| Since Starzl successfully operated the first human liver transplantation in the world in 1963, the liver transplantation has underwent nearly 50 years' development, and became the most effective treatment for patients of last stage liver diseases and the acute liver function failure. But pulmonary complications and bacterial infection are still one of the most important causes of death following the post-operative period in the liver transplantation, Domestic and foreign reports that pulmonary complications after liver transplantation was 40%～60%, the incidence of bacterial infection as high as 36%～80% and mortality by 30%～70%, which are higher than that of acute rejection, kidney failure and blood vessels, biliary tract complications. Factors of pulmonary complications after liver transplantation are complicated, which affect the possibility of pulmonary complications including preoperative, intraoperative and postoperative factors, severe pulmonary complications seriously affect postoperative recovery and survival time-Bacterial infection after liver transplantation is an important and complex issue, which is one of the major that is the postoperative recovery, graft dysfunction and loss of function. As reported as that the vast majority of death after liver transplantation associates with what infections and complications caused by infection, in particular, especially in refractory multiple bacterial infection. With pulmonary complications and bacterial infections of the growing awareness for pulmonary complications after liver transplantation, risk factors of bacterial infection and drug resistance characteristics are valued, complications after liver transplantation has become an important research subject. Through research in August 2004～December 2009 Nanfang Hospital, Southern Medical University study of 163 cases, according to the center of experience and a review of relevant literatures choose a variety of perioperative liver transplantation in a comprehensive analysis of the relevant factors and in order to find the risk factors and pulmonary complications, analyzing bacterial infection after liver transplantation characteristics and prevalence of bacterial resistance, which is more effective for clinical prevention and treatment provide a theoretical basis.Part one Analysis of risk factors for pulmonary complications during the early postoperative period in liver transplantation[OBJECTIVE] Pulmonary complications after liver transplantation is one of the main reasons that is the early impact of the early survival rate of patients after liver transplantation, complications in patients with multiple risk factors, such as multiple organ dysfunction, immune dysfunction, hypoalbuminemia, previous lung disease, intraoperative massive blood transfusion, postoperative ICU routine care and treatment of patients after a lot of fluid replacement. The mainly targeted of liver transplant patients is the end-stage liver disease, such as primary liver cancer, the hepatitis of cirrhosis, liver failure, liver metabolic diseases, congenital, etal. Receptor preoperative is general condition and poor nutritional status. Liver transplant for a long time, trauma, and postoperative immunosuppressive therapy and after a longer period of intravenous fluid treatment have the specificity. In view of perioperative liver transplantation and liver transplantation inherent particularity, it is necessary that pulmonary infection in a variety of causes related factors is to find out the main risk factors from liver transplantation of preoperative, intraoperative and postoperative, providing a theoretical basis for prevention of pulmonary complications in perioperative. The author collected the August 2004～October 2009 implementation of Nanfang Hospital, Southern Medical University, 153 orthotopic liver transplants which were analyzed retrospectively the clinical data to find early postoperative risk factors for pulmonary complications, and to propose preventive measures.