Tailored Treatment May Improve Lung Transplant Outcome in Patients Colonized by Burkholderia Cenocepacia

Purpose: Patients affected by cystic fibrosis (CF) who are colonized by Burkholderia cenocepacia (BC) are often rejected by lung trans- plant centers because of the frequent adverse post operative (PO) course due to intractable sepsis. Few short series have been described by large transplant centers. We report our initial experience in such patients treated with a tailored immunosuppressive regimen after lung transplantation. Methods and Materials: Patients colonized preoperatively by BC who underwent bilateral lung tx for CF at our institution were managed as follows: basiliximab was used as induction treatment on post-operative day (POD) 0 and 4, and maintenance tacrolimus was added on PO hour 12, tailored to keep the trough level in the lower range (10 ng/ml). A 500 mg prednisolone bolus, given after each lung reperfusion, was followed by prednisone 0.3 mg/Kg/day, rapidly tapered to 0.1-0.05 mg/Kg/day at one month after transplantation. No 3rd immunosuppressive agent was added. Antibiotic regimen was determined by prior synergistic testing. Frequent bronchoscopies, enteral nutrition, aggressive respiratory therapy and rapid mobilization were administered during ICU stay. Results: Between June 2005 and September 2007, 4 BC-colonized patients out of 12 CF patients received a bilateral lung transplant from optimal donors. One of them died of fulminant sepsis in the first 2 months. The other three patients are alive at 19, 25 and 27 months PO, and free from acute and chronic rejection. Only 1 of them harbored BC in the subsequent BAL cultures. (1 yr actuarial survival CF BC vs non BC 75% vs 100%). Conclusions: A tailored immunosuppressive treatment associated with appropriate antibiotic prophylaxis and aggressive PO care may result in acceptable outcome in patients colonized by BC prior to lung transplantation.