r 2009 John Wiley & Sons A/S

Transplant Infectious Disease . ISSN 1398 -2273

Short communication

Carbapenem-resistant Acinetobacter baumannii

infections after organ transplantation
 
 P. Reddy,T.R. Zembower, M.G. Ison,T.A. Baker,V. Stosor. Carbapenem-  P. Reddy1, T.R. Zembower1, M.G. Ison1,2,
 
 resistant Acinetobacter baumannii infections after organ  T.A. Baker2, V. Stosor1,2
 
 transplantation.  1
Division of Infectious Diseases, and 2Division of Organ
 Transpl Infect Dis 2010: 12: 87^93. All rights reserved 
  Transplantation, Northwestern University Feinberg School of
  Medicine, Chicago, Illinois, USA
 
 Abstract: Multi-drug resistant (MDR) gram-negative infections 
 
 among solid organ transplant (SOT) recipients have long been 
 
 associated with high morbidity and mortality. Acinetobacter baumannii 

 has emerged as a potent nosocomial pathogen with the recent  Key words: organ transplantation; complications;
 
 acquisition of resistance to broad-spectrum b-lactams,  Acinetobacter; infections
 aminoglycosides, £uoroquinolones, and most notably, carbapenems. 
 
 Despite a national rise in carbapenem-resistant A. baumannii (CRAB)  Correspondence to:

 infections, outcomes among SOT recipients with this emerging MDR  Pavani Reddy, MD, Division of Infectious Diseases,
 Northwestern University Feinberg School of Medicine, 645 N.
 pathogen are largely unknown. This single-center cohort is the ¢rst to 
 Michigan Avenue, Suite 900, Chicago, IL 60611, USA
 describe the characteristics, complications, and outcomes among 
  Tel: 1 1 312 695 5090
 abdominal organ transplant recipients with CRAB. The current study  Fax: 1 1 312 695 5088
 
 suggests that SOT patients with CRAB su¡er from prolonged  E-mail: p-reddy2@md.northwestern.edu
 hospitalization, infection with other MDR organisms, allograft 
 
 dysfunction and loss, and high overall infection-related mortality.  Received 17 October 2008, revised 2 April 2009, accepted for
 
  publication 13 May 2009
 
 
 
