The emergence of vancomycin-resistant enterococci and other resistant organisms in transplantation

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Abstract
Organ transplant recipients are exceptionally vulnerable to infection from both opportunistic and nonopportunistic pathogens in the posttransplant period. Increasingly, many of these organisms have evolved mechanisms of resistance to previously effective antimicrobial agents, due in large part to the overuse or misuse of certain antimicrobials, poor infection control practices, and an increased host severity of illness. This trend has been especially pronounced among the common gram-positive bacteria, including the enterococci and staphylococci. Vancomycin-resistant enterococci have become a dominant pathogen in many liver and kidney transplant centers, with a variable increase in attributable morbidity and mortality. The optimal antimicrobial therapy for this organism remains unknown. The incidence of methicillin-resistant Staphylococcus aureus has continuously risen and drastically limited the choice of antimicrobial options for this virulent organism, which is capable of causing a wide range of infections in organ recipients. Recent reports of glycopeptide-intermediate strains of S. aureus may be a harbinger of high-level vancomycin resistance among the staphylococci. The rising incidence of non-albicans Candida species with azole resistance and or unusual mycelial fungi represents another epidemiologic shift that also poses new therapeutic challenges. This review focuses on these important trends, their clinical impact, and current and future therapeutic options.

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