[METHODS]1. Clinical data A total of 154 cases in this group,134 patients were male and 20 female. The average age are (48.5±8.7) years with an average length of stay (54.9±5.6) d, the average ICU (intensive care unit, ICU), and observing time (3.8±1.7) d. One of the primary disease, including 43 cases of liver cirrhosis, primary liver cancer in 92 patients,17 cases of severe hepatitis,1 case of Budd-Chiari syndrome, liver degeneration in 1 case. After liver transplantation is based on pulmonary complications which were divided into complications groups and control groups.2. Surgery program and immunosuppressive regimen Classic 98 cases,56 cases of piggyback. Immunosuppressive program:After routine use of triple anti-rejection treatment:Tacrolimus 1.5～2.5 mg 2 times a day,Mycophenolate mofetil dispersible tablets 180～360 mg 2 times a day, Methylprednisolone sodium succinate 160-20-80-40-20mg daily reduced,After 5 d to tacrolimus 1.0～2.5 mg 2 times a day, Mycophenolate mofetil dispersible tablets 180～360 mg 2 times a day, Prednisone tablets 10～20 mg day 1,FK506 plasma concentration was maintained at 8～12 ng/mL. Acute rejection in patients are given high-dose methylprednisolone pulse therapy and increase the long anti-rejection drug tacrolimus, mycophenolate mofetil dosage. And infection control are not ideal, reduce or disable the anti-rejection drugs.3,The choice of relevant factors According to the Center of experience and references which are comprehensive selection of 22 statistical analysis of related factors.①,Preoperative factors:Sex, age, smoking history, hepatopulmonary syndrome, and other lung diseases (such as lung inflammation and infection, chronic obstructive pulmonary disease, bronchial asthma, etc.), hypoalbuminemia, liver function Child-Pugh class C rating, Diabetes mellitus, preoperative Hb/(g·L-1), preoperative Hct/%.②,Intraoperative factors:Liver warm ischemia time, cold ischemia time, operation time, anhepatic phase, blood loss, total intraoperative blood transfusions, the amount of intraoperative transfusion of red blood cells, the amount of intraoperative transfusion.③,Postoperative factors:Intensive care unit (ICU) observation with time, invasive mechanical ventilation time, postoperative at least 2d before 3d rehydration fluid balance≤-500 mL, after at least 1d before the 3d rehydration fluid balance≤-500 mL/cases etc.4,Statistical analysisMeeting the diagnostic criteria of cases are classified as pulmonary complications group, the remaining cases classified as the control groupFirst, a major independent risk variables of the perioperative liver transplantation is analyzed in univariate (which count data were compared withχ2 test, measurement data compared using independent sample t test), Comparing the differences between pulmonary complications group and the control group, Find out the initial risk factors for pulmonary complications. Given the existence of certain factors can interact, having a statistically significant risk factors which included in Logistic regression analysis to identify the main risk factors-SPSS13.0 statistical software used byα=0.05 significance level, P<0.05 was considered statistically significant.[RESULTS]1. Univariate analysis of the relevant factors The 22 liver transplantation-related factors which affect the pulmonary complications were analyzed, Such as preoperative liver function Child-Pugh class C rating, intraoperative RBC>10u, infusion volume> 10 L, low albumin, transfusion of blood products> 4L, ICU observing time≥5 d, invasive ventilation ventilation≥48 h, after 3 d before the infusion fluid balance at least 1 d≤-500 mL, after 3 d before the infusion fluid balance at least 2 d≤-500 mL, the 9 factors associated with the presence of pulmonary complications.2. Multivariate analysis of risk factors The nine factor which are statistical significance were include into Logistic regression analysis, then final selecting factors which affects the early pulmonary complications. According to the risk factors as followed:hypoproteinemia, transfusion of blood products> 4L, ICU observing time≥5d, after at least 2d before 3d rehydration fluid balance≤-500ml, induced into Logistic regression equation.3. The connection between infection and risk factors 98 cases,85 patients were cured,13 patients died, mortality was 13.26%, which is directly related with the pulmonary complications in 10 cases, mortality was 10.20%,10 patients, preoperative liver failure with hypoalbuminemia in 8 cases, transfusion of blood products more than 11 cases, negative fluid balance after rehydration in 1 case, invasive mechanical ventilation were more than 48h, observation room in the ICU more than 4 days in 9 cases.