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Hinze CA, Simon S, Gottlieb J. Respiratory infections in lung transplant recipients. Curr Opin Infect Dis 2025; 38:150-160. [PMID: 39927477 DOI: 10.1097/qco.0000000000001097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2025]
Abstract
PURPOSE OF REVIEW Morbidity and mortality rates after lung transplantation still remain higher than after other forms of solid organ transplantation, primarily due to a higher risk of infections and the development of chronic lung allograft dysfunction. Thus, a tiered approach highlighting the most significant respiratory pathogens including common opportunistic infections along with diagnostic, treatment and prevention strategies, including vaccination and prophylaxis is needed. RECENT FINDINGS The need for intense immunosuppressive therapy to prevent rejection, coupled with the transplanted lung's constant exposure to environment and impaired local defence mechanisms leads to frequent infections. Viral and bacterial infections are most frequent while fungal infections mainly involve the tracheobronchial tract but may be fatal in case of disseminated disease. Some infectious agents are known to trigger acute rejection or contribute to chronic allograft dysfunction. Invasive testing in the form of bronchoscopy with bronchoalveolar lavage is standard and increasing experience in point of care testing is gained to allow early preemptive therapy. SUMMARY Timely diagnosis, treatment, and ongoing monitoring are essential, but this can be difficult due to the wide variety of potential pathogens.
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Affiliation(s)
- Christopher Alexander Hinze
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Susanne Simon
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School
| | - Jens Gottlieb
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
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Gao R, Wang W, Qian T, Li X, Yang H, Liu T, Yu H, Man L, Xiong M, Chen J, Wu B. Pulmonary bacterial infection after lung transplantation: risk factors and impact on short-term mortality. J Infect 2024; 89:106273. [PMID: 39278277 DOI: 10.1016/j.jinf.2024.106273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 09/09/2024] [Accepted: 09/10/2024] [Indexed: 09/18/2024]
Abstract
OBJECTIVE To explore the risk factors for pulmonary bacterial infection (PBI) after lung transplantation (LTX) and to evaluate the impact of PBI on short-term postoperative mortality. METHODS We retrospectively analyzed data on 549 recipients who underwent LTX at the Affiliated Wuxi People's Hospital of Nanjing Medical University, China, between January 2018 and December 2021. The risk factors for PBI after LTX were explored by univariate analysis and multivariate logistic regression. Cox proportional hazards regression models were used to estimate the hazard ratios (HR) and 95% confidence intervals (CI) of one-, two-, and three-year mortality. Subgroup analysis was performed by the time of postoperative PBI (≤7 days or 8-30 day after surgery). RESULTS The incidence of postoperative PBI in 549 recipients was 82.70% (454/549). Preoperative history of infections with multidrug-resistant bacteria (OR 12.34, 95% CI 1.69-1572.39), Acinetobacter baumannii infection in donor (OR 3.08, 95% CI 1.26-9.66), and longer cold ischemia time (OR 1.16, 95% CI 1.03-1.32) were risk factors for postoperative PBI. Postoperative PBI was associated with one-year (HR 1.80, 95% CI 1.09-2.96), two-year (HR 1.91, 95% CI 1.20-3.04), and three-year mortality (HR 2.03, 95% CI 1.29-3.19). Subgroup analysis showed that PBI within 7 days after surgery was associated with one-year (HR 1.86, 95% CI 1.12-3.08), two-year (HR 1.99, 95% CI 1.25-3.17), and three-year mortality (HR 2.13, 95% CI 1.35-3.36), while PBI at 8-30 days after surgery was not associated with short-term mortality (one-year: HR 1.36, 95% CI 0.69-2.69; two-year: HR 1.48, 95% CI 0.80-2.76; three-year: HR 1.51, 95% CI 0.82-2.77). CONCLUSIONS Donor-recipient and surgical factors are risk factors for PBI after LTX. Active prevention and treatment of PBI within the first 7 days after surgery may improve short-term survival.
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Affiliation(s)
- Rong Gao
- Department of Laboratory Medicine, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Wenjing Wang
- Department of Intensive Care Unit, the Affiliated Jiangyin Hospital of Nantong University, Jiangyin, Jiangsu 214400, China; Department of Lung Transplantation Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Ting Qian
- Department of Lung Transplantation Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Xiaoshan Li
- Department of Lung Transplantation Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Hang Yang
- Department of Lung Transplantation Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Tianyang Liu
- Department of Lung Transplantation Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Huaqing Yu
- Department of Lung Transplantation Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Lin Man
- Department of Lung Transplantation Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Min Xiong
- Department of Lung Transplantation Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Jingyu Chen
- Department of Lung Transplantation Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu 214023, China.
| | - Bo Wu
- Department of Lung Transplantation Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu 214023, China.
