazidime-avibactam (NXL104) combination against Pseudomonas aeruginosa clinical isolates[J]. Antimicrob Agents Chemother, 2012, 56(3):1606-1608. DOI: 10.1128/AAC.06064-11. [21] 曾志旋, 曹胜华, 陈林.新型β-内酰胺酶抑制剂——阿维巴坦的研究进展[J].国外医药(抗生素分册), 2014, 35(2):58-62.DOI: 10.3969/j.issn.1001-8751.2014.02.002.ZENG ZX, CAO SH, CHEN L. The research advance of a novel β-lactamase inhibitor—avibactam[J]. World Not Antibio, 2014, 35(2):58-62. DOI:10.3969/j.issn.1001- 8751.2014.02.002. [22] LAGACÉ-WIENS P, WALKTY A, KARLOWSKY JA. Ceftazidime-avibactam: an evidence-based review of its pharmacology and potential use in the treatment of Gram-negative bacterial infections[J]. Core Evid, 2014, 9:13-25. DOI: 10.2147/CE.S40698. [23] CASTANHEIRA M, MENDES RE, SADER HS. Low frequency of ceftazidime-avibactam resistance among enterobacteriaceae isolates carrying blaKPC collected in U.S. hospitals from 2012 to 2015[J]. Antimicrob Agents Chemother, 2017, 61(3): e02369-16. DOI: 10.1128/AAC. 02369-16. [24] YANG M, GAO H, WANG X, et al. Tigecycline treatment in a liver transplant infant with carbapenem-resistant Escherichia coli infection: case report[J]. Medicine (Baltimore), 2019, 98(39):e17339. DOI: 10.1097/MD.0000000000017339.
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