肝移植术后感染影响因素的临床研究进展
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摘要
肝脏移植是终末期肝脏疾病治疗的重要手段。由于手术技术、免疫状态、化学放射治疗、宿主与移植物之间的同种免疫机制以及病房环境等因素,肝脏移植患者术后容易出现医院感染。近年来,除了对既往文献报道的传统感染诱发因素有了进一步研究之外,研究者发现,还有一些新的危险因素应在今后被予以关注。这些因素可分为:与术前相关的因素,如终末期肝病评分(MELD)>30、移植前不合理抗菌药物使用史和机械通气等;与术中相关的危险因素,如失血量>10L;与术后相关的危险因素:如术后发生并发症;此外,还有与移植中心的手术开展情况有关因素:如每年进行少于50次移植手术。本文拟对近年来肝移植术后感染危险因素的文献进行综述,为肝移植术后感染相关危险因素防控措施的制定提供依据。
Liver transplantation(LT)is an important therapy of end-stage liver disease.Due to surgical techniques,immune status,chemoradiotherapy,homologous immune mechanism between host and graft,ward environment and other factors,LT patients are prone to nosocomial infections.In recent years,researchers have found some new risk factors that should be paid attention to in future,in addition to traditional infection-inducing risk factors that have been previously reported.These factors include preoperative factors such as model for end-stage liver disease score>30,antibiotics abuse and mechanical ventilation,intraoperative factors such as blood loss of>10 L,postoperative risk factors such as postoperative complications,and factors associated with the experience of transplant centers such as fewer than 50 transplantations a year.This paper aims to review the recent literatures on risk factors of infections after LT,and provide a basis for development of prevention and control measures for factors related to infections after LT.
Liver transplantation(LT)is an important therapy of end-stage liver disease.Due to surgical techniques,immune status,chemoradiotherapy,homologous immune mechanism between host and graft,ward environment and other factors,LT patients are prone to nosocomial infections.In recent years,researchers have found some new risk factors that should be paid attention to in future,in addition to traditional infection-inducing risk factors that have been previously reported.These factors include preoperative factors such as model for end-stage liver disease score>30,antibiotics abuse and mechanical ventilation,intraoperative factors such as blood loss of>10 L,postoperative risk factors such as postoperative complications,and factors associated with the experience of transplant centers such as fewer than 50 transplantations a year.This paper aims to review the recent literatures on risk factors of infections after LT,and provide a basis for development of prevention and control measures for factors related to infections after LT.
引文
[1] Kupeli E,Eyuboglu FO,Haberal M.Pulmonary infections in transplant recipients[J].Curr Opin Pulm Med,2012,18(3):202-212.
[2]林栋栋,刘晋宁.肝移植围术期感染的处理[J].北京医学,2017,39(9):895-896.
[3] Boutros M,Al-Shaibi M,Chan G,et al.Clostridium difficile colitis:increasing incidence,risk factors,and outcomes in solid organ transplant recipients[J].Transplantation,2012,93(10):1051-1057.
[4] Soong RS,Chan KM,Chou HS,et al.The risk factors for early infection in adult living donor liver transplantation recipients[J].Transplant Proc,2012,44(3):784-786.
[5] Rhee KW,Oh SH,Kim KM,et al.Early bloodstream infection after pediatric living donor living transplantation[J].Transplant Proc,2012,44(3):794-796.
[6] Ali M,Ananthakrishnan AN,Ahmad S,et al.Clostridium difficile infection in hospitalized liver transplant patients:a nationwide analysis[J].Liver Transpl,2012,18(8):972-978.
[7] Li C,Wen TF,Mi K,et al.Analysis of infections in the first3-month after living donor liver transplantation[J].World J Gastroenterol,2012,18(16):1975-1980.
[8] Takeda K,Tanaka K,Kumamoto T,et al.Emergency versus elective living-donor liver transplantation:a comparison of a single center analysis[J].Surg Today,2012,42(5):453-459.
[9] Jablonska A,Paradowska E,Studzinska M,et al.Relationship between toll-like receptor 2Arg677Trp and Arg753Gln and toll-like receptor 4Asp299Gly polymorphisms and cytomegalovirus infection[J].Int J Infect Dis,2014,25:11-15.