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Pilmis B, Rouzaud C, To-Puzenat D, Gigandon A, Dauriat G, Feuillet S, Mitilian D, Issard J, Monnier AL, Lortholary O, Fadel E, Le Pavec J. Description, clinical impact and early outcome of S. maltophilia respiratory tract infections after lung transplantation, A retrospective observational study. Respir Med Res 2024; 86:101130. [PMID: 39260187 DOI: 10.1016/j.resmer.2024.101130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/18/2024] [Accepted: 07/21/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND AND RESEARCH QUESTION S. maltophilia infections are associated with significant morbidity and mortality. Little is known regarding its presentation, management, and outcome in lung transplant recipients. STUDY DESIGN AND METHODS This retrospective case control study reviewed S. maltophilia respiratory tract infection in lung transplant recipients (01/01/2011-31/01/2020) and described the clinical, microbiological and outcome characteristics matched with lung transplant recipients without respiratory tract infection. RESULTS AND INTERPRETATION We identified 63 S. maltophilia infections in lung transplant recipients. Among them none were colonized before transplantation. Infections occurred a median of 177 (IQR: 45- 681) days post transplantation. Fifty-four (85.7 %) patients received trimethoprim-sulfamethoxazole (400/80 mg three times a week) to prevent Pneumocystis jirovecii pneumonia (PJP). S. maltophilia strains were susceptible to trimethoprim-sulfamethoxazole, levofloxacin, minocycline and ceftazidime in respectively 85.7 %, 82.5 %, 96.8 % and 34.9 % of cases. Median duration of treatment was 9 days (IQR 7-11.5). Clinical and microbiological recurrence were observed in respectively 25.3 % and 39.7 % of cases. Combination therapy was not associated with a decrease in the risk of recurrence and did not prevent the emergence of resistance. S. maltophilia respiratory tract infection was associated with a decline in FEV-1 at one year. CONCLUSION S. maltophilia is an important cause of lower respiratory tract infection in lung transplant recipients. Trimethoprim-sulfamethoxazole use as prophylaxis for PJP doesn't prevent S. maltophilia infection among lung transplant recipients. Levofloxacin and trimethoprim-sulfamethoxazole appear to be the two molecules of choice for the treatment of these infections and new antibiotic strategies (cefiderocol, aztreonam/avibactam) are currently being evaluated for multi-resistant S. maltophilia infections.
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Affiliation(s)
- Benoît Pilmis
- Equipe Mobile de Microbiologie Clinique, Hôpitaux Saint-Joseph et Marie-Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France; Institut Micalis UMR 1319, Université Paris-Saclay, INRAe Châtenay Malabry, AgroParisTech, Domaine de Vilvert 75352 Jouy-en-Josas, France.
| | - Claire Rouzaud
- Equipe Mobile de Microbiologie Clinique, Hôpitaux Saint-Joseph et Marie-Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France; Service de Maladies infectieuses et Tropicales, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université de Paris, 149 rue de Sèvre, 75015 Paris, France
| | - Deborah To-Puzenat
- Equipe Mobile de Microbiologie Clinique, Hôpitaux Saint-Joseph et Marie-Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Anne Gigandon
- Service de Microbiologie Clinique, Plateforme de dosage des anti-infectieux, Hôpitaux Saint-Joseph et Marie-Lannelongue, 185 rue Raymond Losserand, 75014, Paris, France
| | - Gaelle Dauriat
- Service de Pneumologie et Transplantation Pulmonaire, Hôpitaux Saint-Joseph et Marie-Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Séverine Feuillet
- Service de Pneumologie et Transplantation Pulmonaire, Hôpitaux Saint-Joseph et Marie-Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Delphine Mitilian
- Service de chirurgie thoracique et Transplantation Pulmonaire, Hôpitaux Saint-Joseph et Marie-Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Justin Issard
- Service de chirurgie thoracique et Transplantation Pulmonaire, Hôpitaux Saint-Joseph et Marie-Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Alban Le Monnier
- Institut Micalis UMR 1319, Université Paris-Saclay, INRAe Châtenay Malabry, AgroParisTech, Domaine de Vilvert 75352 Jouy-en-Josas, France; Service de Microbiologie Clinique, Plateforme de dosage des anti-infectieux, Hôpitaux Saint-Joseph et Marie-Lannelongue, 185 rue Raymond Losserand, 75014, Paris, France
| | - Olivier Lortholary
- Service de Maladies infectieuses et Tropicales, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université de Paris, 149 rue de Sèvre, 75015 Paris, France
| | - Elie Fadel
- Service de chirurgie thoracique et Transplantation Pulmonaire, Hôpitaux Saint-Joseph et Marie-Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris-Saclay, Faculté de Médecine, 63 rue Gabriel Péri, 94270 Le Kremlin Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Jérôme Le Pavec
- Service de Pneumologie et Transplantation Pulmonaire, Hôpitaux Saint-Joseph et Marie-Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France; Université Paris-Saclay, Faculté de Médecine, 63 rue Gabriel Péri, 94270 Le Kremlin Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France