  DOI: 10.1111/j.1399-3062.2009.00445.x
 
Invasive bacterial infections have become a leading cause
of morbidity and mortality among solid organ transplant
(SOT) recipients (1). Notably, the emergence of multi-drug
resistant (MDR) gram-negative bacteria among SOT recip-
ients has been associated with an increased risk of allograft
loss (2). Outcomes among transplant recipients with infec-
tion due to extended-spectrum beta-lactamase (ESBL)-
producing Enterobacteriaceae or MDR Pseudomonas aeru-
ginosa have been described previously (2, 3).
Acinetobacter baumannii is almost exclusively a no-
socomial pathogen, associated with soft tissue infection,
urinary tract infection (UTI), catheter-associated blood-
stream infection (BSI), and ventilator-associated pneumo-
nia (VAP) among critically ill patients (4). Already
equipped with intrinsic resistance to the aminopenicillins
and ¢rst- and second-generation cephalosporins, A. bau-
mannii has gained recent notoriety with its acquired resis-
Abbreviations : BSI, bloodstream infection; CRAB, carbapenem-resistant
Acinetobacter baumannii; ERCP, endoscopic retrograde cholangiopancreatography;
ESBL, extended-spectrum beta-lactamase; HCV, hepatitis C virus; ICU, intensive
care unit; MDR, multi-drug resistant; MRSA, methicillin-resistant Staphylococcus
aureus; PTD, post-transplant day; SOT, solid organ transplant; UTI, urinary tract
infection; VAP, ventilator-associated pneumonia; VRE, vancomycin-resistant
Enterococcus
Transpl Infect Dis 2010: 12: 87–93
tance to broad-spectrum antibiotics including b-lactams,
aminoglycosides, £uoroquinolones, and tetracyclines.
Most notably, carbapenem-resistant A. baumannii (CRAB)
has emerged with the acquisition of enzymes (e.g., metallo-
b-lactamases, oxacillinases) capable of hydrolyzing imipe-
nem. This recent rise in MDR A. baumannii infections has
been associated with longer hospital length of stay (5) and
increased patient mortality (6).
Despite a national rise in carbapenem resistance among
A. baumannii (National Nosocomial Infections Surveil-
lance System, unpublished data), outcomes among SOT re-
cipients who acquire this pathogen are largely unknown.
We report the clinical features and outcomes of abdominal
organ transplant recipients who acquired CRAB in the
post-transplant period.
Methods
Northwestern Memorial Hospital (NMH) is an 825 -bed ac-
ademic medical center in Chicago, Illinois. From January 1,
87
Reddy et al: Acinetobacter infections after organ transplant
2004 to December 31, 2005, 794 abdominal organ trans-
plants were performed at NMH including 172 liver, 407 kid-
ney, and 57 combined liver^kidney procedures.W|thin this
time frame, all patients with a positive culture for CRAB
were identi¢ed through the electronic microbiology da-
tabase. Organ recipients who acquired CRAB during the
study period were considered for analysis.
A. baumannii isolates were identi¢ed by the semi-auto-
mated VITEK 2s system (bioMe¤ rieux, Marcy l’Etoile,
France). Further standard biochemical techniques for the
identi¢cation of Acinetobacter were performed if automated
results were o90% accurate. Carbapenem resistance was
de¢ned as a minimum inhibitory concentration of imipe-
nem  16 mg/mL. Routine antimicrobial susceptibility
testing for gentamicin, tobramycin, ampicillin^sulbactam,
imipenem, ceftazidime, aztreonam, cefepime, cipro£oxa-
cin, and trimethoprim^sulfamethoxazole was performed
by the VITEK 2 s system. Additional susceptibility testing
for amikacin, piperacillin^tazobactam, minocycline, tetra-
cycline, and doxycycline was performed by the Kirby^Bau-
er disk di¡usion method and isolates were characterized as
resistant or susceptible based on the interpretative criteria
of the Clinical Laboratory Standards Institute (7 ). Suscep-
tibility to colistin was determined by use of the E-test s
(AB Biodisk, Solna, Sweden).
