approach to fever in the transplant patient
DESCRIPTION
Quick Approach to solid organ transplant patients presenting to the ED with fever to guide initial work-up and managment. Audience: Medical students and junior residents in a small group environmentTRANSCRIPT
Approach to fever in the transplant patientApproach to fever in the transplant patient
Farooq Khan MDCMPGY2 FRCP-EMMcGill UniversityJanuary 6th 2011
Causes of fever in this population
Causes of fever in this population
InfectionRejection/GvHDMalignancyDrug feverHypersensitivity reactionThromboemobolic disease
InfectionRejection/GvHDMalignancyDrug feverHypersensitivity reactionThromboemobolic disease
Surviving sepsis …Surviving sepsis …
Treat infections earlyChoose the right therapyCover for the right agentAnticipate which agents are
responsible
Treat infections earlyChoose the right therapyCover for the right agentAnticipate which agents are
responsible
ConsiderationsConsiderations
Epidemiologic exposures Patient’s net state of immune
suppressionTime from transplantationType of transplantation Immune response is blunted,
anatomy is altered, so signs and symptoms are subtle and atypical
Epidemiologic exposures Patient’s net state of immune
suppressionTime from transplantationType of transplantation Immune response is blunted,
anatomy is altered, so signs and symptoms are subtle and atypical
Epidemiologic exposuresEpidemiologic exposures
Community acquired pathogens (Ask about contacts, geography, socioeconomic status, occupation) Common things are common! Respiratory viruses (flu, paraflu, rsv, adeno) Bacteria (strep, staph, mycoplasma, listeria, salmonella) Endemic fungi (histoplasma, cryptococcus, aspergillus,
cryptosporidia) Reactivation of infection in patient (Were they
known carriers? Were they immunized?) HSV, CMV, VZV, HBV, HCV, HPV TB, fungi, parasites
Nosocomial infection (Ask about recent hospitalizations, previous antibiotic therapy) MRSA, VRE, C diff Legionella, pseudomonas, candida
Community acquired pathogens (Ask about contacts, geography, socioeconomic status, occupation) Common things are common! Respiratory viruses (flu, paraflu, rsv, adeno) Bacteria (strep, staph, mycoplasma, listeria, salmonella) Endemic fungi (histoplasma, cryptococcus, aspergillus,
cryptosporidia) Reactivation of infection in patient (Were they
known carriers? Were they immunized?) HSV, CMV, VZV, HBV, HCV, HPV TB, fungi, parasites
Nosocomial infection (Ask about recent hospitalizations, previous antibiotic therapy) MRSA, VRE, C diff Legionella, pseudomonas, candida
Exposures …Exposures …
Donor derived infection (Where did the graft come from?) Donor had a bloodstream infection (E. coli,
salmonella, strep, staph, candida) that sticks to anastomotic sites in graft recipient
CMV, EBV – seropositive donors TB, histoplasma - can reactivate years later HIV, HTLV, hepatitis - may be missed by
screening Wild and wonderful stuff (Ask about
travel and animals!) Leishmania, strongyloides, dengue,
trypanosoma, West Nile, rabies, toxoplasma, ehrlichiosis, LCMV… Etc.
Donor derived infection (Where did the graft come from?) Donor had a bloodstream infection (E. coli,
salmonella, strep, staph, candida) that sticks to anastomotic sites in graft recipient
CMV, EBV – seropositive donors TB, histoplasma - can reactivate years later HIV, HTLV, hepatitis - may be missed by
screening Wild and wonderful stuff (Ask about
travel and animals!) Leishmania, strongyloides, dengue,
trypanosoma, West Nile, rabies, toxoplasma, ehrlichiosis, LCMV… Etc.
Net state of immune suppression
Net state of immune suppression
Type, dose, timing of immunosuppressive therapy (Look up the meds) Recent/repeated rejection episodes usually
mean an increase in anti-rejection meds dose Level of neutropenia/lymphopenia
Underlying disease or comorbidity (PMH) Including malnutrition, diabetes, uremia, HIV
Invasive catheters, drains, hardware (Do a full physical)
Presence of devitalized tissue or fluid collections (Don’t be afraid to look under that dressing or get that CT)
Type, dose, timing of immunosuppressive therapy (Look up the meds) Recent/repeated rejection episodes usually
mean an increase in anti-rejection meds dose Level of neutropenia/lymphopenia
Underlying disease or comorbidity (PMH) Including malnutrition, diabetes, uremia, HIV
Invasive catheters, drains, hardware (Do a full physical)
Presence of devitalized tissue or fluid collections (Don’t be afraid to look under that dressing or get that CT)
Time after transplantationTime after transplantation
<1 month (post-op infections, high resistance rates) Nosocomial infections (MRSA VRE Candida c.
diff) Aspiration Catheter related Wound infection Anastomotic leak / abscess / ischemia Donor derived (rare) – HSV, CMV, HIV,
trypanosoma, west nile Recipient derived 2° to colonization with
aspergillus or pseudomonas
<1 month (post-op infections, high resistance rates) Nosocomial infections (MRSA VRE Candida c.