[10] Kang SH,Abdel-Massih RC,Brown RA,et al.Homozygosity for the toll-like receptor 2R753Qsingle-nucleotide polymorphism is a risk factor for cytomegalovirus disease after liver transplantation[J].J Infect Dis,2012,205(4):639-646.
[11]胡建国,王兵,王新保.肝癌患者肝移植术后医院感染病原菌分布及耐药性分析[J].中华医院感染学杂志,2014,24(3):588-590.
[12]孟稳利,刘志华,缪洁.肝移植术后肺部感染相关因素临床分析[J].中国现代医学杂志,2013,23(22):104-106.
[13] Lichtenstern C,Hochreiter M,Zehnter VD,et al.Pretransplant model for end stage liver disease score predicts posttransplant incidence of fungal infections after liver transplantation[J].Mycoses,2013,56(3):350-357.
[14] Kaido T,Mori A,Ogura Y,et al.Pre-and perioperative factors affecting infection after living donor liver transplantation[J].Nutrition,2012,28(11-12):1104-1108.
[15]吴晓峰,林栋栋.肝移植术后肺部感染的危险因素[J].北京医学,2014,36(9):766-769.
[16] Bodro M,Sabe N,Tubau F,et al.Risk factors and outcomes of bacteremia caused by drug-resistant ESKAPE pathogens in solid-organ transplant recipients[J].Transplantation,2013,96(9):843-849.
[17] Len O,Rodriguez-Pardo D,Gavalda J,et al.Outcome of Clostridium difficile-associated disease in solid organ transplant recipients:aprospective and multicentre cohort study[J].Transpl Int,2012,25(12):1275-1281.
[18] Zhong L,Men TY,Li H,et al.Prevalence and risk factor for MDR-GNB infection in liver transplantation[J].Front Biosci,2013,18:366-370.
[19] Yang CH,He XS,Chen J,et al.Fungal infection in patients after liver transplantation in years 2003to 2012[J].Ann Transpl,2012,17(4):59-63.
[20] Ikegami T,Shirabe K,Matono R,et al.Etiologies,risk factors,and outcomes of bacterial pneumonia after living donor liver transplantation[J].Liver Transpl,2012,18(9):1060-1068.
[21]覃莉,罗羽鸥,罗艳丽.成人间活体肝移植术后受体真菌感染的易感因素分析.华西医学,2016,31(4):679-682.
[22] Raghuram A,Restrepo A,Safadjou S,et al.Invasive fungal infections following liver transplantation:incidence,risk factors,survival,and impact of fluconazole-resistant Candida parapsilosis(2003-2007)[J].Liver Transpl,2012,18(9):1100-1109.
[23] Barchiesi F,Mazzocato S,Mazzanti S,et al.Invasive aspergillosis in liver transplant recipients:epidemiology,clinical characteristics,treatment,and outcomes in 116cases[J].Liver Transpl,2015,21(2):204-212.
[24]林健文,韩明,王小平,等.公民身后器官捐献肝移植术后早期细菌和真菌感染并发症的临床特点与危险因素分析[J].中华普通外科学文献(电子版),2016,10(5):354-358.
[25] Eschenauer GA,Kwak EJ,Humar A,et al.Targeted versus universal antifungal prophylaxis among liver transplant recipients[J].Am J Transplant,2015,15(1):180-189.
[26] Freire MP,Soares Oshiro IC,Bonazzi PR,et al.Surgical site infections in liver transplant recipients in the model for endstage liver disease era:an analysis of the epidemiology,risk factors,and outcomes[J].Liver Transpl,2013,19(9):1011-1019.
[27] Pereira MR,Scully BF,Pouch SM,et al.Risk factors and outcomes of carbapenem-resistant Klebsiella pneumoniae infections in liver transplant recipients[J].Liver Transpl,2015,21(12):1511-1519.
[28] Wan QQ,Ye QF,Ming YZ,et al.The risk factors for mortality in deceased donor liver transplant recipients with bloodstream infections[J].Transplant Proc,2013,45(1):305-307.
[29] Wan Q,Ye Q,Zhou J.Mortality predictors of bloodstream infections in solid-organ transplant recipients[J].Exp Clin Transplant,2013,11(3):211-214.
[30] Florescu DF,Kalil AC,Qiu F,Schmidt CM,Sandkovsky U.What is the impact of hypogammaglobulinemia on the rate of infections and survival in solid organ transplantation?a metaanalysis[J].Am J Transplant,2013,13(10):2601-2610.
