Pneumocystis carinii pneumonia in heart transplant recipients

Outcomes of Pneumocystis jiroveci pneumonia infections in pediatric heart transplant recipients

PJP is known to cause significant morbidity and rarely death in immunosuppressed patients. The prevalence and outcomes of PJP in pediatric solid-organ transplant patients are not well established. This study utilizes data from the PHTS to establish the prevalence and outcome of PJP in pediatric heart transplant recipients. We conducted a retrospective cohort study using data from the PHTS, including data from 24 institutions between January 1, 1993, and December 31, 2004. Infections that occur in PHTS subjects are recorded in a standardized data collection form. The prevalence and outcomes of PJP in pediatric heart transplant recipients were determined. There were a total of 18 patients (1%) with PJP out of the 1854 pediatric heart transplant recipients in the PHTS database. A majority of PJP occurred two months to two yr post-transplant, and patients with PJP had a significantly decreased mortality compared with other fungal infections. PJP is an infrequent complication experienced by pediatric heart transplant recipients. Patients that have experienced PJP have an increased survival compared to patients with other fungal infections, and most PJP occurred within two yr of transplant.

Non-Aspergillus Fungal Pneumonia in Transplant Recipients

Although species of Aspergillus and Candida account for most deeply invasive and life-threatening fungal infections, the past decades have seen a rise in the immunocompromised population. With this increase, additional fungi have emerged as important agents of morbidity and mortality. These opportunistic fungi are characterized by their ubiquitous presence in the environment, their ability to cause disease in immunosuppressed patients, and their diminished susceptibility to the currently available antifungal agents. Pneumonia, one aspect of a myriad of clinical manifestations caused by these fungal pathogens, is discussed in this article.

Infectious complications after heart transplantation in Chinese recipients

Several factors appear to influence the incidence and type of infectious complications among different populations of transplant recipients. This study sought to assess the incidence and type of infection after transplantation in Chinese heart allograft recipients. A total of 130 infectious episodes occurred in 192 consecutive heart transplantation patients between June 1993 and May 2004. The median length of follow-up was 46.7+/-38.4 months. The 1-, 5- and 10-year survival rates were 81.8+/-2.8%, 63.0+/-3.8% and 45.7+/-7.7%. Infection was the leading cause of early and late deaths. Of the infectious episodes, 66 (51%) were caused by bacteria, 35 (27%) by viruses, 10 (8%) by fungi, 7 (5%) by Mycobacterium tuberculosis and 12 (9%) by other pathogens. The most common bacterial infectious episodes were caused by methicillin-resistant Staphylococcus aureus (20 of 66). The most common viral infections were varicella zoster virus infection in 12 (34%), cytomegalovirus infection in 9 (26%) and hepatitis B virus infection in 8 (23%). There was only one episode of clinical syndrome compatible to Pneumocystis jiroveci pneumonia. In conclusion, there was low incidence of Pneumocystis jiroveci pneumonia and cytomegalovirus infection, and high incidence of Mycobacterium tuberculosis infection in Chinese heart allograft recipients.

Pneumocystis carinii pneumonia in human immunodeficiency virus (HIV)-positive and HIV-negative immunocompromised patients

For 89 human immunodeficiency virus (HIV)-positive and 32 HIV-negative immunocompromised patients who had 121 episodes of Pneumocystis carinii pneumonia (PCP), clinical features and changes over time were compared. HIV-infected patients characteristically had a longer duration of symptoms (23 vs. 13 days; P<.005); were younger (39 vs. 48 years; P<.001); had a higher frequency of sweating, weight loss, and thoracic pain; and had fewer admissions to the intensive care unit (16% vs. 31%; P<.05). In addition, they had significantly higher hemoglobin levels, lower thrombocyte counts, lower C-reactive protein values, and a higher proportion of eosinophils and lymphocytes in bronchoalveolar lavage fluid. After 1995, HIV-negative patients' mean length of stay dropped from 34 days to 16 days (P<.005), and their hospital mortality rate dropped from 29% to 7% (P<.001). HIV-positive patients with PCP differed in several aspects from those without HIV infection. Knowledge gained from experience with treatment of opportunistic infections in patients with AIDS has improved the management of PCP in patients with other immunodeficiencies.

