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Kriegl L, Boyer J, Egger M, Hoenigl M. Antifungal stewardship in solid organ transplantation. Transpl Infect Dis 2022; 24:e13855. [PMID: 35593394 PMCID: PMC9786549 DOI: 10.1111/tid.13855] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 05/10/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Antifungal stewardship (AFS) has emerged as an important component of quality in managing invasive fungal infections (IFIs), and cost-benefit calculations suggest regular training in AFS is well worth the effort. METHODS This review will discuss the most common IFIs in solid organ transplantation (SOT)-recipients, how to diagnose them, and current recommendations for antifungal treatment and prophylaxis before demonstrating key takeaway points of AFS in this high-risk population. RESULTS Effective AFS starts before a patient is admitted for SOT, through education and regular interactions of the interdisciplinary clinical team involved in patient management, considering local factors such as epidemiological data and knowledge of diagnostic options including local turnaround times. Understanding the spectrum of antifungal agents, their efficacy and safety profiles, and pharmacokinetics, as well as duration of therapy is hereby essential. The most frequent IFIs in SOT recipients are caused by Candida species, followed by Aspergillus species, both with increasing resistance rates. Diagnosis of IFI can be challenging due to unspecific clinical presentation and difficult interpretation of microbiological findings and biomarkers. Prophylactic strategies, such as those for invasive aspergillosis in lung transplantation or invasive candidiasis (IC) in certain liver transplant settings, as well as the selection of the appropriate therapeutic agents require detailed knowledge on the pharmacokinetics and drug-drug interactions of antifungals. CONCLUSIONS Here in this review, we address what constitutes good AFS in this heterogeneous field of solid organ transplant recipients.
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Affiliation(s)
- Lisa Kriegl
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Johannes Boyer
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Matthias Egger
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria,BioTechMed‐GrazGrazAustria
| | - Martin Hoenigl
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria,BioTechMed‐GrazGrazAustria,Division of Infectious Diseases and Global Public HealthDepartment of MedicineUniversity of California San DiegoSan DiegoCaliforniaUSA
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Hosseini-Moghaddam SM, Ouédraogo A, Naylor KL, Bota SE, Husain S, Nash DM, Paterson JM. Incidence and outcomes of invasive fungal infection among solid organ transplant recipients: A population-based cohort study. Transpl Infect Dis 2020; 22:e13250. [PMID: 31981389 DOI: 10.1111/tid.13250] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/06/2019] [Accepted: 01/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Invasive fungal infection (IFI) in solid organ transplant (SOT) recipients is associated with significant morbidity and mortality. The long-term probability of post-transplant IFI is poorly understood. METHODS We conducted a population-based cohort study using linked administrative healthcare databases from Ontario, Canada, to determine the incidence rate; 1-, 5-, and 10-year cumulative probabilities of IFI; and post-IFI all-cause mortality in SOT recipients from 2002 to 2016. We also determined post-IFI, death-censored renal allograft failure. RESULTS We included 9326 SOT recipients (median follow-up: 5.35 years). Overall, the incidence of IFI was 8.3 per 1000 person-years. The 1-year cumulative probability of IFI was 7.4% for lung, 5.4% for heart, 1.8% for liver, 1.2% for kidney-pancreas, and 1.1% for kidney-only allograft recipients. Lung transplant recipients had the highest incidence rate and 10-year probability of IFI: 43.0 per 1000 person-years and 26.4%, respectively. The 1-year all-cause mortality rate after IFI was 34.3%. IFI significantly increased the risk of mortality in SOT recipients over the entire follow-up period (hazard ratio: 6.50, 95% CI: 5.69-7.42). The 1-year probability of death-censored renal allograft failure after IFI was 9.8%. CONCLUSION Long-term cumulative probability of IFI varies widely among SOT recipients. Lung transplantation was associated with the highest incidence of IFI with considerable 1-year all-cause mortality.
