SACGR
January 12, 2006
66 year old man s/p lung transplant
• 66-year-old man with chronic obstructive pulmonary
disease
• 4 liters of oxygen at home, usually saturating around 94%
• Bilateral lung transplant
• Extubated POD #1
• Chest tubes pulled POD#5
• Atrial fibrillation POD#6 – started on heparin gtt
• Urine Culture: GNR’s POD#6
• Increasing O2 demands
66 year old man s/p lung transplant
PAST MEDICAL HISTORY
1. Chronic obstructive pulmonary disease
A. FEV1 0.65.
2. Hypertension.
3. Coronary artery disease, status post stent, 12/22/2004.
4. Benign prostatic hypertrophy.
5. Hiatal hernia.
PAST SURGICAL HISTORY
1. Left inguinal hernia repair in 1989.
2. Tracheotomy in January 2004 for respiratory distress secondary to car crash.
3. Tonsillectomy and adenoidectomy in childhood.
MEDICATIONS ON TRANSFER
1. MMF
2. FK-506
3. Ciprofloxacin
4. Prednisone
5. Gancyclovir
6. Ampho Nebs
7. Dapsone
66 year old man s/p lung transplant
ALLERGIES SULFA DRUGS.
Tobacco: 55 pack-years, quit 1/04
EtOH: h/o abuse
FAMILY HISTORY
The patient reports type 2 diabetes on his father’s side. Reports his sister has depression and his
mother has coronary artery disease.
SOCIAL HISTORY
Married with three daughters
66 year old man s/p lung transplant
PHYSICAL EXAMINATION
Temp 37.2 HR 128 BP 102/60 RR 18 SaO2 93% on RA
GENERAL: alert and oriented, lying in bed. No acute distress.
HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular
movements were intact. Mucous membranes moist.
CHEST: crackles at bases. No rales, rhonchi or wheezes. Incision is clean, dry, and intact and
well-healing.
CARDIAC: tachycardic and irregularly irregular.
ABDOMEN: Soft, nontender, nondistended, normal active bowel sounds.
EXTREMITIES: Without clubbing, cyanosis, or edema.
LABS
WBC 19.7 (PMN 18) (down from 25) Hct 29 Plts 350
Na 125 K 5.4 Cl 84 HCO3 34 BUN 19 Crtn 0.9 Glc 101
INR 1.3 PTT 85
FK 8
Complications post Transplant
Kotloff RM, Ahya VN, Crawford SW. Pulmonary complications of solid organ and hematopoietic stem cell transplantation.
Am J Respir Crit Care Med. 2004 Jul 1;170(1):22-48.
Linezolid vs Vancomycin for MRSA
Pneumonia
Wunderink RG, Rello J, Cammarata SK, Croos-Dabrera RV, Kollef MH. Linezolid vs vancomycin: analysis of two double-blind studies of
patients with methicillin-resistant Staphylococcus aureus nosocomial pneumonia. Chest. 2003 Nov;124(5):1789-97.
66 year old man s/p lung transplant
Serratia marcescens
Amikacin
Ampicillin
Ampicillin/sulbactam
Aztreonam
Cefazolin
Cefepime
Cefotetan
Ceftazidime
Ceftriaxone
Cefuroxime
Ciprofloxacin
Clindamycin
Erythromycin
Gentamicin
Imipenem
Levofloxacin
Meropenem
Oxacillin
Piperacillin
Piperacillin/tazobactam
Tetracycline
Tobramycin
Trimeth_Sulfamethoxazole
Vancomycin
Staphylococcus aureus
S
R
I
S
R
S
S
S
S
R
S
S
S
S
S
S
R
S
R
R
S
S
S
S
S
S
S
Community vs Healthcare MRSA
Naimi TS, LeDell KH, Como-Sabetti K, Borchardt SM, Boxrud DJ, Etienne J, Johnson SK, Vandenesch F, Fridkin S, O'Boyle C, Danila RN,
Lynfield R. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA. 2003 Dec
10;290(22):2976-84.
Incidence in a Children’s Hospital in Texas
Risk Factors: chronic disease (50.6%), recent hospitalization (46.6%), documentedMRSAcolonization (30.7%), recent
surgery (14.8%), & previous antibiotic use (11.4%).
Purcell K, Fergie J. Epidemic of community-acquired methicillin-resistant Staphylococcus aureus infections: a 14-year study at Driscoll
Children's Hospital. Arch Pediatr Adolesc Med. 2005 Oct;159(10):980-5.
Community vs Healthcare MRSA
Naimi TS, LeDell KH, Como-Sabetti K, Borchardt SM, Boxrud DJ, Etienne J, Johnson SK, Vandenesch F, Fridkin S, O'Boyle C, Danila RN,
Lynfield R. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA. 2003 Dec
10;290(22):2976-84.
Virulence Factors
Zetola N, Francis JS, Nuermberger EL, Bishai WR.
Community-acquired meticillin-resistant Staphylococcus
aureus: an emerging threat. Lancet Infect Dis. 2005
May;5(5):275-86
Sub-inhibitory concentrations inhibit protein
synthesis
Ohlsen, K, Ziebuhr, W, Koller, KP, et al Effects of subinhibitory concentrations of antibiotics on -toxin (hla) gene expression of methicillinsensitive and methicillin-resistant Staphylococcus aureus isolates. Antimicrob Agents Chemother 1998;42,2817-2823
Sub-inhibitory concentrations inhibit protein
synthesis
Bernardo, K, Pakulat, N, Fleer, S, et al Subinhibitory concentrations of linezolid reduce Staphylococcus aureus virulence factor expression.
Antimicrob Agents Chemother 2004;48,546-555
http://blog.hsl.washington.edu/chest/