diff) Aspiration Catheter related Wound infection Anastomotic leak / abscess / ischemia Donor derived (rare) – HSV, CMV, HIV,
trypanosoma, west nile Recipient derived 2° to colonization with
aspergillus or pseudomonas
Time after transplantationTime after transplantation
1-6 months (highest risk of rejection→highest level of immune suppression→highest rate of opportunistic infection)
Without prophylaxis PCP, Herpesviruses (HSV, VZV, CMV, EBV)
HBV Listeria, nocardia, toxoplasma,
strongyloides, leishmania, trypanosoma With prophylaxis
HCV, cryptococcus, TB, C. diff, respiratory viruses, polyomavirus BK
Anastomotic complications
1-6 months (highest risk of rejection→highest level of immune suppression→highest rate of opportunistic infection)
Without prophylaxis PCP, Herpesviruses (HSV, VZV, CMV, EBV)
HBV Listeria, nocardia, toxoplasma,
strongyloides, leishmania, trypanosoma With prophylaxis
HCV, cryptococcus, TB, C. diff, respiratory viruses, polyomavirus BK
Anastomotic complications
Time after transplantationTime after transplantation
> 6 months (stable levels of immune suppression, community acquired pathogens, late viral infection, malignancy)
CAP, UTI, Aspergillus, other molds, mucor, nocardia
CMV (colitis, retinitis) hepatitis, HSV encephalitis, SARS, West nile
PML, lymphoma, skin cancers
> 6 months (stable levels of immune suppression, community acquired pathogens, late viral infection, malignancy)
CAP, UTI, Aspergillus, other molds, mucor, nocardia
CMV (colitis, retinitis) hepatitis, HSV encephalitis, SARS, West nile
PML, lymphoma, skin cancers
Type of transplantType of transplant
Heart: mediastinitis, peri/myo/endocarditis Staph aureus, staph epi
Lung: pneumonia, empyema CMV, PCP, pseudomonas
Liver: cholangitis, intraabdominal abscess, hepatic abscess, peritonitis Gram -, enterobacter, enterococcus, candida
Renal: UTI/Pyelo, bacteremia Gram-, candida
Heart: mediastinitis, peri/myo/endocarditis Staph aureus, staph epi
Lung: pneumonia, empyema CMV, PCP, pseudomonas
Liver: cholangitis, intraabdominal abscess, hepatic abscess, peritonitis Gram -, enterobacter, enterococcus, candida
Renal: UTI/Pyelo, bacteremia Gram-, candida
Physical exam elements often forgotten
Physical exam elements often forgotten
Oral mucosa Retina, sinuses Skin Neuro exam Dialysis catheters Rectal Think altered anatomy Don’t just examine the CV, Resp, and
Abdo!
Oral mucosa Retina, sinuses Skin Neuro exam Dialysis catheters Rectal Think altered anatomy Don’t just examine the CV, Resp, and
Abdo!
Lab tests that can be useful
Lab tests that can be useful
Pancultures (mouth, urine, stool, blood, sputum, access, wound, fluid drainage) (include virology and fungal cultures)
Antigen-based tests are more useful than serologic tests (Go ELISA or PCR)
Medication levels (e.g. cyclosporin, tacrolimus)
Test organ function (liver, renal, pulmonary, echo, EKG, chest x-ray..) (may deteriorate rapidly in rejection)
Remember, signs and symptoms are limited. Be generous!
Pancultures (mouth, urine, stool, blood, sputum, access, wound, fluid drainage) (include virology and fungal cultures)
Antigen-based tests are more useful than serologic tests (Go ELISA or PCR)
Medication levels (e.g. cyclosporin, tacrolimus)
Test organ function (liver, renal, pulmonary, echo, EKG, chest x-ray..) (may deteriorate rapidly in rejection)
Remember, signs and symptoms are limited. Be generous!
General principles of management
General principles of management
Low threshold for imaging due to lack of clinical manifestations of infection (Argue with the radiologist for that CT if you have to)
May need invasive diagnostic procedures to obtain tissue for culture and histology to rule out rejection (Get your surgeons involved)
Low threshold for imaging due to lack of clinical manifestations of infection (Argue with the radiologist for that CT if you have to)
May need invasive diagnostic procedures to obtain tissue for culture and histology to rule out rejection (Get your surgeons involved)
General principles of management
General principles of management
Resistant organisms are common due to hospital environments and prolonged antimicrobial therapy (Hit hard, go broad)
Be mindful of drug toxicities and interactions with choice of antimicrobial therapy (Check with your (e-)pharmacist)
Catheters, drains, blood clots, fluid collections, devitalized tissue must be removed or antimicrobials will fail (Think source control)
Resistant organisms are common due to hospital environments and prolonged antimicrobial therapy (Hit hard, go broad)
Be mindful of drug toxicities and interactions with choice of antimicrobial therapy (Check with your (e-)pharmacist)
Catheters, drains, blood clots, fluid collections, devitalized tissue must be removed or antimicrobials will fail (Think source control)
ReferencesReferences
N. Singh et al. (eds .), Infectious Complications in Transplant Recipients © Springer-Verlag US 2001, Chapter 4 Post transplant fever in critically ill organ transplant recipients
Infection in the solid organ transplant recipientAuthor Jay A Fishman, MD Section Editor Peter F Weller, MD, FACP Deputy Editor Anna R Thorner, MDhttp://www.uptodateonline.com/online/content/topic.do?topicKey=immuninf/2303&selectedTitle=3~150&source=search_result Last literature review version 16.2:May 2008
N. Singh et al. (eds .), Infectious Complications in Transplant Recipients © Springer-Verlag US 2001, Chapter 4 Post transplant fever in critically ill organ transplant recipients
Infection in the solid organ transplant recipientAuthor Jay A Fishman, MD Section Editor Peter F Weller, MD, FACP Deputy Editor Anna R Thorner, MDhttp://www.uptodateonline.com/online/content/topic.do?topicKey=immuninf/2303&selectedTitle=3~150&source=search_result Last literature review version 16.2:May 2008