During the study period, the predominant immunosup-
pression protocols for liver transplantation di¡ered by un-
derlying disease. For hepatitis C virus (HCV) infection or
hepatocellular carcinoma, the preferred regimen included
methylprednisolone 500 mg on post-transplant day (PTD)
0 followed by a steroid taper over 10 days. Maintenance of
immunosuppression included tacrolimus (Prografs,
Fujisawa Pharmaceuticals, Deer¢eld, Illinois, USA) admin-
istered to achieve a 12-h blood level of 8 ng/mL for deceased-
donor transplants or 5^8 ng/mL for living-donor trans-
plants for the initial 3 months post transplant. Other liver
recipients and combined organ recipients received
alemtuzumab 30 mg as induction therapy and methylpred-
nisolone 500 mg on PTD 0, 250 mg on PTD 1, and 125 mg on
PTD 2. Tacrolimus was administered to achieve 12-h blood
concentrations of 8^10 ng/mL for the ¢rst 3 months post
transplant. Combined organ recipients also received my-
cophenolate mofetil (Cellcepts, Roche, Nutely, New Jersey,
USA) at target dose of 1.5^2.0 g/day.
The kidney recipient in this case series was infected with
HCV and received induction basiliximab 20 mg on PTD 0
and 2, methylprednisolone 500 mg on PTD 0, mycopheno-
late mofetil 1.0 g/day, and tacrolimus to achieve 12-h blood
concentrations of 8^10 ng/mL.
Medical records were reviewed to collect data on patient
demographics, transplant history, immunosuppressant
use, co-morbid conditions, and clinical presentation, com-
plications, and outcomes associated with CRAB. Estab-
88 Transplant Infectious Disease 2010: 12: 87^93
lished criteria were used to de¢ne clinical infection (8).
Summary statistics were performed using SAS software,
version 9.1 (SAS Institute). When appropriate, categorical
variables were compared using Fisher’s exact test.
Study patients
During the study period, 248 patients with A. baumannii
were identi¢ed. Among abdominal organ transplant recip-
ients with A. baumannii (n 5 14), 6 (42.9%) acquired a
carbapenem-resistant isolate. In contrast, among
non-transplant patients with A. baumannii (n 5 234), only
32 (13.7%) patients acquired a carbapenem-resistant isolate
(odds ratio 4.73, 95% con¢dence interval 1.35^16.38,
P 5 0.01). Of note, case patients were accrued during a mul-
ti-city CRAB outbreak that occurred within the study pe-
riod (9). Table 1 summarizes the important clinical,
epidemiologic, and transplant features of the 6 recipients
who acquired CRAB.
Case 1
A 61-year-old man with hepatitis B cirrhosis underwent or-
thotopic liver transplantation complicated by bile leak and
ampullary stenosis early in the postoperative course. In-
terventions included re-operation and endoscopic retro-
grade cholangiopancreatography (ERCP) with biliary
stent placement. After an extended intensive care unit
(ICU) stay for ventilatory failure and prolonged mechanical
ventilation, the patient was discharged to a subacute nurs-
ing facility. On PTD 45, the patient was re-admitted with
sepsis. He underwent ERCP, biliary traction sphincter-
otomy, balloon dilation of the choledochocholedochostomy
anastamotic stricture, and biliary stent replacement.
Post-transplant course was further complicated by car-
bapenem-sensitive A. baumannii urinary and respiratory
tract infections and subsequently, invasive pulmonary
aspergillosis. On PTD 89, the patient developed CRAB
VAP. CRAB-directed antimicrobial therapy with amp-
icillin^sulbactam, amikacin, and nebulized tobramycin
was administered. The pneumonia resolved and he was
discharged on PTD 103.
Case 2
A 66 -year-old woman with end-stage liver disease due to
non-alcoholic steatotic liver disease and hepatorenal syn-
drome underwent combined liver and kidney transplanta-
tion. The immediate postoperative course was complicated
by a retroperitoneal hematoma and delayed renal allograft
 Reddy et al: Acinetobacter infections after organ transplant

