肺移植受者30例术后早期感染诊疗分析

目的总结和分析肺移植受者术后早期感染特点及预后。 方法回顾性分析河南省人民医院肺移植科2015年10月至2018年1月实施的30例肺移植受者临床资料。供肺来自于27例心脏死亡器官捐献供者。30例受者中双肺移植2例，单肺移植28例。受者术中予亚胺培南西司他丁，术后联合应用亚胺培南西司他丁＋卡泊芬净＋更昔洛韦预防感染。术后免疫抑制方案为他克莫司＋吗替麦考酚酯＋泼尼松。住院期间对受者常规行胸部X线或胸部CT、支气管镜检查和病原学监测等；术后3个月内每1至2周门诊随访1次。 结果2例供者气道分泌物培养阳性，1例考虑为非结核分枝杆菌感染。术后30 d内，22例受者共发生24例次细菌感染(呼吸系统感染21例次，血流感染3例次)，感染发生率为73.3%(22/30)。呼吸系统感染包括单纯气道感染9例次，气道感染合并侵袭性肺部感染9例次，胸腔感染3例次。呼吸系统感染中16例次为单一病原体感染，5例次为2种及以上病原体混合感染。呼吸系统感染共分离出病原体26株：鲍曼不动杆菌10株(8株为泛耐药)，耐碳氢酶烯类肺炎克雷伯杆菌5株，铜绿假单胞菌3株(2株为泛耐药)，泛耐药嗜麦芽窄食单胞菌和泛耐药纹带棒杆菌各2株，黏质沙雷菌、阴沟肠杆菌、耐甲氧西林金黄色葡萄球菌和非结核分枝杆菌各1株。血流感染包括耐碳氢酶烯类肺炎克雷伯杆菌2例次和脑膜炎黄杆菌1例次。21例次呼吸系统细菌感染中考虑合并真菌感染3例次。10例鲍曼不动杆菌感染受者经治疗后，7例感染控制，其余3例分别于肺移植术后第40、45和60天死亡。5例耐碳氢酶烯类肺炎克雷伯杆菌感染受者抗感染治疗后，4例感染控制，1例于肺移植术后第50天死亡。随访至2019年7月，9例受者死亡，其余受者均可进行日常活动。 结论肺移植术后早期感染以气道感染和移植肺侵袭性感染多见，感染病原体以泛耐药或多耐药的革兰阴性杆菌为主。

Clinical analysis of the diagnosis and treatment of early infection after lung transplantation in a series of 30 cases

ObjectiveTo summarize and analyze the clinical characteristics and prognosis of early infection after lung transplantation. MethodsA retrospective analysis of the clinical data of 30 lung transplant recipients from October 2015 to January 2018 in the Department of Lung Transplant of Henan Provincial People′s Hospital was conducted. The donor lungs were harvested from 27 donors (donation after cardiac death). Among the 30 lung transplant recipients, 2 had double-lung transplant and 28 had single-lung transplant. The recipients were given imipenem and cilastatin during transplantation, and imipenem and cilastatin, caspofungin, ganciclovir were used to prevent infection after transplantation. The postoperative immunosuppressive regimen inclued tacrolimus, mycophenolate mofetil and prednisone. During the hospitalization period, the recipients had routine chest X-ray or chest CT, bronchoscopy and pathogenic monitoring and so on. The recipients were follow-up every 1 to 2 weeks within 3 months after transplantation. ResultsTwo donor lungs had positive outcomes of airway secretions microbiology test, 1 was considered to be infected by nontuberculous mycobacteria. Within 30 days after transplantation, the incidence of infection was 73.3% (22/30), 22 recipients had 24 cases of bacterial infection (21 cases of respiratory system infection and 3 cases of bloodstream infection). Respiratory system infection included 9 cases of airway infection, 9 cases of airway infection combined with invasive lung infection, and 3 cases of pleural cavity infection. Among respiratory system infection, 16 cases were caused by single pathogen and 5 were caused by multiple pathogens. A total of 26 strains of pathogens were isolated from respiratory system infection: 10 strains of Acinetobacter baumanii (8 strains were pan-resistant), 5 strains of carbapenem-resistant Klebsiella pneumoniae, and 3 strains of Pseudomonas aeruginosa (2 strains were Pan-resistant), 2 strains of pan-resistant Stenotrophomonas maltophilia, 2 strains of pan-resistant Corynebacterium striatum, and 1 each of Serratia marcescens, Enterobacter cloacae, methicillin resistant Staphylococcus aureus and Nontuberculous mycobacteria. Three cases of bloodstream infection were caused by carbapenem-resistant Klebsiella pneumoniae (2 cases) and Flavobacterium meningitidis (1 case). Among 21 cases of respiratory system bacterial infection, 3 cases of fungal infection were considered. Ten recipients infected with Acinetobacter baumanii were treated with anti-microbial treatments, the infection was controlled in 7 recipients; the remaining 3 recipients died on the 40th, 45th and 60th day after transplantation. After anti-microbial treatments, 4 in 5 recipients infected with carbapenem-resistant Klebsiella pneumoniae were controlled, and 1 died on the 50th day after transplantation. Follow-up as of July 2019, 9 recipients died, the sruvivers have normal daily life. ConclusionsThe most common infections in the early period after lung transplantation were airway infection and invasive infection. The most common pathogens were pan-resistant or multi-resistant gram negative bacilli.