The only complications were a minor pneumothorax after a transbronchial biopsy and minor
hemoptysis after a transthoracic needle aspiration. Direct microscopic examination of the
respiratory samples (Gram stain, potassium hydroxide, or cotton blue preparations) were
positive in 3/5 cases of aspergillosis and in 3/4 cases of nocardiosis (101). A serum sample
should also be submitted. Pneumonia is the infection with the highest related mortality
rate, and this can also be maintained for SOT recipients, so prompt empirical therapy is highly
recommended for patients in critical conditions after obtaining adequate samples. The
selection of the empirical therapy will be guided by the characteristics of the patient and the
clinical situation.
Postsurgical Infections
Complications in the proximity of the surgical area must always be investigated. Surgical
problems leading to devitalized tissue, anastomotic disruption, or fluid collections markedly
predispose the patient to potentially lethal infection. In the early posttransplantation period,
renal and pancreas transplant recipients may develop surgical site infection (SSI), perigraft
hematomas, lymphoceles, and urinary fistula (136). Incisional SSIs were detected in 55 of 1400
consecutive renal transplants in Spain a median of 20 days after transplantation. The most
frequently isolated pathogens wereEscherichia coli(31.7%),P. aeruginosa(13.3%),Enterococcus
faecalis(11.6%),Enterobacterspp. (10%), and coagulase-negative staphylococci (8.3%). Risk
factors were diabetes, and use of sirolimus (137). In another study, risk factors for SSI in KT
recipients included reoperation, chronic glomerulonephritis, acute graft rejection, delayed
graft function, diabetes, and high body mass index (138). SSI requires rapid debridement and
effective antimicrobial therapy and should prompt the exclusion of adjacent cavities or organ
involvement. Liver transplant recipients are at risk for portal vein thrombosis, hepatic vein
occlusion, hepatic artery thrombosis, and biliary stricture formation and leaks. Heart
transplant recipients are at risk for mediastinitis and infection at the aortic suture line, with
resultant mycotic aneurysm, and lung transplantation recipients are at risk for disruption of
the bronchial anastomosis. In intestinal transplant recipients, abdominal wall closure with
mesh should be avoided because of the high rate of infectious complications (139).
Intra-abdominal Infection
In OLT recipients intra-abdominal infections may be responsible for 50% of bacterial
complications and cause significant morbidity (140); they include intra-abdominal abscesses,
biliary tree infections, and peritonitis (141). In nonabdominal transplantations, intra-abdominal
infections may be caused by preexisting problems such as biliary tract litiasis, diverticulitis,
CMV disease, etc.
Risk factors for intra-abdominal complications after OLT include prolonged duration of
surgery, transfusion of large volumes of blood products, use of a choledochojejunostomy
(Roux-en-Y) instead of a choledochostomy (duct-to-duct) for biliary anastomosis, repeat
abdominal surgery, biliary-tract dehiscence or obstruction, intra-abdominal hematomas,
vascular problems of the allograft (e.g., the thrombosis of the hepatic artery or the ischemia
of the biliary tract may condition the apparition of cholangitis and liver abscesses), previous
antibiotic administration, and CMV infection (142). Occasionally, the complications will appear
after the performance of some procedure such as a liver biopsy or a cholangiography. These
infections may be bacteremic and, in fact, OLT recipients show the highest rate of secondary
bloodstream infections (143). Most common microorganisms includeEnterobacteriaceaebacilli,
enterococci, anaerobes, andCandida.
In a series published by Singh et al., the biliary tree was the origin of 9% of infections
associated with fever in the ICU (9). Biliary anastomosis leaks may result in peritonitis or
perihepatic collections, cholangitis, or liver abscesses (144–146). OLT recipients are especially
predisposed to suffer cholangitis. Recent data suggest that duct-to-duct biliary anastomosis
stented with a T tube tends to be associated with more postoperative complications (147). A
percutaneous aspirate with culture of the fluid is required to confirm infection. Culture of
T tube is unreliable, since it may only reflect colonization.
Infections in Organ Transplants in Critical Care 397