Clinical and epidemiologic features of organ recipients colonized or infected with carbapenem-resistant Acinetobacter baumannii (CRAB)

Case

Characteristics 1 2 3 4 5 6

Transplant type Liver Kidney^liver Kidney^liver Kidney^liver Kidney^liver Kidney

Transplant Hepatitis B NASH, HRS Alcoholic Hepatitis C, Hepatic Cryptogenic FSGS
reason cirrhosis, HRS failure s/p HCC resection, HRS cirrhosis, HRS
MELD 40 26 39 44 35 N/A
Cold ischemia 6 8 8 10 6 UA
time (h)
Operative time 515 498 449 767 480 220
(min)
Age (years) 61 66 64 62 33 49
Sex Male Female Male Female Male Male
Ethnicity Caucasian Caucasian Asian Caucasian Caucasian African American
Induction IS Alemtuzumab Alemtuzumab Alemtuzumab None Alemtuzumab Basiliximab
Maintenance IS TAC, MMF TAC, MMF TAC, MMF TAC, prednisone TAC, MMF, TAC, MMF, prednisone
prednisone
Prior antibiotics Carbapenem 41 BL^BLI Carbapenem Carbapenem Carbapenem
BL^BLI cephalosporin Fluororquinolone BL^BLI
Metronidazole Metronidazole Vancomycin Vancomycin
Vancomycin Vancomycin
CRAB site PNA PNA PNA 1 BSI 1 UTI Respiratory tract PNA 1 BSI 1 UTI PNA 1 BSI 1 SSI 1 empyema
Prior infections Biliary sepsis Polymicrobial None VRE, CoNS peritonitis VRE UTI/BSI Pseudomonas aeruginosa
Acinetobacter UTI A. baumannii BSI Enterobacter BSI SSI  UTI
baumannii UTI Klebsiella PNA Ocular HSV, Stenotrophomonas Klebsiella PNA
A. baumannii PNA Klebsiella BSI maltophilia BSI Clostridium di⁄cile
Aspergillus PNA Candida S. maltophilia SSI colitis
peritonitis
Transplant Bile leak DGF DGF Delayed closure DGF DGF
complications Ampullary stenosis Hematoma Bile leak Hepatic artery ischemia Cardiac arrest Hematoma
Re-operation Allograft Ischemic Bile leak Pancytopenia Urine leak
rejection cholangiopathy Hepatic necrosis, SSI Allograft rejection
Re-operation Re-operation Nephrectomy
Re-operation
Outcome Survived Died Died Died Died Died

NASH, non-alcoholic steatotic hepatitis; HCC, hepatocellular carcinoma; HRS, hepatorenal syndrome; FSGS, focal segmental glomerulosclerosis; TAC,
tacrolimus; MMF, mycophenolate mofetil; BL, beta lactam; BLI, beta-lactamase inhibitor; PNA, pneumonia; UTI, urinary tract infection; BSI, bloodstream
infection; SSI, surgical site infection; DGF, delayed renal allograft function; N/A, not applicable; UA, unavailable; MELD, model for end-stage liver disease; IS,
immunosuppression; VRE, vancomycin-resistant Enterococcus; HSV, herpes simplex virus; 41, fourth generation; CoNS, coagulase-negative
Staphylococcus.

Table1

function secondary to acute tubular necrosis. On PTD 20,
the patient was diagnosed with a Klebsiella pneumoniae
UTI and Candida peritonitis, treated with piperacillin^ta-
zobactam and £uconazole, respectively. The patient re-
turned to the hospital on PTD 54 with fevers, ascites, and
declining renal function. Over the next month, her hospital
course was marked by respiratory failure with prolonged
mechanical ventilation and tracheostomy placement, per-
sistent ascites, prolonged lymphopenia, and renal allograft
dysfunction requiring hemodialysis. Antibiotic therapy
was administered for urinary, respiratory, and BSI due to
an ESBL-producing K. pneumoniae. The patient was re-
hospitalized on PTD 214 with K. pneumoniae, Proteus mira-
bilis, and vancomycin-resistant Enterococcus faecium (VRE)
urosepsis and hydronephrosis of the allograft necessitat-
ing nephrostomy tube placement. Renal allograft biopsy