[CONCLUSION]l.Preoperative liver function Child-Pugh class C rating, intraoperative RBC> 10u, fluid volume> 10 L, low albumin, transfusion of blood products> 4L, ICU observing time≥5 d, invasive mechanical ventilation ventilation≥48 h, after 3 d before the infusion fluid balance at least 1 d≤-500 mL, after 3 d before the infusion fluid balance at least 2 d≤-500 mL and other nine are pulmonary complications after liver transplantation related factors. Including hypoproteinemia, transfusion of blood products> 4L, ICU observing time≥5d, after rehydration at least 2d before 3d≤-500ml fluid balance after liver transplantation are the major risk factors for pulmonary complications.2.We should take effective preventive and treatment measures In response to these risk factors, strengthen high-risk patients in monitoring in early postoperative, and strive to early detection and timely treatment of pulmonary complications. The above measures can help to reduce the incidence of postoperative pulmonary complications and improve the success rate of surgery.Part Two Analysis of epidemiology and drug resistance of bacterial infection during the early postoperative period in liver transplantation[OBJECTIVE] Bacterial infection after liver transplantation is still the success rate of liver transplantation and an important complication of postoperative survival, with the change of spectrum of bacteria and drug abuse, domestic and international coverage of the bacterial infection after liver transplantation gradual is increasing gradually, bacterial spectrum of bacterial infection, some changes have taken place, resistance rates became more complex gradually. We are from August 2004 to December 2009 in force in 163 cases of liver transplantation in patients with bacterial infections,by identifing bacterial culture and analyzing sensitivity test characteristics of bacterial infections, to more effective prevention and treatment of bacterial infections.[METHODS]1.Clinical data In August 2004 to December 2009 in our hospital 163 cases of liver transplant patients are used as the research object, after a regular basis (2 to 3 times/week) to collect specimens to send bacterial smears. Specimens of species included:Respiratory specimens (sputum, throat swab), abdominal effusion, bile, urine, blood, deep vein puncture tube and other clinical specimens. Corresponding local and systemic signs of infection, Or the corresponding parts of two or more than two consecutive samples can be judged for the same strain of bacteria (excluding pollution and normal flora), smear test results were repeatedly positive specimens which were sent to collect the appropriate bacterial culture and sensitivity test.2.Bacteria identification and susceptibility testing Bacteria is isolated in accordance with the "National Clinical Laboratory Procedures", Ring vaccination after the separation of samples is according to routine immunization in the diameter of gcm in the MH (Muller a Hinton) agar plate (Trade Co., Jiangmen City, Kaelin public property). Required at 35℃incubator (U.S. SHELAB company) is incubated for 18 to 24 hours, A number of typical colonies were picked with sterile saline according to turbidity meter (U.S. BD company) identification of selected bacterial cultures stressed the company's U.S. BD PHOENIX-100 automatic analyzer of bacteria, Criteria and the interpretation of results with reference to the Committee for Clinical Laboratory Standards (CLSI) 2007 Designation of the standards of specified standards. 3.With reference to Ministry of Health in 2001 "issued by the diagnostic criteria of nosocomial infection (Trial)" and related literature, provides the following diagnostic criteria.①Patients have fever, cough, diarrhea, abdominal pain, nausea, vomiting, frequent urination, urgency, dysuria and other systemic or local infection of the clinical manifestations, and complications can not be explained by other.②More than 1 pathogen is isolated from samples which are from sterile sites (blood, urine cleaning, bile, pleural effusion peritoneal drainage fluid, venous catheter, etc.).③There are bacteria from the same part of the specimens which are cultured for pathogens, When necessary, the imaging, surgery or pathological examination are confirmed,2 for 2 times or more than 1 species of the same pathogen is cultured, The same or different parts of one kind of bacteria is isolated.④Bacterial colonization or bacterial infection of the skin areas is not included in statistics.4.GroupThat meets the diagnostic criteria of cases which are classified as bacterial infection, the remaining cases classified as the control group.5.Statistical analysisCalculated frequency and percentage by using statistical software SPSS13.0.