General Considerations

Ihe vast majority of liver transplant recipients have at least one episode of infection at some time after their transplantation and many have more than one episode. Infections or their complications are believed to account for most of the deaths. Vigilance for infection must remain high, since immunosuppression-induced blunting of the inflammatory response may mask the classic signs and symptoms of infection. Iiming of infection after transplantation can be organized into three segments: less than 1 month, 1 to 6 months, and greater than 6 months. Infection in the first 30 postoperative days is primarily from bacteria and fungi. Ihe patient is typically at the greatest levels of immunosuppression and the anastomoses are at their most vulnerable during the first month. Ihe vast majority of infectious agents seen in less than 1 month are the same nosocomial agents seen in similar surgical patients. Opportunistic organisms are notably absent in the first month. CMV is discussed below.

During the first postoperative month, intraabdominal infections—including cholangitis, peritonitis, as well as liver and other intraabdominal abscesses—predominate. Presentation is marked by fever, abdominal pain and distension, ascites, and occasionally jaundice. Workup should include CBC with differential, liver function tests, urinalysis, chest x-ray, abdominal ultrasound, and blood and fluid cultures. Evaluation may include ultrasound, CI scan, I-tube cholangiography, ERCP, liver biopsy, and cultures of blood, urine, or aspirated fluid. Ihe organisms responsible tend to be enterococci, gram-negative aerobes, anaerobes, Staphylococcus, and Candida species. Patients may also present with pneumonia or urinary tract infections related to intubation or indwelling bladder catheterization while hospitalized. Cultures may need to be held in order for fungi, viruses, CMV, Nocardia species, and Mycobacterium tuberculosis to grow. Shell-vial cultures should be obtained if there is any suspicion of CMV disease.

From 1 to 6 months, most infection is from viruses [reactivation, donor transmission, Epstein-Barr virus (EBV)] or opportunistic organisms. After 6 months, the incidence of serious infection declines, with cholangitis predominating. Risk of infection after 6 months approaches that of the general population, although morbidity and mortality may be higher.13 A high index of suspicion should be maintained whenever immunosuppression is high.14 Close monitoring is essential, as rapid deterioration can take place while the patient is still in the ED.

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