Transplant Infectious Disease 2010: 12: 87^93 89

Reddy et al: Acinetobacter infections after organ transplant
suggested rejection. Computed tomography of the chest
demonstrated bibasilar consolidation. Despite aggressive
supportive measures, the patient su¡ered from cardiopul-
monary arrest and anoxic brain injury, expiring on PTD
219. Respiratory cultures later identi¢ed CRAB and MDR
P. aeruginosa.
Case 3
A 64 -year-old man with alcoholic cirrhosis and hepatorenal
syndrome underwent combined liver^kidney transplanta-
tion from a donation-after-cardiac-death donor complicated
by postoperative heart failure, delayed renal allograft
function, and respiratory failure with prolonged mechani-
cal ventilation and tracheostomy placement. He was dis-
charged to a subacute nursing facility placement on PTD
14 but was re-admitted 3 days later with ischemic
cholangiopathy, bile leak, and loculated peri-hepatic £uid
collections, prompting ERCP and pancreatic and biliary
stent placements. The hospitalization was complicated by
marked lymphopenia, hospital-acquired pneumonia, and
UTI. CRAB was isolated in culture from both sites, and col-
istin was administered for 10 days. Recurrent CRAB uro-
sepsis was identi¢ed on PTD 38. Directed antimicrobial
therapy included piperacillin, colistin, and tigecycline for
14 days. The transplant ureteral stent was removed as a
possible source of recurrent UTI. However, the patient had
progressive, refractory multisystem organ failure compli-
cated by acute neutropenia. Supportive care was with-
drawn and the patient died on PTD 52. MDR P. aeruginosa
was isolated from premortem blood cultures.
Case 4
A 62-year-old female with HCV cirrhosis underwent com-
bined liver^kidney transplantation after a right hepatic
lobe resection for hepatocellular carcinoma was compli-
cated by acute liver failure and hepatorenal syndrome.
The immediate post-transplant course was complicated by
right heart failure, hepatic congestion precluding bile duct
anastamosis and abdominal wall closure, hepatic artery is-
chemia, and hepatic necrosis. She required multiple re-op-
erations for choledochocholedochostomy, hepatic artery
revision, and wound closure, debridement, and revision.
Post-transplant infectious complications included polymi-
crobial peritonitis with coagulase-negative staphylococci
and VRE, BSI due to carbapenem-susceptible Acinetobacter,
ocular infection with herpes simplex virus, and wound in-
fection and BSI due to Stenotrophomonas maltophilia. The
patient was discharged to a subacute nursing facility on
PTD 41, but several hospital admissions followed due to
carbapenem-susceptible Acinetobacter BSI, methicillin-re-
90 Transplant Infectious Disease 2010: 12: 87^93
sistant Staphylococcus aureus (MRSA) BSI, and Escherichia
coli UTI. Though CRAB was isolated from a respiratory
tract culture, there was no evidence of pneumonia. The pa-
tient clinically improved without CRAB-directed antimi-
crobial therapy and was discharged in stable condition on
PTD 125. She subsequently died at an outside hospital on
PTD 162. Her death was attributed to sepsis, but the etio-
logic agent was not identi¢ed.
Case 5
A 33 -year-old man with Werner syndrome, cryptogenic cir-
rhosis, and hepatorenal syndrome underwent combined liv-
er^kidney transplant complicated by delayed renal
allograft function necessitating renal replacement therapy.
He also required prolonged mechanical ventilation and
tracheostomy placement after periods of apnea and brady-
cardic arrest. The transplant hospitalization was marked
by lymphopenia, neutropenia, and multiple infections in-
cluding VRE urosepsis, Clostridium di⁄cile colitis, and an
ESBL-producing Enterobacter cloacae BSI. The patient was
transferred to a subacute nursing facility on PTD 27. He
was re-admitted on PTD 51 with sepsis attributed to a
VRE UTI and an ESBL-producing K. pneumoniae and
CRAB VAP. Initially, the patient improved on linezolid, imi-
penem, and amikacin. However, on PTD 70, CRAB was iso-
lated from the blood and urine. Despite therapy with
tigecycline, ampicillin^sulbactam, doxycycline, and colis-
tin, multisystem organ failure progressed. Multiple infec-
tious complications followed, including disseminated
herpes zoster virus infection, VRE peritonitis, recurrent
K. pneumoniae and CRAB VAP, K. pneumoniae peritonitis,
and coagulase-negative staphylococci BSI. Supportive
measures were withdrawn; the patient died on PTD 130.
Details of this case have been reported previously (10).
Case 6
A 49 -year-old man with peripheral vascular disease, HCV
infection, and end-stage renal disease due to focal segmen-
tal glomerulosclerosis underwent deceased-donor kidney
transplant with an extended criteria donor organ and with
ureteroureteral anastamosis. The postoperative course
was marked by delayed allograft function and renal re-
placement therapy; allograft biopsy suggested acute rejec-
tion. The biopsy was complicated by a large hematoma that
required surgical evacuation on PTD 14. Following dis-
charge, hematoma recurrence and a P. aeruginosa surgical
site infection prompted re-admission on PTD 46. The pa-
tient was placed on prolonged imipenem therapy. A urine
leak due to disruption of the ureteroureteral anastomosis
on PTD 60 led to percutaneous nephrostomy tube place-
 Reddy et al: Acinetobacter infections after organ transplant

