INFECTIONS IN THE FIRST YEAR AFTER LIVER TRANSPLANT IN PAEDIATRICS AT WDGMC Mary Duncan Transplant coordinator
INFECTIONS IN THE FIRST YEAR
AFTER LIVER TRANSPLANT IN PAEDIATRICS AT WDGMC
Mary Duncan
Transplant coordinator
About the study
• Infection rates and causative agents
• Paediatric liver and liver/kidney transplants
• 65 children with 69 transplants
• 2005 to 2014 with 1 yr follow up
• Ethics approval from Wits HREC (M160257)
Presentation
• Results from this study
• Compare these to international findings
• Improve clinical practice
Results: Demographics
Category Paediatric recipients (n=69) (%)
Gender male 27 (39)
female 42 (61)
Population group
black 35 (51)
white 24 (35)
indian 5 (7)
mixed 4 (6)
asian 1 (1)
Sector private 63 (91)
public 6 (9)
Median age at
transplant 49 months (IQR 27 – 152m)
Results: Recipient age
Results: Recipient weight
The median weight at transplant was 13.9 kg (IQR 9.4-28.0 kg; range 5-82 kg)
28.0% of the recipients weighed <10 kg
Results: Transplants
Category Paediatric recipients (n=69) (%)
Cause of liver
failure acute 4 (6)
chronic 65 (94)
Transplant
numbers 1 65 (94)
2 4 (6)
Transplanted
organs liver only 62 (90)
CKL 7 (10)
Donor type deceased 53 (77)
living 16 (23)
1. Metabolic: Wilsons (2), MSUD (1), oxalosis (4), alpha 1 antitrypsin (4) 2. Genetic: PCKD (3), cystic fibrosis (1) 3. Malignancy: HCC (1), Hepatoblastoma (2) 4. Other: Atypical haemolytic ureamic syndrome (1), cholestatic cirrhosis
Results: Aetiology of Chronic ESLD
0 5 10 15 20 25 30 35 40 45
biliary atresia
metabolic
auto-immune disease
genetic
budd chiari / vod
malignancy
chronic allograft rejection
alagille syndrome
cryptogenic
other
1
2
3
4
Data • All children who presented clinically with signs and
symptoms of infection in the first year
• 245 infectious events in 65 children
• Many of which were polymicrobial
• 253 were lab confirmed infections – 3.9/child
• Majority were found in blood (91), urine (38) and abdomen (38)
• Majority occurred in first 6months
Results: Lab Confirmed Infections
76.3%
16.6%
7.1%
Bacterial Viral Fungal / yeast
0
50
100
150
200
250
Nu
mb
er
of in
fectio
ns
Bacterial Infections
62.2%
37.3%
0.5%
Gram negative Gram positive Mycobacteria
0
20
40
60
80
100
120
140
Num
ber
of in
fections
Gram Positive Infections: n = 72
0
5
10
15
20
25
30
Num
ber
of in
fections 38%
34%
Gram Negative Infections: n = 120
0
10
20
30
40
50
6041.7%
20.8%
11.7% 10%
Nu
mb
er
of in
fectio
ns
Viral Infections: n = 42
02468
101214161820
42.9%
16.7%
9.5%
No
of In
fectio
ns
Fungal/Yeast Infections: n = 18
0
1
2
3
4
5
6
7
8
9
candidaparapsilosis
candida albicans candidadubliniensis
unidentifiedyeasts
38.9%
11.1%
5.6%
44.4%
Nu
mb
er
of in
fectio
ns
Blood Based Infections
Category Site of specimen - blood (n=91)
n %
Bacterial 54 59.3
Viral 31 34.1
Fungus/yeast 6 6.6
Gram positive 24 44.4
Gram negative 30 55.6
Antimicrobial resistance
Total number of resistant organisms
n = 49 (%)
Bacterial 48/49 (98%)
Gram positive
Gram negative
Mycobacteria (mycobacterium tubercolosis)
11/48 (22,9%)
36/48 (75,0%)
1/48 (2,1%)
Fungi/yeast (candida parapsilosis) 1/49 (2,0%)
Summary
• Findings
• Relation to international trends
• Patient survival: 90 days 83% (71 – 90% CI)
1 year 78% (67 – 86% CI)
• Implications for clinical practice
References • Vermer A, Wade JJ, Cheeseman P et al. Risk factors for fungal infection in
paediatric liver transplant recipients. Paediatric Transplantation, 2005: 9, 220 – 225
• Ashkenazi-Hoffnung L, Moser-Glassberg Y, Bilavsky E et al. Children post liver transplantation hospitalised with fever are at a high risk for bacterial infections. Transplant Infectious Diseases, 2016: 18, 333 – 340
• Garcia S, roque J, Ruza F et al. Infection and associated risk factors in the immediate postoperative period of paediatric liver transplantation: A study of 176 transplants. Clinical Transplantation, 1998: 12, 190 – 197
• George DL, Arnow PM, Fox A et al. Patterns of Infection after Paediatric Liver Transplantation. American Journal of Diseases of Children, 1992: 146, 924 – 929
• Green M. Introduction: Infections in Solid Organ Transplanation. American Journal of Transplantation, 2013: 13, 3 – 8
• Green M, Michaels M. Infections in Paediatric Solid Organ Transplant Recipients. Journal of the Pediatric Infectious Diseases Society, 2012: 1 (2), 144 – 151
• Allen U. Minimizing Infection risks after paediatric Organ Transplants: Advice for practitioners. Paediatric Child Health, 2013: 18 (3), 143 - 148
Thank you
• Anne de Voll - Zabrocki
• WDGMC
• Medical students – Chanceplant
• Redcap for data capture
• Biomedical statistician Petra Gaylard
• Colleagues, Doctors
Antimicrobial resistance
0
2
4
6
Number of infections
Reasons for Mortality
0
1
2
3
4
5
6
7
8
9
Number of Deaths
Enterovirus
Candida parapsilosis Candida albicans
Klebsiella sp
Enterococcus faecium
Blood – 33.9%
Urine – 15.5%
Abdominal collections – 15.5%
Sputum – 18%
Pus Swabs – 5.3%
Stool – 4.1%
IV lines – 2.9%
1 2
8 7
10
1 1
4
15
20
0
5
10
15
20
25
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Growth