【作者】 王志强；

【导师】 陈刚；

【作者基本信息】 华中科技大学 ， 外科学（器官移植）， 2020， 博士

【摘要】 【背景】供者来源的感染(DDI)是实体器官移植(SOT)术后少见但危险的并发症,治疗不当可引起移植肾切除或受者死亡。研究表明,在体外肺灌注期间进行广谱抗生素治疗,可显着降低供肺感染所致的细菌负荷,降低内毒素水平,改善临床供体肺因DDI导致的肺功能下降。在我院供者来源的耐碳青霉烯类肺炎克雷伯菌(CRKP)感染高发期间,临床医生们也采用了各种抗生素体外灌洗供者器官的方法,其中高浓度美罗培南的方案似乎收到了不错的临床效果。因此我们设计了通过小鼠肾脏携带细菌模型在体外利用高浓度美罗培南预防供者来源CRKP感染的可行性实验研究。【方法】从同济医院检验科获得肾移植术后供者来源的CRKP感染高发期间具有代表性的菌株并进一步鉴定,行药敏试验,行PCR检测菌株的碳青霉烯酶耐药基因。使用菌液灌洗无菌小鼠肾脏并4℃浸泡保存过夜,制作携带CRKP的小鼠肾脏,然后置于含有不同浓度梯度美罗培南的HTK保存液中灌洗及保存1h或3h。无菌生理盐水灌洗经过治疗后的小鼠肾脏,取灌洗后液体接种于MH培养基,记录细菌生长情况。【结果】该菌株仅对替加环素和复方新诺明敏感,对青霉素类、头孢菌素类、青霉素/青霉素酶抑制剂、头孢西丁、碳青霉烯类抗菌药物均有不同程度的耐药。PCR检测碳青霉烯酶耐药基因,结果显示该菌株bla KPC阳性,经基因测序后与Gen Bank数据库序列对比后证实为KPC-2型CRKP。在相同治疗时间下,随着美罗培南浓度的提高,未看到有培养后菌落减少的趋势;相同美罗培南浓度在1h和3h的治疗时间点也未见到明显的菌落差异。【结论】大剂量美罗培南体外处理供肾对供者来源的耐碳青霉烯肺炎克雷伯菌没有清除作用。对于临床中经过高浓度美罗培南灌洗后的供体器官,移植后供者来源的CRKP感染有所减少的现象,可能是综合治疗的结果,体外的灌洗治疗对于清除细菌似乎没有明显的作用。【背景】供者来源的耐碳青霉烯类肺炎克雷伯菌(CRKP)感染因其居高不下的高病死率,防治非常重要。但在以往有限的传统药物选择下,如何组合用药以降低受者病死率和移植肾切肾率,尚不清楚。【方法】回顾性分析华中科技大学同济医学院附属同济医院2016年1月~2017年12月期间12例供者来源CRKP感染肾移植受者的治疗经过和移植肾、移植受者预后,总结肾移植术后供者来源CRKP感染的诊疗经验。同时研究替加环素联合美罗培南治疗的疗效并讨论其可能机制。【结果】12例受者的移植肾来自7个供者,其中10例受者肾脏分别来自5个供体,2例受者接受儿童供双肾肾移植手术。12例受者检出的均为产KPC-2酶CRKP,其中器官保存液培养CRKP阳性12例,术后引流液培养CRKP阳性8例,血培养阳性2例,尿培养阳性4例。手术后确诊CRKP感染的平均天数为(3.3±0.9)天。所有菌株均表现出对替加环素敏感或中介。研究早期的2例受者接受单独替加环素治疗,好转出院,其中一例于出院一周后因CRKP败血症和尿路感染再次入院治疗;2例受者接受替加环素+大剂量美罗培南静滴治疗,1例死亡,1例移植肾切除后恢复透析;而接受替加环素+大剂量延时美罗培南泵入治疗的8例受者全部好转出院,其中仅有1例2月后CRKP尿路感染再次入院治疗。此外,3例受者结合局部用药,其中1例受者因移植肾周严重化脓行手术清创+连续负压封闭引流缝合后治愈。另外,有8例受者发现了伴随的细菌或真菌感染的局部感染,在针对性的用药后,局部感染未转移培养均转阴。在单药片搭桥法联合药敏试验中的替加环素与美罗培南并未发现明显的协同作用。【结论】替加环素联合大剂量延时美罗培南对防治肾移植术后供者来源CRKP感染有较好疗效,该方案为在缺乏头孢他啶-阿维巴坦的用药条件下,提供较为可靠的治疗参考。供肾器官保存液或组织培养有助于受者CRKP感染的早期诊断和早期治疗。【目的】探讨肾移植术后供肾携带性耐碳青霉烯类肺炎克雷伯菌(CRKP)感染在对替加环素联合美罗培南方案不耐受的情况下,采用新型抗生素头孢他啶-阿维巴坦的治疗效果及其具体方案。【方法】通过分析1例肾移植术后供肾携带性CRKP导致血行肺部感染患者的临床诊疗经过,结合文献,探讨肾移植术后严重CRKP感染的抗感染治疗方案及围手术期处理。【结果】受者术后在供肾器官保存液培养CRKP阳性的第一时间应用了替加环素联合大剂量延时美罗培南的治疗方案,后多次送检引流液、血、尿培养均无细菌生长,但用药一周后,患者出现严重腹痛伴胰酶指标明显升高(淀粉酶716/脂肪酶961),立即停用替加环素,并给予禁食和抑制胰酶分泌治疗。术后第15d患者突然出现寒战发热伴呼吸困难,床边胸片可见双肺多发斑片影,急查血、尿培养均报告CRKP阳性,遂给予头孢他定-阿维巴坦(2.5g,q12h)联合美罗培南(1.0g,q12h)抗感染。连续用药15d后,患者肺部感染显著好转,d35复查肺部CT可见感染灶基本完全吸收。考虑到肾移植术后已超过1个月,虽然每天尿量可达2000ml/d,但血肌酐一直未恢复正常,遂行移植肾穿刺活检。病理结果提示可疑轻度急性细胞性排斥反应,给予兔抗胸腺细胞球蛋白(r ATG)(25mg/d,iv drip)治疗3天。然而d40,患者再次发热(38.6℃)伴呼吸困难,2天后回报血、尿培养再次为CRKP阳性,肺部CT与上次比较并未出现明显加重的感染灶。遂重新给予头孢他定-阿维巴坦(2.5g q12h)联合应用亚胺培南(1.0g q12h),患者发热症状很快得以控制,d45血及尿培养CRKP均转阴,继续治疗达疗程15天停药。后期随访11月,未见感染复发。【结论】头孢他啶-阿维巴坦联合碳青霉烯的治疗方案对于肾移植术后供者来源的CRKP血行感染治疗效果良好,不良反应少,但应注意足疗程以防止感染复发。更多还原

【Abstract】 【Backgroud】 Donor-derived infection(DDI)is a rare but dangerous complication after solid organ transplantation(SOT).Improper treatment can result in nephrectomy or death of the recipient.Studies have shown that broad-spectrum antibiotic treatment during extracorporeal lung perfusion can significantly reduce the bacterial load caused by pulmonary infection,reduce endotoxin levels,and improve the pulmonary function decline caused by DDI in clinical donors.During the high incidence of the donor-derived carbapenem-resistant Klebsiella pneumoniae(CRKP)infection in our hospital,clinicians also used a variety of antibiotics to lavage donor organs in vitro,of which high-dose meropenem seems to have received good clinical results.Therefore,we designed a feasibility experimental study to prevent donor-derived CRKP infection with high-concentration meropenem in vitro through a mouse kidney-carrying bacterial model.