Prevention of nosocomial infection in solid organ transplantation

Despite improvements in survival rates, infection remains an important cause of morbidity and mortality following solid organ transplantation. Prevention of infection and, failing this, prompt diagnosis and treatment remain the cornerstones of management. During the peri-operative admission, when the level of immunosuppression is at its height, nosocomial infection accounts for the majority of infective morbidity. Although the measures taken to prevent nosocomial infection may vary, centres undertaking such procedures must ensure that strategies are in place to protect patients. The importance of basic infection control measures cannot be over-emphasised. In addition, appropriate prophylactic agents, rapid diagnostic techniques and the early institution of appropriate therapy are essential. As developments in this field advance, the epidemiology of infection will continue to change, demanding an ongoing assessment of preventative, diagnostic and therapeutic strategies.

Pneumocystis carinii infection in heart transplant recipients. Efficacy of a weekend prophylaxis schedule

Most series of heart transplant patients report incidences of Pneumocystis carinii pneumonia (PCP) below 5% but do not individually describe the cases. From August 1988 to March 1994, 138 patients received 1 or more heart transplants at our institution. No anti-PCP chemoprophylaxis was provided, and 5 (3.6%) patients developed PCP. Incidence for listeriosis was 0.7% and for nocardiosis, 3.6%. We found descriptions of 14 more heart transplant patients with PCP in the medical literature. Data from the 19 patients follow. Mean age was 52 years, and PCP was diagnosed a median of 75 days after heart transplant (range, 37-781 d). Clinical presentation was acute (less than 48 h) with fever (89%), shortness of breath (84%), dry cough (74%), and hypoxia (63%). Cytomegalovirus was isolated from lung or blood in 74% of patients. Chest X-ray usually showed interstitial pneumonia (84%). Three patients required ventilatory support. All patients were treated with trimethoprim-sulfamethoxazole (TMP/SMX) (4 also with corticosteroids and 5 with ganciclovir). Mortality was 26%. Older age was the only significant poor prognostic factor (61 versus 49 years; p < 0.03). From March 1994, 50 heart transplant patients were given TMP/SMX prophylaxis at our institution (1 double-strength tablet, 160/800 mg, every 12 hours on Saturdays and Sundays), and no new cases of PCP, Listeria or Nocardia have been detected since then. Tolerance has been excellent. Heart transplant recipients are at a substantial risk of PCP pneumonia, which presents with an abrupt onset and a high mortality. Weekend TMP/SMX chemoprophylaxis was very effective at our institution.

Pneumocystis carinii pneumonia in HIV-negative patients with haematologic disease

Since 1990, Pneumocystis carinii pneumonia (PCP) was diagnosed in 15 adult HIV-negative haematologic patients in our hospital. None of them had received PCP prophylaxis. All except one had been treated with prednisone. Symptoms usually started after stopping or tapering. In six patients the diagnosis of PCP was delayed because of confounding bacterial isolates from blood, sputum or urine leading to unsuccessful antibiotic treatment. PCP was diagnosed by demonstrating pneumocysts in bronchoalveolar lavage fluid. In four patients additional fungal or viral pathogens were identified. The infections were not clustered. The patients were treated with co-trimoxazole and, in case of a pO2 < 60 mmHg, with prednisone. Three patients died (20%); they all had a coinfection with cytomegalovirus and/or aspergillus. The others recovered completely. There were no relapses. Primary PCP prophylaxis should be considered in patients with lympho-proliferative disease and exposure to prednisone.

Infections in solid-organ transplant recipients

Solid-organ transplantation is a therapeutic option for many human diseases. Infections are a major complication of solid-organ transplantation. All candidates should undergo a thorough infectious-disease screening prior to transplantation. There are three time frames, influenced by surgical factors, the level of immunosuppression, and environmental exposures, during which infections of specific types most frequently occur posttransplantation. Most infections during the first month are related to surgical complications. Opportunistic infections typically occur from the second to the sixth month. During the late posttransplant period (beyond 6 months), transplantation recipients suffer from the same infections seen in the general community. Opportunistic bacterial infections seen in transplant recipients include those caused by Legionella spp., Nocardia spp., Salmonella spp., and Listeria monocytogenes. Cytomegalovirus is the most common cause of viral infections. Herpes simplex virus, varicella-zoster virus, Epstein-Barr virus and others are also significant pathogens. Fungal infections, caused by both yeasts and mycelial fungi, are associated with the highest mortality rates. Mycobacterial, pneumocystis, and parasitic diseases may also occur.