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McCort M, MacKenzie E, Pursell K, Pitrak D. Bacterial infections in lung transplantation. J Thorac Dis 2021; 13:6654-6672. [PMID: 34992843 PMCID: PMC8662486 DOI: 10.21037/jtd-2021-12] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 02/18/2021] [Indexed: 12/30/2022]
Abstract
Lung transplantation has lower survival rates compared to other than other solid organ transplants (SOT) due to higher rates of infection and rejection-related complications, and bacterial infections (BI) are the most frequent infectious complications. Excess morbidity and mortality are not only a direct consequence of these BI, but so are subsequent loss of allograft tolerance, rejection, and chronic lung allograft dysfunction due to bronchiolitis obliterans syndrome (BOS). A wide variety of pathogens can cause infections in lung transplant recipients (LTRs), including a number of nosocomial pathogens and other multidrug-resistant (MDR) pathogens. Although pneumonia and intrathoracic infections predominate, LTRs are at risk of a number of types of infections. Risk factors include altered anatomy and function of airways, impaired immunity, the microbial flora of the donor and recipient, underlying medical conditions, and genetic factors. Further work on immune monitoring has the potential to improve outcomes. The infecting agents can be derived from the donor lung, pre-existing recipient flora, or acquired from the environment over time. Certain infections may preclude lung transplantation, but this varies from center to center, and more recent studies suggest fewer patients should be disqualified. New molecular methods allow microbiome studies of the lung, gut, and other sites that may further our knowledge of how airway colonization can result in infection and allograft loss. Surveillance, early diagnosis, and aggressive antimicrobial therapy of BI is critical in LTRs. Antibiotic resistance is a major barrier to successful management of these infections. The availability of new agents for MDR Gram-negatives may improve outcomes. Other new therapies, such as bacteriophage therapy, show promise for the future. Finally, it is important to prevent infections through peri-transplant prophylaxis, vaccination, and infection control measures.
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Affiliation(s)
- Margaret McCort
- Albert Einstein College of Medicine, Division of Infectious Disease, New York, NY, USA
| | - Erica MacKenzie
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
| | - Kenneth Pursell
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
| | - David Pitrak
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
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Bazemore K, Rohly M, Permpalung N, Yu K, Timofte I, Brown AW, Orens J, Iacono A, Nathan SD, Avery RK, Valantine H, Agbor-Enoh S, Shah PD. Donor derived cell free DNA% is elevated with pathogens that are risk factors for acute and chronic lung allograft injury. J Heart Lung Transplant 2021; 40:1454-1462. [PMID: 34344623 DOI: 10.1016/j.healun.2021.05.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 05/21/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute and chronic forms of lung allograft injury are associated with specific respiratory pathogens. Donor-derived cell free DNA (ddcfDNA) has been shown to be elevated with acute lung allograft injury and predictive of long-term outcomes. We examined the %ddcfDNA values at times of microbial isolation from bronchoalveolar lavage (BAL). METHODS Two hundred and six BAL samples from 51 Lung Transplant Recipients (LTRs) with concurrently available plasma %ddcfDNA were analyzed along with microbiology and histopathology. Microbial species were grouped into bacterial, fungal, and viral and "higher risk" and "lower risk" cohorts based on historical association with downstream allograft dysfunction. Analyses were performed to determine pathogen category association with %ddcfDNA, independent of inter-subject variability. RESULTS Presence of microbial isolates in BAL was not associated with elevated %ddcfDNA compared to samples without isolates. However, "higher risk" bacterial and viral microbes showed greater %ddcfDNA values than lower risk species (1.19% vs. 0.65%, p < 0.01), independent of inter-subject variability. Histopathologic abnormalities concurrent with pathogen isolation were associated with higher %ddcfDNA compared to isolation episodes with normal histopathology (medians 1.23% and 0.66%, p = 0.05). Assessments showed no evidence of correlation between histopathology or bronchoscopy indication and presence of higher risk vs. lower risk pathogens. CONCLUSION %ddcfDNA is higher among cases of microbial isolation with concurrent abnormal histopathology and with isolation of higher risk pathogens known to increase risk of allograft dysfunction. Future studies should assess if %ddcfDNA can be used to stratify pathogens for risk of CLAD and identify pathogen associated injury prior to histopathology.