【 Methods 】 A representative strain of donor-derived CRKP infection after kidney transplantation during the high-incidence were obtained from the Department of Clinical Laboratory of Tongji Hospital and further identified.Drug susceptibility test was performed,and the carbapenemase resistance gene of the strain was detected by PCR.The sterile mouse kidney was lavaged with bacterial solution and stored overnight at 4℃ to prepare kidneys of mice carrying CRKP,then stored in HTK preservation solution containing meropenem at different concentration gradients for 1 or 3 hours.The treated mice kidneys was lavaged with sterile saline,and the liquid after lavage was inoculated into the MH medium,and record the growth of the bacteria.【 Results 】 The representative strain was only sensitive to tigecycline and sulfamethoxazole,and has different degrees of resistance to penicillins,cephalosporins,penicillin/penicillinase inhibitors,cefoxitin and carbapenems.The carbapenemase resistance gene was detected by PCR and the result showed that the strain was positive for bla KPC.After sequencing with the Gen Bank database,it was confirmed to be KPC-2.At the same treatment time,with the increase of meropenem concentration,no bacterial colonies reduction trend was observed after culture;the same meropenem concentration did not show significant bacterial colonies differences at the treatment time points of 1h and 3h.【Conclusions】 In vitro high-concentration meropenem is not feasible for the treatment of donor-derived CRKP infection.The reduction in donor-derived CRKP infection after transplantation may be the result of comprehensive treatment for the donor organs that have been irrigated with high concentration of merepenem in clinical practice.In vitro lavage therapy does not seem to have a significant effect on removing bacteria.【 Backgroud 】 The prevention and treatment of donor-derived carbapenem-resistant Klebsiella pneumoniae(CRKP)infection is very important because of its high mortality.However,with limited traditional drug options in the past,it is not clear how to combine drugs to reduce mortality and the nephrectomy rate of transplanted kidney.【Methods】A retrospective analysis was made on the treatment and prognosis of 12 renal transplant recipients with donor-derived CRKP infection in Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology from January 2016 to December 2017.To summarize the experience of diagnosis and treatment of donor-derived CRKP infection after renal transplantation.To study the effect of tigecycline combined with meropenem and discuss its possible mechanism.【Results】The kidney grafts for the 12 recipients were harvested from 7 donors,of which kidney grafts for 10 recipients were from 5 donors,and kidney grafts for the remaining 2recipients were underwent en-bloc kidney transplantation from pediatric donor kidneys harvested from a child.KPC-2-producing CRKP was detected in the 12 recipients,of which organ preservation solution culture retained positive CRKP in 12 cases,postoperative drainage solution culture returned positive CRKP in 8 cases,blood culture returned positive CRKP in 2 cases and urine culture returned positive CRKP in 4 cases.The average number of days for diagnosis of CRKP infection after the surgery was(3.3 ± 0.9)days.All strains were sensitive or intermediary to tigecycline.In the early stage of the study,2 patients were improved and discharged after treatment with tigecycline alone,one of which was re-admitted for CRKP sepsis and urinary tract infection one week after discharge.Two recipients received tigecycline + high-dose intravenous meropenem treatment,one of which died and the other resumed dialysis after transplant nephrectomy.However,8 recipients received tigecycline + high-dose prolonged meropenem pumping treatment,and all of them were improved and discharged,only 1 of which was re-admitted due to CRKP urinary tract infection after 2 months.In addition,three recipients were combined with local medications,and one of them was cured by surgical debridement +continuous VSD suture due to severe suppuration around the transplanted kidney.In addition,8 recipients found local infections accompanied by bacterial or fungal infections.After targeted medication,the local infections and cultures turned negative without transfer.No significant synergistic effect was found between tigecycline and meropenem in the single-pill bypass method combined with drug sensitivity test.