Organ transplantation under necessary concurrent immunosuppression contains a high risk of contracting tuberculosis (TB), and reactivation of dormant TB has been regarded as a predominant mode of acquisition. 1 Living in high endemic area renders these high-risk individuals of getting TB from community and hence it is one of the causes of late-onset TB. Treatment of drug-resistant TB has a longer course as compared to drug-sensitive TB and there are more chances of failure. 2 Pulmonary TB is the frequent site of involvement but extra pulmonary TB is also not rare affecting 16% of cases. 3 Drug toxicity and drug interactions with immunosuppressive agents may result in inadequate immunosuppressive levels that can lead to graft failure. 4 The following is a case series of multidrug-resistant TB (MDR-TB). Transplant physicians and Infectious Diseases specialist managed the patients according to World Health Organization (WHO) guidelines with monthly follow-up of sputum culture and managed drug toxicities.

Background Carbapenem-resistant Gram-negative (CRGN) bacteraemia has high mortality and limited therapeutic options. We assessed the risk factors and outcome of CRGN bacteraemia treated with limited options. Methods A prospective cohort study done at a tertiary care hospital in Pakistan, from October 2021 to August 2022. All patients >18 years with CRGN bacteraemia were assessed for demographics, source, risk factors and treatment received. Outcome was assessed as bacterial clearance and all-cause mortality at Day 14 of bacteraemia. Results We included 175 patients. Median age was 45 years (IQR 30–58) and the majority of our patients were on haemodialysis (75%). We found 14 day mortality in 26.8% of our patients; in addition, microbiological clearance was achieved in 95%. The central line (49.7%) was the most common source and Klebsiella spp. (47%) the most common organism. On multivariate analysis, risk factors for mortality were Foley’s catheter [aOR 2.7 (95% CI 1.1–6.5)], mechanical ventilation [aOR 5.1 (95% CI 1.6–15.8)] and Pitt bacteraemia score >4 [aOR 3.48 (95% CI 1.1–10.5)]. Source control was a significant protective factor [aOR 0.251 (95% CI 0.09–0.6)]. The majority received a colistin-based regimen with no difference in mortality between monotherapy and combination therapy. Conclusions Our cohort of CRGN bacteraemia is unique, comprising younger patients mostly on haemodialysis with a central line as the source of bacteraemia and we have found 14 day mortality of 27%. Colistin with various combinations can be an effective option in patients with renal failure having prompt source control.

Introduction: Carbapenem are recommended for the treatment of Ceftriaxone (CRO) resistant Enterobacterales, however, there are concerns of cost and resistance. Our aim is to compare the outcome of CRO resistant E-coli and Klebsiella bacteremia between Carbapenem and Beta-lactam/beta-lactamase inhibitors (BL/BLI).Methods A prospective cohort study conducted from October 2021 to June 2022. All adult patients with E coli or Klebsiella spp. bacteremia, CRO resistant and sensitive to both BL/BLI and Carbapenem were included. The patients were divided into BL/BLI and Carbapenem groups. Demographics, clinical features, comorbidities, laboratory parameters and intensive care unit stay were compared. Outcomes were bacteriological clearance, clinical success and all-cause mortality at day 14 of bacteremia.Results A total of 156 patients, 93(59.6%) in BL/BLI and 63(40%) in Carbapenem group were included. There was no difference in co-morbidities, risk factors and severity of disease. The 14 day all-cause mortality was 14.1%. No statistically significant difference was found between BL/BLI and Carbapenem group regarding bacteriological clearance (p = 0.27) and mortality (p = 0.95). The Carbapenem group had less clinical success rate (69.8% vs 82.8%, p = 0.057), however not statistically significant.Conclusion BL/BLIs were as effective as Carbapenem in microbiological clearance, clinical success and mortality in CRO resistant E-coli and Klebsiella bacteremia.

Introduction: Whipple's disease (WD) is a rare multi-systemic disorder caused by actinomycetes, Tropheryma whipplei. It presents with weight loss, arthralgia, and diarrhea and may involve the heart, lung, or central nervous system. The use of immunosuppressive medications or underlying immunodeficiency states are associated risk factors. Six cases in transplant recipients have so far been reported worldwide. We describe our experience of WD in renal transplant recipients.Methods: All renal transplant recipients who presented with diarrhea and were diagnosed with WD on duodenal biopsy from 2016 till 2019 were included. Their data regarding duration since transplantation, immunosuppressive therapy, symptoms, treatment response, and outcome were analyzed.Results: Seven cases were diagnosed as WD based on duodenal biopsy, with histological findings of periodic acid Schiff-positive granules in macrophages. All were males. The most common symptoms were chronic diarrhea and weight loss. Average time since transplantation was 4.8 years. All patients were on azathioprine and everolimus. Clinical relapse or adverse effects was seen in five of seven patients treated with doxycycline and hydroxychloroquine which was discontinued. Trimethoprim/sulfamethoxazole for 1 year, with initial intravenous ceftriaxone in two patients, resulted in complete remission in all patients at a follow-up period averaging 1.5 years. Conclusion:WDs in renal transplant recipients most commonly presents as an intestinal disorder. Treatment of 1 year with trimethoprim/sulfamethoxazole has good response with complete remission at 1.5 years of follow up.

No abstract