ment. Numerous hospital admissions for UTIs and persis-
tent abdominal wound infection followed over the next 2
months. Delayed graft function persisted, and when a renal
biopsy on PTD 129 indicated moderate cellular rejection,
the patient received methylprednisolone. On PTD 193,
CRAB was isolated from the abdominal wound and the
bloodstream. Tobramycin and colistin were initiated. Ulti-
mately, ongoing abdominal infection prompted transplant
nephrectomy. Multiple infectious complications followed,
including VAP and parapneumonic empyema with MDR
P. aeruginosa and CRAB, and cytomegalovirus syndrome.
Despite aggressive antibiotic therapy, the patient died due
to sepsis on PTD 217.
Results
Our cohort included 1 deceased-donor kidney, 1 orthotopic
liver, and 4 simultaneous liver^kidney recipients. Recipi-
ents were predominantly male (66.7%) and Caucasian
(66.7%) with a median age of 61.5 years (range 35^68
years). Cytomegalovirus donor (D)/recipient (R) serostatus
included 2 (33.3%) D 1 /R , 2 (33.3%) D 1 /R 1 , and 2
(33.3%) D /R 1 . Five isolates were typed; 4 (cases 2, 3, 5,
and 6) resembled the isolate involved in the citywide out-
break.
All 6 recipients developed signi¢cant surgical and medi-
cal post-transplant complications before the acquisition of
CRAB. Hepatic complications included bile leak (n 5 2),
ampullary stenosis, ischemic cholangiopathy (n 5 2), and
hepatic allograft dysfunction. Complications of kidney
transplantation included post-transplant hematoma
(n 5 2), delayed renal allograft function (n 5 4), renal allo-
graft rejection (n 5 2), and ureteral stenosis with urinary
leak and urinoma.
All 6 patients had risk factors for colonization and/or in-
fection with an MDR pathogen (11, 12). In the 30 days before
CRAB identi¢cation, all were exposed to a subacute nurs-
ing facility and 5 (83%) patients were in the ICU. All 6 pa-
tients were colonized or infected with another MDR
organism including MRSA, VRE, ESBL-producing Enter-
obacteriaceae, or MDR P. aeruginosa. In addition, all 6 pa-
tients had a central venous catheter, 4 (66.7%) required
mechanical ventilation, and 3 (50%) required renal replace-
ment therapy before CRAB acquisition. All patients re-
ceived broad-spectrum antibiotic therapy, including
anaerobic coverage. Details of antecedent antibiotic use
are noted in Table 1. Speci¢cally, carbapenem was used in
4 (66.7%), cephalosporin in 1 (16.7%), vancomycin in 4
(66.7%), metronidazole in 2 (33.3%), and extended spec-
trum b-lactam/ESBL inhibitors in 3 (50%).
CRAB was acquired a median of 93.5 days after trans-
plantation (range 17^218 days). Most patients (83%) suf-
fered from CRAB pneumonia, and half of these recipients
subsequently developed CRAB BSI. Additional sites of
CRAB infection included the urinary tract and the surgical
site. A sixth patient was colonized, but not infected, with
the organism.
Four (80%) of 5 infected patients received antimicrobial
therapy for CRAB while 1 patient died before the identi¢ca-
tion of CRAB. Details of therapy are outlined inTable 2. All
4 patients were treated with a multi-drug regimen: 2 pa-
tients received ampicillin^sulbactam in combination with
an aminoglycoside (1 of whom received tigecycline) while
the other 2 were treated with colistin and tigecycline alone.
Subsequent to CRAB acquisition, all patients had poor
outcomes. Four kidney recipients su¡ered from graft fail-

