Original clinical science
Lung transplantation for patients with cystic fibrosis and Burkholderia cepacia complex infection: A single-center experience

https://doi.org/10.1016/j.healun.2010.06.007Get rights and content

Background

Pre-operative infection with organisms from the Burkholderia cepacia complex (BCC), particularly B cenocepacia, has been linked with a poorer prognosis after transplantation compared to patients with cystic fibrosis (CF) without this infection. Therefore, many transplant centers do not list these patients for transplantation.

Methods

We report the early and long-term results of a cohort of lung transplant recipients with CF and pre-operative BCC infection. Patients with pre-transplantation BCC infection were identified by case-note review. BCC species status was assigned by polymerase chain reaction (PCR)-based techniques. Survival rates were compared to recipients with CF without BCC infection. Survival rates in BCC subgroups were also compared, and then further analyzed pre- and post-2001, when a new immunosuppressive and antibiotic regime was introduced for such patients.

Results

Two hundred sixteen patients with CF underwent lung transplantation and 22 had confirmed pre-operative BCC infection, with 12 of these being B cenocepacia. Nine B cenocepacia–infected recipients died within the first year, and in 8 BCC sepsis was considered to be the cause of death. Despite instituting a tailored peri-operative immunosuppressive and microbiologic care approach for such patients, post-transplantation BCC septic deaths occurred frequently in those with pre-transplantation B cenocepacia infection. In contrast, recipients infected with other BCC species had significantly better outcomes, with post-transplantation survival comparable to other recipients with CF.

Conclusions

Mortality in patients with B cenocepacia infection was unacceptably high and has led to our center no longer accepting patients with this condition onto the lung transplant waiting list. Long-term survival in the non–B cenocepacia BCC group was excellent, without high rates of acute rejection or bronchiolitis obliterans syndrome (BOS) longer term, and these patients continue to be considered for lung transplantation.

Section snippets

Case review

A retrospective review was performed of the lung transplantation database at the Freeman Hospital, from 1989 (program start) to the present date. Case notes and microbiology results for all transplant recipients with CF, including adults and children, were examined. Clinical progress from charts and case notes was recorded.

Peri-transplantation management

All BCC-infected patients underwent bilateral lung transplantation via bilateral thoracotomy (clamshell) incisions with bilateral apical and basal chest drains. Initially,

BCC genomovar status of recipients

A total of 216 patients with CF underwent lung transplantation. Microbiology culture and genetic techniques confirmed pre-transplantation infection with BCC genomovars in 22 recipients (10% of the transplant cohort; Table 1a, Table 1b, Table 2).

None of the patients identified with BCC infections developed de novo infection post-transplantation. Pre-transplantation (i.e., at transplant listing assessment), day-of-transplantation and multiple post-transplantation isolates were analyzed. All

Discussion

Collectively, our cohort of 22 patients, including those with B cenocepacia and other BCC genomovars, did not show statistically significantly poorer survival than the non–BCC-infected cohort of CF recipients. However, when sub-analyzed, there were clearly poorer outcomes among those with pre-transplantation B cenocepacia infection. The outcomes in this subset of patients are unacceptably poor, leading to the decision to discontinue listing them for lung transplantation.

The emergence of BCC

Disclosure statement

The first two authors (A.D.S. and G.M.) contributed equally to this study. A.D.S. was supported by the Breathe North Branch of the British Lung Foundation and a HEFCE Senior Lectureship. The authors are grateful to Professor J. Govan, University of Edinburgh, for helping to perform the pulsed-field gel electrophoresis experiments referred to in this study, as previously published in Thorax 2004;59(6):526-8. We also thank the transplant coordinators and administrative staff for their support in

References (40)

  • B.D. Alexander et al.

    Survival after lung transplantation of cystic fibrosis patients infected with Burkholderia cepacia complex

    Am J Transplant

    (2008)
  • S.D. Aaron

    Antibiotic sensitivity testing should not be routine for patients with cystic fibrosis who are infected with multiresistant bacterial organisms

    Paediatr Respir Rev

    (2007)
  • S.D. Aaron et al.

    Combination antibiotic susceptibility testing to treat exacerbations of cystic fibrosis associated with multiresistant bacteria: a randomised, double-blind, controlled clinical trial

    Lancet

    (2005)
  • F. Harrison

    Microbial ecology of the cystic fibrosis lung

    Microbiology

    (2007)
  • E. Mahenthiralingam et al.

    Taxonomy and pathogenesis of the Burkholderia cepacia complex

    Chronic Respir Dis

    (2005)
  • J.R. Govan et al.

    Evolving epidemiology of Pseudomonas aeruginosa and the Burkholderia cepacia complex in cystic fibrosis lung infection

    Future Microbiol

    (2007)
  • J.J. Lipuma

    Update on the Burkholderia cepacia complex

    Curr Opin Pulmon Med

    (2005)
  • T.G. Liou et al.

    Lung transplantation for cystic fibrosis

    Curr Opin Pulmon Med

    (2006)
  • S. Husain et al.

    Burkholderia cepacia infection and lung transplantation

    Sem Respir Infect

    (2002)
  • C. Chaparro et al.

    Infection with Burkholderia cepacia in cystic fibrosis; outcome following lung transplantation

    Am J Respir Crit Care Med

    (2001)
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