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