【Conclusions】 Tigecycline combined with high-dose prolonged meropenem is effective in preventing and treating CRKP infection from donors after renal transplantation.This drug regimen can provide reliable treatment reference in the absence of Ceftazidime-avibactam.Donor organ preservation solution or tissue culture is helpful for the early diagnosis and preventive treatment of infection in the recipient.【Objective】 To investigate the effect of the new antibiotic ceftazidine-avibactam on carbapenem-resistant Klebsiella pneumoniae(CRKP)infection after kidney transplantation in the case of tigecycline and meropenem intolerance.【Methods】 Through the analysis of the clinical diagnosis and treatment of a patient with lung infection caused by donor renal-carried CRKP after kidney transplantation,combined with the literature,to explore the anti infection treatment plan and perioperative management of severe CRKP infection after solid organ transplantation.【Results】 At the first time of CRKP positive culture in the donor organ preservation solution,the recipient used tigecycline combined with large dose of delayed meropenem.After several times of examination,the drainage solution,blood and urine culture were all free of bacterial growth,but after one week of treatment,the patient had severe abdominal pain with a significant increase in pancreatic enzyme index(amylase 716/lipase 961),and immediately stopped tigecycline,Fasting and inhibition of pancreatic enzyme secretion were given.On the 15 th day after operation,the patient suddenly developed chills and fever with dyspnea.On the chest film beside the bed,multiple spots of both lungs could be seen.CRKP was reported to be positive in blood and urine culture.Therefore,ceftazidine-avibatan(2.5G q12h)and meropenem(1.0g q12h)were given for anti-infective treatment.After 15 days of continuous administration,the patient’s pulmonary infection improved significantly.On D35,the pulmonary CT showed that the infection was basically completely absorbed.Considering that more than one month after the renal transplantation,although the daily urine volume can reach 2000 ml/d,the blood creatinine has not been restored to normal,the renal transplantation biopsy was carried out.The pathological results showed that there was a slight acute rejection of suspected(susceptive)cells.RATG(25mg/d,IV drip)was given for 3 days.However,on D40,the patient was febrile again(38.6 ℃)with dyspnea.Two days later,the blood and urine cultures were positive for CRKP again.There was no significant aggravation of pulmonary CT infection compared with the last time.After that,ceftazidine-avibatan(2.5gq12h)combined with imipenem(1.0g q12h)was given again.The fever symptoms of the patients were quickly controlled.The CRKP in blood and urine culture of D45 turned negative,and the treatment continued for 15 days.Follow up of 11 months showed no recurrence.【Conclusions】The treatment of ceftazidime-avibactam combined with carbapenem has a good effect on CRKP hemorrhagic infection of DDI after renal transplantation,and has few adverse reactions.However,it is necessary to pay attention to the course of foot treatment to prevent infection from recurring.更多还原