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Affiliation(s)
- Seyed M Hosseini-Moghaddam
- ICES, ON, Canada.,Multiorgan Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada.,Division of Infectious Diseases, Department of Medicine, Western University, London, ON, Canada.,Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | | | | | | | - Shahid Husain
- Multiorgan Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Danielle M Nash
- ICES, ON, Canada.,Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - J Michael Paterson
- ICES, ON, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Family Medicine, McMaster University, Hamilton, ON, Canada
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A Rare Case of Pulmonary Coinfection by Lichtheimia ramosa and Aspergillus fumigatus in a Patient With Delayed Graft Function After Renal Transplantation. Transplant Proc 2019; 51:551-555. [PMID: 30879588 DOI: 10.1016/j.transproceed.2018.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 12/09/2018] [Indexed: 11/21/2022]
Abstract
Pulmonary coinfection with Mucor and Aspergillus species has not been reported in organ transplant recipients. Here, we report a rare case of pulmonary coinfection with invasive fungal species in a renal transplant recipient with delayed graft function. The patient was first treated with a regime containing voriconazole, but the infection only worsened. Then, bronchoalveolar lavage fluid culture and internal transcribed spacer region sequencing were performed, and simultaneous pulmonary infection by Lichtheimia ramosa and Aspergillus fumigatus was clearly diagnosed. Susceptibility testing determined that the fungi were sensitive to amphotericin B and posaconazole. Therefore, a therapeutic regime containing posaconazole and amphotericin B liposome, which are less toxic to the kidney, was planned and resulted in resolution of the infectious symptoms. The present case demonstrates the importance of identifying fungal pathogens early and definitively, determining the effective anti-fungal medications, and administering the properly planned therapeutic regime in a timely manner to treat cases of coinfection in transplant recipients.
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De Vega Sánchez B, Varela Falcón LH, Vielba Dueñas D, Sayago Silva I, De la Fuente Galán L, Disdier Vicente C. Empiema por Aspergillus fumigatus en pacientes con trasplante cardiaco. Rev Esp Cardiol (Engl Ed) 2018. [DOI: 10.1016/j.recesp.2017.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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de Vega Sánchez B, López Ramos I, Ortiz de Lejarazu R, Disdier Vicente C. Fungal Empyema: An Uncommon Entity With High Mortality. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.arbr.2017.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Pemán J, Aguilar G, Valía JC, Salavert M, Navarro D, Zaragoza R. Jávea consensus guidelines for the treatment of Candida peritonitis and other intra-abdominal fungal infections in non-neutropenic critically ill adult patients. Rev Iberoam Micol 2017; 34:130-142. [DOI: 10.1016/j.riam.2016.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/24/2016] [Accepted: 12/02/2016] [Indexed: 12/28/2022] Open
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de Vega Sánchez B, López Ramos I, Ortiz de Lejarazu R, Disdier Vicente C. Fungal Empyema: An Uncommon Entity With High Mortality. Arch Bronconeumol 2017; 53:641-642. [PMID: 28495076 DOI: 10.1016/j.arbres.2017.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 03/29/2017] [Accepted: 03/30/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Blanca de Vega Sánchez
- Servicio de Neumología, Hospital Clínico Universitario de Valladolid, Valladolid, España.
| | - Irene López Ramos
- Servicio de Microbiología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Raúl Ortiz de Lejarazu
- Servicio de Microbiología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Carlos Disdier Vicente
- Servicio de Neumología, Hospital Clínico Universitario de Valladolid, Valladolid, España; CIBERES (Centro de Investigación en Red Enfermedades Respiratorias), Valladolid, España
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De Vega Sánchez B, Varela Falcón LH, Vielba Dueñas D, Sayago Silva I, De la Fuente Galán L, Disdier Vicente C. Aspergillus fumigatus Empyema in Heart Transplant Recipients. ACTA ACUST UNITED AC 2017; 71:402-403. [PMID: 28473264 DOI: 10.1016/j.rec.2017.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 02/14/2017] [Indexed: 11/30/2022]
Affiliation(s)
| | - Luis Horacio Varela Falcón
- Unidad Insuficiencia Cardiaca, Servicio Cardiología, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - David Vielba Dueñas
- Servicio Neumología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Inés Sayago Silva
- Unidad Insuficiencia Cardiaca, Servicio Cardiología, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Luis De la Fuente Galán
- Unidad Insuficiencia Cardiaca, Servicio Cardiología, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Carlos Disdier Vicente
- Servicio Neumología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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9
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A Review of Lung Transplantation and Its Implications for the Acute Inpatient Rehabilitation Team. PM R 2016; 9:294-305. [DOI: 10.1016/j.pmrj.2016.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 09/21/2016] [Accepted: 09/23/2016] [Indexed: 12/12/2022]
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10
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Grau S. The Delphi method applied to fungal infection: There is still some way to go. Rev Iberoam Micol 2016; 33:185-186. [DOI: 10.1016/j.riam.2016.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 03/16/2016] [Accepted: 03/21/2016] [Indexed: 11/25/2022] Open
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