[RESULTS]1.86 patients with suspected bacterial infection and clinical data of patients diagnosed. According to the diagnostic criteria,86 patients were diagnosed as bacterial infection, infection rate was 52.7%,72 patients were male and 14 female. The average age of 54.3 (32～74) years and average length of stay 71.4 (33～193)d. Primary disease, including 41 cases of liver cirrhosis (3 cases of acute liver failure),38 cases of primary liver cancer (pathological classification:which 37 cases with hepatocellular liver cancer,1 case with bile duct cells in liver cancer),7 cases of severe hepatitis. After 86 patients were routinely treated with triple anti-rejectio (TacrolimusFK506), mycophenolate mofetil, methylprednisolone sodium succinate; 5d later changed to FK506, mycophenolate mofetil, strong pine chip), FK506 plasma concentration was maintained at 8～12ng/ml.2.The type and site of pathogen infection 163 patients underwent liver transplant patients, there were 86 patients which were complicated by bacterial infection, and a total of 166 strains were isolated. Bacterial infection in G-78 (46.2%), G+64 strains (39.3%),24 strains of fungi (14.5%), Bacterial infections were as follows:Bowman Acinetobacter, Staphylococcus haemolyticus, Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus, Staphylococcus epidermidis, feces field bacteria, Enterococcus faecalis, Stenotrophomonas oligotrophicAeromonas dairy Huang hen enterococci, The site of the main respiratory tract infection, followed by blood, night, urine, bile, puncture fluid and equipment.3.Time distribution of bacterial infection The average time for infection were 13.6 (1～52) d,98.8% of which occurred one month later, Time distribution of bacterial infection were analyzed, which were found after 1 week,2 weeks,3 weeks,4 weeks and 5 weeks, and detected 73,63,20,8,2. The rate of detection is the highest after the first or second week, with time, the rate is decline.4.Antimicrobial susceptibility test results G-bacteria is higher resistance on the second and third generation cephalosporins and quinoline Well ketones, and sensitive on carbapenems andβ-lactamase inhibitor compound. G+ bacteria is sensitive on amino glycopeptide (vancomycin, teicoplanin) and oxazolidinone (linezolid).5.Treatment and prognosis 86 cases of bacterial infection were receiving antibiotic therapy, Suspected patients, the results of bacterial culture and sensitivity results return, when the position is not taken according to empirical treatment, Penicillins and cephalosporins were adjusted after the drug susceptibility of results returning, and the treatment is administered in sufficient quantities.86 cases, 69 patients were cured, 17 patients died, mortality was 19.7%, Which is directly related to infection with the pathogen in 10 cases, mortality was 11.6%, There were 5 cases of patients Bowman Acinetobacter infection,3 cases of enterococcal infections,2 cases with the Bowman Acinetobacter and Stenotrophomonas oligotrophic single cell bacteria, Staphylococcus in 10 deaths. The direct cause of deathis is in 2 cases of GVHD, 4 cases because of complications of biliary and vascular death,1 patient died of lung hemorrhage.[CONCLUSION]1. Bacterial infection after liver transplantation were as follows:Bowman Acinetobacter, Staphylococcus haemolyticus, Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus, Staphylococcus epidermidis, feces field bacteria, Enterococcus faecalis, Stenotrophomonas oligotrophic Aeromonas, dairy Huang hen enterococci, G-bacteria is more than G+bacteria.2. The main position is respiratory tract infection (68.2%) and blood the night (9.6%), there is 98.8% occurring one month later, Time distribution of bacterial infection was analyzed,which was found after 1 week,2 weeks mainly,As the operation time on,the incidence of bacterial infections was decreased,Tips for the susceptibility of liver transplant patients (within 1 month after surgery,especially in 2 weeks) should strengthen the respiratory tract,blood and other vulnerable parts of the monitoring of bacterial infection, Strive for early detection and timely treatment of bacterial infections.3. Antimicrobial susceptibility test results of this study show: Carbapenems, inhibitor class of antibiotics aminoglycosides and oxazolidinone respectively are highly sensitive on G+ bacteria and G- bacteria. As antibiotics are widely used in liver transplantation prophylactic and empirical treatment, new drug-resistant strains of bacteria appear, and the continual emergence of multi-resistant bacteria are increased gradually.4.Anti-bacterial therapy should be combined with the types of pathogens, drug resistance properties of the drug of choice and so on reasonable. Confirmed infected patients should be selected based on susceptibility results of sensitive drugs, according to adequate, with a course of antibiotic treatment.5.Different resistance mechanisms in different bacteria, and the chosen is according to changes in bacterial resistance to various antibiotics. |
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