Infection with Klebsiella pneumoniae carbapenemase (KPC)‐producing K. pneumoniae in solid organ transplantation

Abstract

Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae is spreading globally and represents a challenge in infection control and treatment. Solid organ transplant (SOT) recipients are especially at risk for infection by multidrug-resistant bacteria, and little is known about infection with KPC-producing organisms in this setting. The aim of this study was to describe the clinical and microbiologic aspects of KPC-producing K. pneumoniae infections in SOT recipients. A KPC-2-producing K. pneumoniae outbreak was identified in a public teaching tertiary care hospital in São Paulo, Brazil, in June 2009. During the outbreak, cases of KPC-2-producing K. pneumoniae infection in SOT recipients occurred between July 2009 and February 2010; these cases were retrospectively reviewed. Overall, 12 episodes of infection with KPC-producing K. pneumoniae occurred in 2 heart, 4 liver, and 6 kidney transplant recipients with incidence rates of 16.7%, 12.9%, and 26.3% in heart, liver, and kidney transplantation, respectively. Infection occurred at a median time of 20 days after transplantation. Primary infection sites were as follows: 4 urinary tract infections, 4 bloodstream infections, 2 pneumonias, and 2 surgical site infections. All patients except one had received antibiotics in the last 30 days, mostly piperacillin-tazobactam or glycopeptides. All strains exhibited susceptibility to amikacin and gentamicin. Patients were treated with tigecycline plus polymyxin B (3 cases), polymyxin B plus carbapenem (3 cases), polymyxin B alone (3 cases), or tigecycline plus imipenem (1 case). In 2 cases, patients received only carbapenem, and death occurred before the final culture result. The overall 30-day mortality rate was 42%. In this series of KPC-producing K. pneumoniae infection in SOT recipients, the infection occurrence was high during an institutional outbreak and was potentially life threatening.

Study of the risk factors related to acquisition of urinary tract infections in patients submitted to renal transplant

“…(25) . Other authors have identifi ed 26.3% of UTIs to be caused by K. pneumoniae carbapenemase-producing strains in renal transplant patients (26) . One study performed in an Italian teaching hospital over 7 months demonstrated an increase in multi-resistant bacteria strains; in the samples that showed K. pneumoniae, the urinary tract was the most frequent infection site (27) .…”

Carbapenem-resistant Enterobacteriaceae in special populations: Solid organ transplant recipients, stem cell transplant recipients, and patients with hematologic malignancies

“…Reported mortality rates among SOT recipients with CRE infection generally range from 30-50%, and post-transplant CRKP infections have been associated with as much as a 10-fold risk of death. [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] However, a more recent cohort of 164 SOT recipients across 15 international sites confirmed that while CRE infection typically occurs in the early post-transplant period, the one-year survival rate of patients who developed CRE infection within the first year of transplant was 72%. 34 While CRKP infections remain the most common type of CRE infection in SOT recipients, infections due to carbapenem-resistant Enterobacter spp., as well as NDM-and OXA-48-producing K. pneumoniae have also been reported.…”

“…19 The incidence of post-SOT CRKP infection varies considerably by center and type of transplant (Table 1). [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] In general, CRKP infections occur early after transplant, with most studies reporting a median time of <50 days from transplant to infection. Reported mortality rates among SOT recipients with CRE infection generally range from 30-50%, and post-transplant CRKP infections have been associated with as much as a 10-fold risk of death.…”

“…Centers from New York City and Italy have reported that 6-9% of liver transplant recipients develop CRE infection. 20,23,24,39 In this group, surgical site and intraabdominal infections are common, and a high proportion of cases involve bacteremia. 23,24 Necrotizing soft The study evaluated episodes of CRE bacteremia only c The study evaluated episodes of CRE bacteriuria only tissue infections have also been described.…”

Lessons learned from excess mortality associated withKlebsiella pneumoniaecarbapenemase 2-producingk. pneumoniaein liver transplant recipients

“…7 The limited amount of clinical data currently prevents definite conclusions on the eligibility of patients with end-stage liver disease and persistent CRKP carriage for transplantation. 10 Nevertheless, we propose that specifically in a CRKP outbreak situation (which implies a high risk of progression to fatal infection), these patients should not be considered for LT. 3 Thilo Busch, Ph.D. 3 Joachim M€ ossner, M.D., Ph.D. 4 Michael Bartels, M.D., Ph.D. 5 Udo X. Kaisers, M.D., Ph. The data are presented as means and standard deviations.…”