A frequent dilemma is discerning the likelihood of pneumonia in critically ill liver transplant recipients with pulmonary infiltrates. Of 90 consecutive liver transplant patients in the ICU over a 3 year period, 44% (40) developed pulmonary infiltrates. The etiologies were pneumonia (38%, 15/40), pulmonary edema (40%, 16/40), atelectasis (10%, 4/40), ARDS (8%, 3/40), contusion (3%, 1/40), and unknown (3%, 1/40). Pneumonia was due to MRSA in 27% (4/15), P. aeruginosa in (27%, 4/15), invasive aspergillosis in (20%, 3/15), and E. cloacae, Serratia marcesens and PCP in (7%, 1115) each. None of the patients had CMV or HSV pneumonia. 75% of MRSA and all Aspergillus pneumonias, but only 14% of the Gram negative pneumonias occurred within 30 days of transplantation. 27% of the pneumonias occurred >365 days post transplant; all of these were in patients with recurrent viral HBV or HCV, disseminated PTLD or late rejection. Of patients with pneumonia, 87% were ventilated and 40% had bacteremia. Clinical pulmonary infection score >6 (Pugin et al., Am Rev Resp Dis 1991) (73% vs. 6%, p =.0001), abnormal temperature (73% vs 28%, p=.005), and creatinine >1.5 mg/dl (80% vs 50%, p = .05) were predictors of pneumonia vs other etiologies of pulmonary infiltrates. Mortality in patients with pneumonia was 47%; worse APACHE neurological score, but not total APACHE II score (p=.04), leukocytosis (p=.05), higher BUN (p=.06), and higher alanine aminotransferase (p=.04) were significant predictors of mortality in patients with pneumonia.These data have implications not only for identifying pneumonia as potential cause of pulmonary infiltrates, but the likely etiology of pneumonia, and thus selection of empiric antibiotic therapy in critically ill liver transplant recipients. Pugin score >6 in patients with pulmonary infiltrates warrants antimicrobial therapy. Early onset, within 30 days, raises the spectre of aspergillosis.
Full conference title:
38th Interscience Conference on Antimicrobial Agents and Chemotherapy
- ICAAC 38th