Carbapenem-resistant Acinetobacter baumannii (CRAB): site of infection, antibiotic susceptibilities, and antibiotic management

Antibiotic susceptibilities (minimum inhibitory concentration)

Case Transplant CRAB source AMP-S IMIP CIP DOXY COL TET AMIK TOB Antibiotic therapy

1 OLT PNA 1 UTI ND  16 4 ND ND ND 32 8 AMP-S 1 AMIK

2 CRT/OLT PNA  32  16 4 S ND R  64  16 Died before RX
3 CRT/OLT PNA 1 BSI 1 UTI  32  16 4 S o2 R R 8 COL,TIG, PIP, DOXY
4 CRT/OLT Respiratory tract 4  16 4 I ND R R  16 Colonization, no RX
5 CRT/OLT PNA 1 BSI 16  16 4 ND ND R 16  16 AMP-S, DOXY,TIG, AMIK
6 CRT PNA 1 BSI 1 SSI  32  16  4 S 0.5 R 4 4 COL 1 TIG

OLT, orthotopic liver transplant; CRT, deceased donor kidney transplant; PNA, pneumonia; UTI, urinary tract infection; BSI, bloodstream infection; SSI, skin
and soft tissue infection; ND, not done; S, susceptible by Kirby^Bauer; R, resistant by Kirby^Bauer; AMP-S, ampicillin^sulbactam; IMIP, imipenem; CIP,
cipro£oxacin; DOXY, doxycycline; COL, colistin;TET, tetracycline; AMIK, amikacin;TOB, tobramycin;TIG, tigecycline; PIP, piperacillin; RX, therapy.