[31] Giannella M,Bartoletti M,Morelli MC,et al.Risk factors for infection with carbapenem-resistant Klebsiella pneumoniae after liver transplantation:the importance of pre-and posttransplant colonization[J].Am J Transplant,2015,15(6):1708-1715.
[32] Gao F,Ye Q,Wan Q,et al.Distribution and resistance of pathogens in liver transplant recipients with Acinetobacter baumannii infection[J].Ther Clin Risk Manag,2015,11:501-505.
[33]浦燕萍,顾燕,杨富,等.肝移植患者术后多重耐药鲍曼不动杆菌感染影响因素[J].中华肝脏外科手术学电子杂志,2016,5(3):158-162.
[34]张红志,陈凡,高伟,等.成人活体肝移植术后早期感染情况及危险因素分析[J].实用器官移植电子杂志,2015,3(3):139-141.
[35] Liu T,Zhang Y,Wan Q.Methicillin-resistant Staphylococcus aureus bacteremia among liver transplant recipients:epidemiology and associated risk factors for morbidity and mortality.[J].Infect Drug Resist,2018,11:647-658.
[36]Hand J,Patel G.Multidrug-resistant organisms in liver transplant:mitigating risk and managing infections.[J].Liver Transpl,2016,22(8):1143-1153.
[2]林栋栋,刘晋宁.肝移植围术期感染的处理[J].北京医学,2017,39(9):895-896.
[3] Boutros M,Al-Shaibi M,Chan G,et al.Clostridium difficile colitis:increasing incidence,risk factors,and outcomes in solid organ transplant recipients[J].Transplantation,2012,93(10):1051-1057.
[4] Soong RS,Chan KM,Chou HS,et al.The risk factors for early infection in adult living donor liver transplantation recipients[J].Transplant Proc,2012,44(3):784-786.
[5] Rhee KW,Oh SH,Kim KM,et al.Early bloodstream infection after pediatric living donor living transplantation[J].Transplant Proc,2012,44(3):794-796.
[6] Ali M,Ananthakrishnan AN,Ahmad S,et al.Clostridium difficile infection in hospitalized liver transplant patients:a nationwide analysis[J].Liver Transpl,2012,18(8):972-978.
[7] Li C,Wen TF,Mi K,et al.Analysis of infections in the first3-month after living donor liver transplantation[J].World J Gastroenterol,2012,18(16):1975-1980.
[8] Takeda K,Tanaka K,Kumamoto T,et al.Emergency versus elective living-donor liver transplantation:a comparison of a single center analysis[J].Surg Today,2012,42(5):453-459.
[9] Jablonska A,Paradowska E,Studzinska M,et al.Relationship between toll-like receptor 2Arg677Trp and Arg753Gln and toll-like receptor 4Asp299Gly polymorphisms and cytomegalovirus infection[J].Int J Infect Dis,2014,25:11-15.
[10] Kang SH,Abdel-Massih RC,Brown RA,et al.Homozygosity for the toll-like receptor 2R753Qsingle-nucleotide polymorphism is a risk factor for cytomegalovirus disease after liver transplantation[J].J Infect Dis,2012,205(4):639-646.
[11]胡建国,王兵,王新保.肝癌患者肝移植术后医院感染病原菌分布及耐药性分析[J].中华医院感染学杂志,2014,24(3):588-590.
[12]孟稳利,刘志华,缪洁.肝移植术后肺部感染相关因素临床分析[J].中国现代医学杂志,2013,23(22):104-106.
[13] Lichtenstern C,Hochreiter M,Zehnter VD,et al.Pretransplant model for end stage liver disease score predicts posttransplant incidence of fungal infections after liver transplantation[J].Mycoses,2013,56(3):350-357.
[14] Kaido T,Mori A,Ogura Y,et al.Pre-and perioperative factors affecting infection after living donor liver transplantation[J].Nutrition,2012,28(11-12):1104-1108.
[15]吴晓峰,林栋栋.肝移植术后肺部感染的危险因素[J].北京医学,2014,36(9):766-769.
[16] Bodro M,Sabe N,Tubau F,et al.Risk factors and outcomes of bacteremia caused by drug-resistant ESKAPE pathogens in solid-organ transplant recipients[J].Transplantation,2013,96(9):843-849.
