Infections and their prevention

Early infections are usually caused by Gram-negative bacilli; after a few days these give way to mixed organisms, with Candida colonization of the oropharynx and Gram-positive colonization of catheters. Multiple-resistant bacteria may appear, usually in the sicker patients who are still ventilator dependent, with a sensitivity pattern depending on antibiotic utilization. Biliary colonization is common, but should not prompt antibiotic treatment in the absence of symptoms while the T-tube is in situ. Late infections include cytomegalovirus, herpesvirus, Pneumocystis, and invasive Aspergillus.

Viral infection (herpesvirus and cytomegalovirus) of the liver occurs in about 10 per cent of patients between the second and sixth postoperative week; the risk depends on the serological states of the donor and the recipient. Severity ranges from being virtually asymptomatic to a systemic illness with fever, arthralgia, malaise, hepatitis, pneumonitis, and enteritis. Diagnosis is by serology and liver biopsy. Treatment involves a reduction in immunosuppression and the antiviral agent ganciclovir. Ganciclovir produces a leukopenia with suppression of T-cell production.

Broad-spectrum antibiotics are usually prescribed routinely for the first 2 days. Oral nystatin, amphotericin, and low-dose Septrin are used for prophylaxis. Fluconazole is a useful systemic anti-Candida prophylactic which mildly inhibits cyclosporine A metabolism. Intravenous liposomal amphotericin should be prescribed (150 mg/day for adults) if Candida or Aspergillus infection is suspected. There appears to be little role for selective antibiotic digestive decontamination. Antimicrobial agents are only part of a systematic approach to infection prevention, which also inlcudes high-quality nursing care and adherence by medical staff to agreed protocols for prevention of cross-infection. Nutritional factors are also important.

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