Table 2

Transplant Infectious Disease 2010: 12: 87^93 91

Reddy et al: Acinetobacter infections after organ transplant
ure requiring renal replacement therapy and 1 liver^kidney
recipient experienced hepatic dysfunction. Renal allograft
rejection occurred in 2 recipients. The kidney recipient un-
derwent transplant nephrectomy in an unsuccessful at-
tempt to control CRAB infection. Despite multi-drug
therapy, 4 (66.7%) patients died subsequent to CRAB diag-
nosis, with CRAB a primary or contributing factor to death.
A ¢fth patient died from sepsis of unclear etiology. All
deaths occurred within the ¢rst year post transplant, with
median of 162 days (range 53^219 days). T|me from CRAB
acquisition to infection-related death among these 5 pa-
tients was a median of only 36 days (range 1^71 days).
Discussion
MDR A. baumannii infections are associated with mortal-
ity rates of 16^49% among hospitalized patients (5, 6, 13).
However, outcomes of transplant recipients infected with
MDR A. baumannii infections are not well de¢ned. We re-
port our center’s recent experience with CRAB infections
among liver and/or kidney transplant recipients.
Singh et al. (14) noted that liver transplant recipients in-
fected with an MDR organism are signi¢cantly less likely
to survive at 1 year compared to non-infected liver trans-
plant counterparts or to those infected with susceptible
pathogens (14). Our cohort had similar poor outcomes, in-
cluding 66.7% renal allograft loss, 66.7% CRAB-related
mortality, and 80% overall infection-related mortality
within the ¢rst year of transplantation. In a retrospective
study of Acinetobacter infections among critically ill surgi-
cal patients, the reported mortality in the organ transplant
subset (n 5 30) was 64.5%. Immunosuppression, primarily
as a result of organ transplantation, was predictive of poor
outcomes. While carbapenem resistance was prevalent in
this cohort, it is unclear what proportion of the transplant
recipients had MDR A. baumannii (15). Among the ¢rst to
examine this emerging pathogen in immunocompromised
hosts, Sopirala et al. (16) found that lung transplant recipi-
ents with MDR A. baumannii infection su¡er from allo-
graft rejection (66.7%) or even death (33.3%).
Risk factors for MDR A. baumannii acquisition among
immunocompetent patients are well de¢ned (11, 12). The
present study suggests that such characteristics as central
venous catheter use, prolonged ICU stay, and mechanical
ventilation are also associated with CRAB acquisition and
infection among SOT recipients. Baran et al. (11) noted that
patients who received prior antibiotic therapy were at
5 -fold greater risk of CRAB. Not surprisingly, all patients
in this study were exposed to antimicrobial agents known
to predispose to CRAB, such as carbapenems, cephalospor-
92 Transplant Infectious Disease 2010: 12: 87^93
ins, and extended spectrum b-lactam/ESBL inhibitors (11,
17^19). Among 6 lung transplant recipients with MDR A.
baumannii, antecedent mechanical ventilation and broad-
spectrum antibiotic exposure were common characteris-
tics (16).
Case patients had established risk factors for coloniza-
tion and infection with MDR bacteria after SOT. Several
studies have demonstrated that biliary complications or
the need for re-operation are associated withVRE coloniza-
tion and infection after liver transplantation (20, 21). Nota-
bly, ischemic injury and other biliary complications
occurred among 3 liver transplant recipients in the present
study. Among renal transplant recipients, Linares et al. (2,
22) found that post-transplant urinary obstruction, post-
transplant nephrostomy, and a post-transplant hemodialy-
sis requirement are risk factors for the acquisition of anti-
biotic-resistant bacteria for kidney recipients. Four of 5
kidney recipients in the present study su¡ered from de-
layed graft function and a post-transplant hemodialysis
requirement, supporting these ¢ndings. Surgical interven-
tion was common among cases patients; 66.7% of patients
colonized or infected with CRAB underwent re-operation
post transplantation.
Another common characteristic of this small cohort in-
cluded the use of alemtuzumab induction immunosuppres-
sion. Alemtuzumab results in profound and prolonged
immunosuppressive e¡ects but its association with the
development of MDR bacterial infections remains unclear
(23). Our cohort suggests that further study is required
to clarify the risk of bacterial infection with this agent.
Optimal therapies for the treatment of CRAB infections
are not well de¢ned. Among immunocompetent patients
with a sulbactam-susceptible Acinetobacter isolate, mono-
therapy with sulbactam was as e¡ective as imipenem in
the treatment of VAP (24) and BSI (25). In the present study,
sulbactam therapy was only administered in conjunction
with an aminoglycoside, doxycycline and/or tigecycline
(see Table 2); 1 patient survived and 1 died. Uncontrolled
studies suggest that the use of colistin in combination with
other antimicrobials (including cabapenems, ampicillin^
sulbactam, aminoglycosides, and rifampin) may have some
success in the treatment of VAP due to MDR A. baumannii
(26, 27 ). T|gecycline, a glycylcycline derivative of tetracy-
cline, has demonstrated success in the treatment of CRAB
infections (28), however, its utility in the treatment of seri-
ous infection or BSI remains unclear (29). Patients in this
study who received colistin and/or tigecycline died, demon-
strating the need for further study of these agents in the
SOT population.
In summary, our experience suggests that poor allograft
outcomes and high mortality occur in patients who acquire
CRAB in the early post-transplant period. In most cases,
CRAB infection was directly implicated in or at least con-

tributed to mortality.Though this report is limited by small
cohort size and retrospective data collection, common fea-
tures among this cohort included receipt of combined or-
gan transplants, alemtuzumab induction, technical
complications, and prior infection with other antimicrobi-
al-resistant pathogens. Further study is required to de¢ne
acquisition risk factors speci¢c to organ recipients.
Acknowledgements:
Funding source: Northwestern University Feinberg School
of Medicine.
Potential con£icts of interest: None.
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