1. SEPSIS IN POST TRANSPLANT
PATIENTS
Dr.Hina Aamir Abbasi
SIUT

2. Case
 47 yrs old male patient
 Renal transplant 6 months ago
 Presented with complain of…
 Fever
 Cough
 Shortness of breath
 Confusion
 Fatigue
 Weight loss for the last two weeks

3.  Patient was a case of End stage renal disease
secondary to glomerulonephritis and was
dialysis dependant prior to renal transplant
 Donor was his healthy elder brother.
 Post transplant 6 months were uneventful.

4. Drug history
Post Transplant, patient had been on
immunosuppressive drugs ;
 Azathioprine
 Tacrolimus
 Prednisolone

5. Contd..
 Patient was febrile 100F fever, H/R 104b/m,
R/R 40 br/min B.P100/60 and decreased
urine output and GCS 12/15
 Patient admitted in Transplant ICU and put
on ventilatory support as his ABG’s showed
picture of severe acidosis and hypoxemia.

6. Diagnosis..
 Sepsis or acute cellular rejection??

7. Graft biopsy
 Renal biopsy graft was sent which showed
normal cellular infiltration and no
rejection…

8. Differential diagnosis
 Disseminated tuberculousis
 Pneumocystitis carnii pneumonia
 Interstitial pneumonia
 Klebsiella pneumonia
 Cytomegalovirus infection
 MRSA

9. Haematological investigations
 Hb- 11.4
 TLC 2900
 Platelet 145
 Na 135
 K 3.8
 HCO3 15
 Cl 111
 FBS 127
 Urea 54
 Cr 1.40

10. Investigations
 Blood culture
 Viral serology for CMV, EBV
 Tracheal culture and BAL
 Stool D/R
 Urine C/S
 Sputum AFB & C/S
 Xray chest
 CT scan chest

11. Xray chest

12. CT scan chest

13. Results
 Patient’s x ray showed diffuse interstitial
infiltrates….suggestive of atypical
pneumonia …
 Tracheal C/S were negative
 Cultures from Broncho Alveolar Lavage
were positive for Pneumocystits Carnii

14. Treatment
 Septran DS
(sulfamethoxazole/trimethoprim).
 Vancomycin
 Acyclovir
 Hydrocortisone
 Tacrolimus
 Omeprazole

15. Management
 Chest physiotherapy
 Nebulisation
 Ventilator bundles
 DVT prophylaxis
 Stress ulcer prophylaxis
 Fluid management and TPN of the patient
continued as per hospital protocol

16.  Initially patient showed improvement but
after 10 days his GCS began to drop
 His MRI brain was done and CSF culture
sent

17. MRI and CSF cultures
 MRI brain showed multiple abnormal and
intensify areas in b/l basal ganglia brain
stem with post contrast enhancement seen,
like infective in nature.
 CSF culture was positive for CMV

18.  Patient had superimposed CMV infection
and was given Ganciclovir for 14 days and
showed improvement
 He was extubated and later on shifted to
ward after 45 days of admission in
Transplant ICU

19. Case discussion
 As immunosupressive agents and graft
survival have improved , infectious
complications have become a major
obstacle to infection free survival

20. The net state of
Immunosuppression
Epidemiological
exposures

21. Challenges
 Identification of infection in transplant recipients is
difficult , as inflamatory response are blunted by
immunosupression
 Fever may have no infectious etiology and in fact may
be an early signs of rejection.
 Even if source of infection identified then balance to
be kept between transplant rejection and modification
of immune supression
 Antibiotics chosen carefully as many are toxic to
allografts.

22. Post transplant sepsis risk factors
 Co-morbid (DM, immunosuppression)
 Malnutrition
 Unrecognised or undertreated infections
 Colonisation by resistant organisms (MRSA
, Pseudomonas ,enterobacter)
 Prolong surgery
 Infected graft
 Multiple blood transfusion
 Graft injury; prolong ischemia

24. Data shows…
 Infection affects all kidney transplant recipients, in
one form or another.
 Over 50 percent of transplant patients have at least one
infection in the first year following transplantation.
 If the patient’s graft is working well more than
six months post-transplant, they donot
require additional immunosuppression to combat
rejection, he or she is primarily at risk for infections
encountered by the general population such as
pneumonias and urinary tract infections.

25. Etiololgy
 Pneumonia
 Urosepsis
 Wound infection
 Cellulitus
 Viral…...CMV, PCP, EBV, Polyoma virus
 Fungal…Mucormycosis, Aspergillus,
 Candida
 Tuberculosis

26. Miscellaneous causes of fever
 Underlying malignancy
 Superimposed infections
 Febrile neutropenia
 Endocarditis
 Meningitis
 Drug induced
 Thromboembolic phenomenon

27. Incidence
bacteria
tuberculosis
viral
fungal
meningitis
endocarditis5

28. Underlying cause
 Over immunosuppression
 Potent immunosuppressive agents

29. Approach to post transplant septic
patient
 Think of a wider horizon….
 Empirical therapy includes …….
 Broad spectrum antibiotics
 Antivirals
 Antifungals
 Septran (trimethoprin and sulfamethoxazole)
 Continue immunosuppressive drugs

30. General principles of management
 Low threshold for imaging as lack of clinical
manifestation of infection
 Invasive diagnostic approach is required for
culture and histology
 Pancultures (sputum, stool, urine, wound,CSF
) including virology and fungal cultures
 Medication level (azathioprine, cyclosporine)

31. Considerations
 Epidemiological exposures
 Patient’s net state of immune
 Time from transplantation
 Type of transplantation
 Immune response is blunted, sign and
symptoms are altered
 Anticipate possible organism
 Early treatment
 Cover for the right agent

32. Thankyou