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Upper Extremity Infections In The Solid Organ Transplant Population: The Cleveland Clinic Experience
Rachel E. Aliotta, MD, Sayf Al Said, MD, DeAsia Jacob, MD, Bahar Bassiri Gharb, MD, PhD, Antonio Rampazzo, MD, PhD.
Cleveland Clinic, Cleveland, OH, USA.

PURPOSE: As the length of lifetime survival after organ transplantation continues to increase, the consequences of long-term immunosuppression, such as opportunistic and rare infections of the hand and upper extremity, are thought to be a high-risk reality. This study examines our experience with upper extremity infections (UEI) in the solid organ transplant population to further provide clinical, treatment and outcome data in this growing population of patients, as very limited studies with few patients are available in the literature.
METHODS: A large tertiary care center institutional database of 16,640 transplant patients was queried for UEI events between years 2005-2017, revealing 238 patients with UEIs, defined by the clinical suspicion of an infectious in an area between the shoulder and fingertip. Multivariable analysis using linear and logistic regression models to assess for the length of hospital stay and the likelihood of surgical intervention were performed using the SPSS software.
RESULTS: The mean age at the infection was 54.2 15.1 years of age. The infections were diagnosed at a median of 5 (IQR 10) years after transplantation. The most common infections were diagnosed in patients transplanted with kidneys (51.3%) and livers (19.7%). The most common location of infection was the forearm (31.1%), digits (27.5%), and upper arm (17.2%). The most common infection type was cellulitis (68.9%), abscess (31.9%), joint sepsis (7.0%), infectious tenosynovitis (3.7%), and osteomyelitis (1.1%). By far Staphylococcus Aureus was the most common pathogen cultured (11%). In 15.8% of the patients cultures were negative. In 93.4% of the patients the infection resolved after treatment and in 87.9% there was no recurrence. Only 8.1% of patient had recurrent infections, 3.7% ended up with an unresolved infection, and one mortality due to UEI. Immunosuppression with Tacrolimus or Prednisone were associated with shorter time to infection after transplantation. 43.2% of the patients were treated with IV antibiotics, 23.1% with oral antibiotics. 16.1% of the patients require bed side I&D and 13.9% formal OR debridement. Multivariable analysis revealed that patients with lung and bowel transplants, hypertension and patients on prophylactic antifungal medication were associated with a longer hospital stay, while patients on Azathioprine and Sirolimus immunosuppression and azithromycin prophylactic antibiotics were associated with shorter length of hospital stay (P < .001). Abscess, tenosynovitis, and septic joints were associated with higher odds of surgical intervention (P = .001).
CONCLUSION: This data demonstrates high cure rates and low recurrence rates for treatment of upper extremity infections. Based on culture driven data, it suggests that prompt recognition and treatment covering for common bacteria is not unreasonable as a first line. Providers should therefore escalate treatment regimens based on culture driven data. Patients who have been able to reduce their immunosuppression regimens to maintenance levels should still be considered high risk for soft tissue infections, and constant vigilance is advised.


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