Bacterial Infections

UTIs associated with indwelling catheters are the most common bacterial infection in all transplant recipients, occurring in 30 to 40 percent. 9 The organisms responsible for UTIs in transplant patients are similar to those in nontransplant patients: Escherichia coli, enterococci, and Pseudomonas aeruginosa. UTIs in the first 6 months posttransplant have a high incidence of progressing to urosepsis and usually require longer courses of intravenous agents. UTIs during this period should all be investigated for the possibility of complicating obstruction and stone formation. Infections occurring after this period can be treated for shorter periods with less intensive courses.

The gastrointestinal tract is the next most common source of bacterial infection in the renal transplant patient. Acute bacterial gastroenteritis secondary to Salmonella, Campylobacter, and Listeria is common in these patients. While these bacteria usually have a benign course, occasionally Salmonella can spread hematogenously, resulting in endocarditis requiring a prolonged, intensive antibiotic course.

Diverticulitis, often complicated by perforation, is the other common gastrointestinal infection encountered in transplant patients. 10 Patients commonly present with findings of vague abdominal pain as the only symptom of this potentially life-threatening disease. A high index of suspicion should be maintained when evaluating transplant recipients with abdominal pain.

Listeria monocytogenes is a common opportunistic bacterial infection usually acquired by ingesting contaminated foods. Presentation is with diarrhea and abdominal cramps, which can quickly progress to pneumonia, enophthalmitis, and meningitis. Treatment consists of ampicillin and gentamicin, or trimethoprim-sulfamethoxazole (TMP-SMX).

Nocardia asteroides in renal transplant patients typically presents with fever, cough, and pulmonary infiltrates, eventually spreading to skin and central nervous system.11 Nocardia can be effectively treated with TMP-SMX.

Mycobacteria tuberculosis occurs in renal transplant patients both as a primary and as a reactivation disease.12 Risk factors for mycobacterial infection include malnutrition, history of inadequate treatment, or recent exposure to a contact with tuberculosis. There is no typical presentation for a transplant patient with tuberculosis. Instead, a highly variable presentation has been described, including cavitary pulmonary disease, miliary disease, and multiorgan involvement. Diagnosis is rarely aided by tuberculin skin testing. Definitive diagnosis is by organism identification and culture from sputum, pleural effusions, and bronchoalveolar lavage, lung, or bone marrow biopsy. Therapeutic options are complicated because of the CYA drug interactions with many antituberculosis medications.

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