[17] Len O,Rodriguez-Pardo D,Gavalda J,et al.Outcome of Clostridium difficile-associated disease in solid organ transplant recipients:aprospective and multicentre cohort study[J].Transpl Int,2012,25(12):1275-1281.
[18] Zhong L,Men TY,Li H,et al.Prevalence and risk factor for MDR-GNB infection in liver transplantation[J].Front Biosci,2013,18:366-370.
[19] Yang CH,He XS,Chen J,et al.Fungal infection in patients after liver transplantation in years 2003to 2012[J].Ann Transpl,2012,17(4):59-63.
[20] Ikegami T,Shirabe K,Matono R,et al.Etiologies,risk factors,and outcomes of bacterial pneumonia after living donor liver transplantation[J].Liver Transpl,2012,18(9):1060-1068.
[21]覃莉,罗羽鸥,罗艳丽.成人间活体肝移植术后受体真菌感染的易感因素分析.华西医学,2016,31(4):679-682.
[22] Raghuram A,Restrepo A,Safadjou S,et al.Invasive fungal infections following liver transplantation:incidence,risk factors,survival,and impact of fluconazole-resistant Candida parapsilosis(2003-2007)[J].Liver Transpl,2012,18(9):1100-1109.
[23] Barchiesi F,Mazzocato S,Mazzanti S,et al.Invasive aspergillosis in liver transplant recipients:epidemiology,clinical characteristics,treatment,and outcomes in 116cases[J].Liver Transpl,2015,21(2):204-212.
[24]林健文,韩明,王小平,等.公民身后器官捐献肝移植术后早期细菌和真菌感染并发症的临床特点与危险因素分析[J].中华普通外科学文献(电子版),2016,10(5):354-358.
[25] Eschenauer GA,Kwak EJ,Humar A,et al.Targeted versus universal antifungal prophylaxis among liver transplant recipients[J].Am J Transplant,2015,15(1):180-189.
[26] Freire MP,Soares Oshiro IC,Bonazzi PR,et al.Surgical site infections in liver transplant recipients in the model for endstage liver disease era:an analysis of the epidemiology,risk factors,and outcomes[J].Liver Transpl,2013,19(9):1011-1019.
[27] Pereira MR,Scully BF,Pouch SM,et al.Risk factors and outcomes of carbapenem-resistant Klebsiella pneumoniae infections in liver transplant recipients[J].Liver Transpl,2015,21(12):1511-1519.
[28] Wan QQ,Ye QF,Ming YZ,et al.The risk factors for mortality in deceased donor liver transplant recipients with bloodstream infections[J].Transplant Proc,2013,45(1):305-307.
[29] Wan Q,Ye Q,Zhou J.Mortality predictors of bloodstream infections in solid-organ transplant recipients[J].Exp Clin Transplant,2013,11(3):211-214.
[30] Florescu DF,Kalil AC,Qiu F,Schmidt CM,Sandkovsky U.What is the impact of hypogammaglobulinemia on the rate of infections and survival in solid organ transplantation?a metaanalysis[J].Am J Transplant,2013,13(10):2601-2610.
[31] Giannella M,Bartoletti M,Morelli MC,et al.Risk factors for infection with carbapenem-resistant Klebsiella pneumoniae after liver transplantation:the importance of pre-and posttransplant colonization[J].Am J Transplant,2015,15(6):1708-1715.
[32] Gao F,Ye Q,Wan Q,et al.Distribution and resistance of pathogens in liver transplant recipients with Acinetobacter baumannii infection[J].Ther Clin Risk Manag,2015,11:501-505.
[33]浦燕萍,顾燕,杨富,等.肝移植患者术后多重耐药鲍曼不动杆菌感染影响因素[J].中华肝脏外科手术学电子杂志,2016,5(3):158-162.
[34]张红志,陈凡,高伟,等.成人活体肝移植术后早期感染情况及危险因素分析[J].实用器官移植电子杂志,2015,3(3):139-141.
[35] Liu T,Zhang Y,Wan Q.Methicillin-resistant Staphylococcus aureus bacteremia among liver transplant recipients:epidemiology and associated risk factors for morbidity and mortality.[J].Infect Drug Resist,2018,11:647-658.
[36]Hand J,Patel G.Multidrug-resistant organisms in liver transplant:mitigating risk and managing infections.[J].Liver Transpl,2016,22(8):1143-1153.