Infections in Immunocompromised Hosts and Organ Transplant Recipients: Essentials
Infections in Immunocompromised Hosts and Organ Transplant Recipients: Essentials
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DOI：
10.1002/lt.22378
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发表时间：
2011-11-01
影响因子：
4.6
通讯作者：
Fishman, Jay A.
中科院分区：
文献类型：
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作者：
Fishman, Jay A.
(1)为什么我们需要了解这些患者？无论他们的专业是什么，医生们越来越多地面临着引起不同程度免疫抑制的治疗的副作用：癌症的化疗和干细胞移植，实体器官移植，自身免疫性疾病和风湿病的治疗。这些病人的管理越来越多地回归到社区医生。传染病临床医师面临着重大挑战。(2)感染可能的病因多种多样；它们的范围从影响整个社区的常见细菌和病毒病原体到仅对免疫功能低下的宿主具有临床意义的机会性病原体。(3)免疫抑制治疗会削弱炎症反应，从而导致临床和放射学表现减弱。因此，早期诊断要困难得多，但它是成功治疗的关键。通常需要侵入性诊断程序。(4)由于经验性治疗的紧迫性以及药物毒性和药物相互作用的频率，这些患者的抗菌治疗往往比其他患者更复杂。(5)药物相互作用和药物毒性是常见的。抗菌治疗的开始或停止可能改变钙调磷酸酶抑制剂、抗真菌药物和其他药物的水平。(6)移植物排斥反应和移植物抗宿主病可能与感染混淆。(7)新的病原体和受损宿主感染的新表现也是问题。对细胞免疫功能有长期缺陷的个体（人类免疫缺陷病毒）和嗜中性粒细胞减少的宿主（红球菌、隐孢子虫和青霉菌）常见的病原体；分枝杆菌种类（如鸟分枝杆菌复合体）；b.在移植受者中发现了梭状孢子菌和梭状孢子菌。抗微生物药物耐药性是主要问题[万古霉素耐药肠球菌；耐甲氧西林金黄色葡萄球菌；假单胞菌、窄养单胞菌和伯克霍尔德菌；真菌（酵母和霉菌）；抗更昔洛韦巨细胞病毒[c]。目前对较新的病毒性病原体（如人疱疹病毒6、人疱疹病毒8和BK病毒）和常见呼吸道病毒（如呼吸道合胞病毒、腺病毒和偏肺病毒）的治疗方法很少。来自流行地区的患者可能患有寄生虫（例如，恰加斯病和利什曼原虫）。
Key Points(1) Why do we need to know anything about these patients? Regardless of their specialties, physicians are increasingly confronted with the side effects of therapies that cause varying degrees of immunosuppression: chemotherapy and stem cell transplantation for cancer, solid organ transplantation, and therapies for autoimmune and rheumatological diseases. The management of these patients is increasingly being returned to community-based physicians. The infectious disease clinician is faced with major challenges.(2) The possible etiologies of infections are diverse; they range from common bacterial and viral pathogens that affect the entire community to opportunistic pathogens that are clinically significant only for immunocompromised hosts.(3) Inflammatory responses are impaired by immunosuppressive therapy, and this results in diminished clinical and radiological findings. Thus, an early diagnosis is much more difficult, but it is the key to successful therapy. Invasive diagnostic procedures are often required.(4) Antimicrobial therapies are often more complex in these patients versus other patients because of the urgency of empiric therapy and the frequency of drug toxicity and drug interactions.(5) Drug interactions and drug toxicity are common. The initiation or cessation of antimicrobial therapies may alter the levels of calcineurin inhibitors, antifungal agents, and other drugs.(6) Graft rejection and graft-versus-host disease may be confused with infections.(7) New pathogens and new manifestations of infections in compromised hosts are also problems:a. Pathogens common to individuals with prolonged defects in their cellular immune function (human immunodeficiency virus) and to neutropenic hosts [Rhodococcus, Cryptosporidium, and Penicillium species; Mycobacterium species (eg, Mycobacterium avium complex); and Scedosporium] have been identified in transplant recipients.b. Antimicrobial resistance is a major problem [vancomycin-resistant Enterococcus; methicillin-resistant Staphylococcus aureus; Pseudomonas, Stenotrophomonas, and Burkholderia species; fungi (both yeasts and molds); and ganciclovir-resistant cytomegalovirus].c. There are few therapies for newer viral pathogens (eg, human herpesvirus 6, human herpesvirus 8, and BK virus) and common respiratory viruses (eg, respiratory syncytial virus, adenoviruses, and Metapneumovirus).d. Patients from endemic regions may have parasites (eg, Chagas disease and Leishmania).