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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