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Affiliation(s)
- Katrina Bazemore
- Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | | | - Nitipong Permpalung
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Kai Yu
- National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Irina Timofte
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Department of Medicine, University of Maryland, College Park, Maryland
| | - A Whitney Brown
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia
| | - Jonathan Orens
- Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland
| | - Aldo Iacono
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Department of Medicine, University of Maryland, College Park, Maryland
| | - Steven D Nathan
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Department of Medicine, University of Maryland, College Park, Maryland
| | - Robin K Avery
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Hannah Valantine
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Sean Agbor-Enoh
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
| | - Pali D Shah
- Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland.
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Tejada S, Campogiani L, Mazo C, Romero A, Peña Y, Pont T, Gómez A, Román A, Rello J. Acute respiratory failure among lung transplant adults requiring intensive care: Changing spectrum of causative organisms and impact of procalcitonin test in the diagnostic workup. Transpl Infect Dis 2020; 22:e13346. [PMID: 32473604 DOI: 10.1111/tid.13346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/14/2020] [Accepted: 05/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim was to identify the causing organisms and assess the association of procalcitonin (PCT) with bacterial pneumonia within 24 hours of intensive care unit admission (ICU-A) among lung transplant (LT) adult recipients. METHODS Secondary analysis from a prospective cohort study. All LT adults admitted to ICU for acute respiratory failure (ARF) over 5 years were included. Patients were followed until hospital discharge or death. RESULTS Fifty-eight consecutive LT patients were enrolled. The most important cause of ICU-A due to ARF was pneumonia 29 (50%) followed by acute rejection 3 (5.2%) and bronchiolitis obliterans syndrome exacerbation 3 (5.2%). Microorganisms were isolated from 22/29 cases with pneumonia (75.9%): 17 (77.2%) bacterial, 4 (18.2%) viral, 1 (4.5%) Aspergillus fumigates, with Pseudomonas aeruginosa being the most common cause (45.5%) of pneumonia, with 10 patients presenting chronic colonization by P aeruginosa. Median [Interquartile range (IQR)] PCT levels within 24 hours after admission were higher in pneumonia (1.5 µg/L; IQR:0.3-22.0), than in non-pneumonia cases (0.2 µg/L; IQR:0.1-0.7) (P = .019) and PCT levels within 24 hours helped to discriminate bacterial pneumonia (8.2 µg/L; IQR:0.2-43.0) from viral pneumonia and non-pneumonia cases (0.2 µg/L; IQR:0.1-0.7). The overall negative predictive value for bacterial pneumonia was 85.1%, increasing to 91.6% among episodes after 6 months of LT. CONCLUSIONS Causes of severe pneumonia in LT are changing, with predominant role of P aeruginosa and respiratory viruses. PCT ≤ 0.5 μg/L within 24 hours helps to exclude bacterial pneumonia diagnosis in LT adults requiring ICU-A. A negative PCT test allows antimicrobial de-escalation and requires an alternative diagnostic to bacterial pneumonia.
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Affiliation(s)
- Sofia Tejada
- CIBER de Enfermedades Respiratorias (CIBERES), Instituo Salud Carlos III, Madrid, Spain.,Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
| | - Laura Campogiani
- Clinical Infectious Diseases, Department of System Medicine, Tor Vergata University, Rome, Italy
| | - Cristopher Mazo
- CIBER de Enfermedades Respiratorias (CIBERES), Instituo Salud Carlos III, Madrid, Spain.,Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain.,Department of Donor & Transplant Coordination, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Anabel Romero
- ONCOBELL Program - Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Yolanda Peña
- CIBER de Enfermedades Respiratorias (CIBERES), Instituo Salud Carlos III, Madrid, Spain.,Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
| | - Teresa Pont
- Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain.,Department of Donor & Transplant Coordination, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Aroa Gómez
- Department of Donor & Transplant Coordination, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Antonio Román
- Respiratory Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jordi Rello
- CIBER de Enfermedades Respiratorias (CIBERES), Instituo Salud Carlos III, Madrid, Spain.,Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain.,Anesthesia Department, Clinical Research in the ICU, CHU Nimes, Universite de Nimes-Montpellier, Nimes, France
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