Infected bilomas in liver transplant recipients: Clinical features, optimal management, and risk factors for mortality
ABSTRACT Infected hepatic fluid collections (bilomas) are a major infectious complication of liver transplantation. Limited data exist on management and outcome of biloma.
We report a cohort study of 57 liver transplant recipients with posttransplantation bilomas undertaken to identify the clinical features of biloma, management strategies, and outcome.
Fever (44%) and abdominal pain (40%) were the most common presenting symptoms, but one-third of patients were asymptomatic; 79% had elevated hepatic enzyme levels. Patients without hepatic artery thrombosis (HAT) had the highest rates of resolution with percutaneous drainage and anti-infective therapy (64%). Retransplantation was necessary in 64% of patients with HAT and biloma. Independent predictors of resolution with nonsurgical therapy were absence of HAT (odds ratio [OR] 7.69; P=.01) and absence of Candida (OR, 9.09; P=.02) or enterococcal infection (OR, 7.69; P=.03). Patients with bilomas had significantly greater mortality (Cox proportional hazard ratio [HR], 2.38; P=.008, by log rank test) and graft loss (HR, 4.31; P<.0001). Predictors of mortality by multivariable analysis included renal insufficiency (OR, 12.51; P=.02) or infection with Candida species (OR, 4.93; P=.03) or gram-negative bacilli (OR, 9.12; P=.01).
Posttransplantation biloma should be suspected in patients with fever or abdominal pain or abnormalities of hepatic enzymes, and it can be confirmed by computerized tomography and radiographically guided aspiration. Bilomas are most likely to be successfully treated nonsurgically in patients without HAT and without Candida or enterococcus infection.
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ABSTRACT: Bacteria are the leading cause of infections after solid organ transplantation. In the recent years, a progressive growth in the incidence of multi-drug resistant (MDR) and extensively-drug reistant (XDR) strains has been observed. While methicillin-resistant S. aureus (MRSA) infection is declining in non-transplant and SOT patients worldwide, vancomycin-resistant enterococci, MDR/XDR Enterobacteriaceae and MDR/XDR non-fermenters are progressively growing as a cause of infection is solid organ transplant (SOT) patients and represent a global threat. Some SOT patients develop recurrent infections, related to anatomical defects in many cases, which are difficult-to-treat and predispose to the acquisition of MDR pathogens. As the antibiotics active against MDR bacteria have several limitations for its use, which include less clinical experience, higher incidence of adverse effects, less knowledge of the pharmacokinetics of the drug and, in most cases, are only available for parenteral administration, it is mandatory to know deeply the main characteristics of these drugs to safely treat SOT patients with MDR bacterial infections. Nonetheless, preventive measures are the cornerstone to control the spread of these pathogens. Thus, applying the CDC's and ESCMID's recommended antibiotic policies and strategies to control the transmission of MDR strains in the hospital is essential for the management of SOT patients.This article is protected by copyright. All rights reserved.Clinical Microbiology and Infection 05/2014; DOI:10.1111/1469-0691.12687 · 5.20 Impact Factor
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ABSTRACT: Orthotopic liver transplantation is becoming an increasingly routine procedure for a variety of benign and malignant diseases of the liver and biliary system. Continued improvements in surgical techniques and post-transplantation immunosuppression regimens have resulted in better graft and patient survival. A number of potentially treatable nonvascular complications of liver transplantation are visible at imaging, and accurate diagnosis of these complications allows patients to benefit from potential treatment options. Biliary complications include stricture (anastomotic and nonanastomotic), leak, biloma formation, and development of intraductal stones. Pathologic conditions, including hepatitis C infection, hepatocellular carcinoma, hepatic steatosis, and primary sclerosing cholangitis, may recur after liver transplantation. Transplant patients are at increased risk for developing de novo malignancy, including post-transplantation lymphoproliferative disorder, which results from immunosuppression. Patients are also at increased risk for systemic infection from immunosuppression, and patients with hepatic artery and biliary complications are at increased risk for liver abscess. Transplant recipients are typically followed with serial liver function testing; abnormal serum liver function test results may be the first indication that there is a problem with the transplanted liver. Ultrasonography is typically the first imaging test performed to try to identify the cause of abnormal liver function test results. Computed tomography, magnetic resonance imaging, angiography, and/or cholangiography may be necessary for further evaluation. Accurately diagnosing nonvascular complications of liver transplantation that are visible at imaging is critically important for patients to benefit from appropriate treatment. (©)RSNA, 2015.Radiographics 01/2015; 35(1):87-104. DOI:10.1148/rg.351130023 · 2.73 Impact Factor
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ABSTRACT: The purpose of this study is to provide an overview of bacterial biliary tract infections in liver transplant recipients with a focus on pathogenesis and conservative treatment strategies. The development of interventional endoscopic and radiologic interventions has improved the outcome of conservative treatments for bile tract strictures and bilomas. However, recent data show an important rise of infections with multidrug-resistant (MDR) pathogens in liver transplant recipients. Both recurrent cholangitis and infected bilomas are bacterial biliary tract infections in liver transplant recipients responsible for significant morbidity and graft loss, which require a multidisciplinary approach. Risk factors for biliary tract strictures and bilomas formation have recently been identified. With the improved outcome of a conservative management including prolonged and/or recurrent antibiotic treatments, the risk of selecting resistant pathogens is increased. There is an urgent need to develop new strategies to reduce the risk of secondary infections by MDR isolates in liver transplant recipients.Current opinion in organ transplantation 04/2014; DOI:10.1097/MOT.0000000000000083 · 2.38 Impact Factor