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Perils of medical tourism Dr Theo Gouliouris Microbiology and Infectious Diseases StR Addenbrookes Hospital, Cambridge.

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Presentation on theme: "Perils of medical tourism Dr Theo Gouliouris Microbiology and Infectious Diseases StR Addenbrookes Hospital, Cambridge."— Presentation transcript:

1 Perils of medical tourism Dr Theo Gouliouris Microbiology and Infectious Diseases StR Addenbrookes Hospital, Cambridge

2 Case history 55 year old man, Pakistani origin ESRD secondary to hypertensive nephrosclerosis 2007 Haemodialysis via AV fistula 2009 Transplant waiting list

3 Case history Summer 2010 Travelled to Pakistan August 2010 HCV antibody and PCR positive Removed from transplant waiting list pending antiviral therapy September 2010 commenced on ribavirin 200 mg daily October 2010 travelled to Pakistan against medical advice

4 Acute presentation May 2011 Presented to Addenbrookes unwell Living-related kidney transplant in Pakistan Nov 2010 –Donor and HLA match unclear –Recipient CMV positive Complications –ARDS, ventilated in ICU for 4 days –Wound dehiscence and infected perinephric haematoma, treated with imipenem and colistin –Poor graft function: creatinine 477 mol/L Medications: Prednisolone 10mg od, Tacrolimus 3mg/4mg, Mycophenolic acid 720mg bd

5 Examination Vomiting Febrile T 38.9°C Tachycardia Widespread vesicular rash consistent with shingles Open wound in right iliac fossa, packed, discharging pus Commenced on empirical piperacillin-tazobactam and aciclovir Barrier nursed

6 Baseline investigations Blood testResultNormal range Urea mmol/l Creatinine mol/l Albumin g/l ALP U/l ALT60-50 U/l Bilirubin mol/l CRP590-6 mg/l WCC x10 9 /l Neutrophils x10 9 /l Lymphocytes x10 9 /l Haemoglobin8.8 g/dl Platelets x10 9 /l PT s

7 CT abdomen and pelvis

8 Management and progress Ultrasound-guided drainage of 3 largest collections Clinical deterioration –Ongoing fever –Productive cough –CXR pulmonary infiltrates –Metabolic acidosis –Diarrhoea Mycophenolate and tacrolimus stopped Transplant nephrectomy 12 days post-admission

9 Microbiology / virology results Skin vesicles: VZV DNA detected Blood: Low-grade CMV viraemia Stool: Norovirus detected Wound swabs: –Multidrug-resistant ESBL-producing Klebsiella pneumoniae and E. coli –vancomycin-resistant Enterococcus faecium Peri-nephric abscess aspirates –Filamentous mould - Aspergillus terreus (amphotericin B resistant) –Meropenem-resistant Klebsiella pneumoniae

10 AntimicrobialMIC (mg/l)S/I/RBreakpoint Ampicillin>64R8 Amoxillin/Clavulanate64R8 Cefotaxime>256R1-2 Ceftazidime>256R1-8 Ertapenem>16R0.5-1 Imipenem16R2-8 Meropenem16R2-8 AztreonamNot doneR2-4 Piperacillin/Tazobactam>64R16 Colistin32R2 Ciprofloxacin>8R0.5-1 Gentamicin1S8-16 Amikacin2S8-16 Tobramycin4I2-4 Tigecycline0.5S1-2 Fosfomycin4S(32) Klebsiella pneumoniae antibiogram

11 Real-time PCR detection of New Delhi metallo- beta-lactamase Purple - control NDM positive extract DNA Green - clinical isolate extract DNA Black/blue - PCR negative control isolates Courtesy of R. Swayne and M.Ellington, Cambridge HPA

12 Histopathology results

13 GII.4 – Most prevalent norovirus in humans Adapted from Glass et al. Norovirus Gastroenteritis. N Engl J Med 2009;361:1776 GII Cluster GI Cluster GIV Cluster Courtesy of M. Curran, Cambridge HPA

14 Further management Recurrent collections requiring drainage procedures Antimicrobial therapy complex – renal impairment, drug interactions and toxicity, multiple MDR organisms, need for prolonged treatment Long courses of tigecycline (63d), amikacin (45d) and voriconazole

15 Transplant tourism Common –5 to 10% of kidney transplants performed worldwide –Pakistan 2006: 2/3 of 2000 transplants for foreign recipients 1 Ethical issues –Organ trafficking –Transplant commercialism Declaration of Istanbul on Organ Trafficking and Transplant Tourism, Naqvi et al, Transpl Int 2007; 20: 934

16 Literature review of outcomes 21 case series between 1990 and 2012 Total no. of patients 1331 (range 5 – 515) Countries: India (62%), Pakistan (13%), China (12%), Philippines (3%), Egypt (3%), Iran Graft 1-yr survival rate 86.9% (range %) Patient 1-yr survival rate 91.9% (range %) Acute rejection common 23.4% (range 10-50%)

17 Infective complications Infections common, esp. CMV, wound infections Significant risk of BBV acquisition –HIV 0.8% –HBV 4% –HCV 16% Risk of TB 3% Malaria reported (1.8%) Little emphasis on resistant organisms (mainly ESBL producing Enterobacteriaceae, one panresistant Acinetobacter baumannii)

18 Aspergillus infections in renal transplants 1.3% one-year cumulative incidence of invasive fungal infections in renal transplants 1 14% of IFI caused by Aspergillus spp. (<5% A. terreus) Usually pulmonary or disseminated infection Recognised association with transplant tourism 2 17 cases identified Infection in transplanted graft 35% Graft loss or death 76% 1.Pappas et al, CID 2010; 50: Shoham et al, Transplant ID 2010; 12: 371

19 Outcome Discharged from hospital on day 82 Last clinical review: wound completely healed, incisional hernia HCV RNA negative

20 Conclusions Transplant tourism is associated with significant morbidity and mortality, particularly related to infection NDM-1 producers, pose a significant risk to patients who travel to the Indian subcontinent for medical treatment Patients returning following hospitalisation in endemic countries should be screened for the presence of resistant bacteria and isolated Rapid molecular detection methods for antimicrobial resistance facilitate prompt diagnosis

21 Acknowledgments Dr S.H. Aliyu, Dr S. Ojha, Prof S. J. Peacock, Dr M.E. Török Renal Transplant team Microbiology and Infectious Diseases colleagues Dr Matthew Ellington, Dr Rosie Swayne (Cambridge HPA) Dr Martin Curran (Cambridge HPA) Dr Verena Broecker (Histopathology Department) Dr Winterbottom (Radiology Department)

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