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Alsaeed M, Husain S. Infections in Heart and Lung Transplant Recipients. Infect Dis Clin North Am 2024; 38:103-120. [PMID: 38280759 DOI: 10.1016/j.idc.2023.11.003] [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] [Indexed: 01/29/2024]
Abstract
Infections in heart and lung transplant recipients are complex and heterogeneous. This article reviews the epidemiology, risk factors, specific clinical syndromes, and most frequent opportunistic infections in heart and/or lung transplant recipients that will be encountered in the intensive care unit and will provide a practical approach of empirical management.
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Affiliation(s)
- Mohammed Alsaeed
- Division of Infectious Diseases, Multi-Organ Transplant Program, Department of Medicine, University of Toronto, University Health Network, 585 University Avenue, 11 PMB 138, Toronto, Ontario M5G 2N2, Canada; Division of Infectious Diseases, Department of Medicine, Prince Sultan Military Medical City, Makkah Al Mukarramah Road, As Sulimaniyah, Riyadh 12233, Saudi Arabia
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, Department of Medicine, University of Toronto, University Health Network, 585 University Avenue, 11 PMB 138, Toronto, Ontario M5G 2N2, Canada.
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Neofytos D, Stampf S, Hoessly LD, D’Asaro M, Tang GN, Boggian K, Hirzel C, Khanna N, Manuel O, Mueller NJ, Van Delden C. Bacteremia During the First Year After Solid Organ Transplantation: An Epidemiological Update. Open Forum Infect Dis 2023; 10:ofad247. [PMID: 37323422 PMCID: PMC10267299 DOI: 10.1093/ofid/ofad247] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/04/2023] [Indexed: 06/17/2023] Open
Abstract
Background There are limited contemporary data on the epidemiology and outcomes of bacteremia in solid organ transplant recipients (SOTr). Methods Using the Swiss Transplant Cohort Study registry from 2008 to 2019, we performed a retrospective nested multicenter cohort study to describe the epidemiology of bacteremia in SOTr during the first year post-transplant. Results Of 4383 patients, 415 (9.5%) with 557 cases of bacteremia due to 627 pathogens were identified. One-year incidence was 9.5%, 12.8%, 11.4%, 9.8%, 8.3%, and 5.9% for all, heart, liver, lung, kidney, and kidney-pancreas SOTr, respectively (P = .003). Incidence decreased during the study period (hazard ratio, 0.66; P < .001). One-year incidence due to gram-negative bacilli (GNB), gram-positive cocci (GPC), and gram-positive bacilli (GPB) was 5.62%, 2.81%, and 0.23%, respectively. Seven (of 28, 25%) Staphylococcus aureus isolates were methicillin-resistant, 2/67 (3%) enterococci were vancomycin-resistant, and 32/250 (12.8%) GNB produced extended-spectrum beta-lactamases. Risk factors for bacteremia within 1 year post-transplant included age, diabetes, cardiopulmonary diseases, surgical/medical post-transplant complications, rejection, and fungal infections. Predictors for bacteremia during the first 30 days post-transplant included surgical post-transplant complications, rejection, deceased donor, and liver and lung transplantation. Transplantation in 2014-2019, CMV donor-negative/recipient-negative serology, and cotrimoxazole Pneumocystis prophylaxis were protective against bacteremia. Thirty-day mortality in SOTr with bacteremia was 3% and did not differ by SOT type. Conclusions Almost 1/10 SOTr may develop bacteremia during the first year post-transplant associated with low mortality. Lower bacteremia rates have been observed since 2014 and in patients receiving cotrimoxazole prophylaxis. Variabilities in incidence, timing, and pathogen of bacteremia across different SOT types may be used to tailor prophylactic and clinical approaches.
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Affiliation(s)
- Dionysios Neofytos
- Correspondence: Dionysios Neofytos, MD, MPH, Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève 14, Switzerland (); or Christian van Delden, MD, Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève 14, Switzerland ()
| | - Susanne Stampf
- Clinic for Transplantation Immunology and Nephrology (Swiss Transplant Cohort Study), University Hospital of Basel, Basel, Switzerland
| | - Linard D Hoessly
- Clinic for Transplantation Immunology and Nephrology (Swiss Transplant Cohort Study), University Hospital of Basel, Basel, Switzerland
| | - Matilde D’Asaro
- Transplant Infectious Diseases Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Gael Nguyen Tang
- Transplant Infectious Diseases Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Katia Boggian
- Division of Infectious Diseases, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Cedric Hirzel
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | - Oriol Manuel
- Division of Infectious Diseases, University Hospital of Vaud, Lausanne, Switzerland
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Switzerland
| | - Christian Van Delden
- Correspondence: Dionysios Neofytos, MD, MPH, Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève 14, Switzerland (); or Christian van Delden, MD, Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève 14, Switzerland ()
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Chen J, Li J, Huang F, Fang J, Cao Y, Zhang K, Zhou H, Cai J, Cui W, Chen C, Zhang G. Clinical characteristics, risk factors and outcomes of Klebsiella pneumoniae pneumonia developing secondary Klebsiella pneumoniae bloodstream infection. BMC Pulm Med 2023; 23:102. [PMID: 36978069 PMCID: PMC10052803 DOI: 10.1186/s12890-023-02394-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/21/2023] [Indexed: 03/29/2023] Open
Abstract
Abstract
Purpose
The clinical characteristics of Klebsiella pneumoniae (KP) pneumonia and KP bloodstream infection (KP-BSI) are often reported, while the risk factors for KP pneumonia developing into secondary KP-BSI (KP-pneumonia/KP-BSI) are largely unknown. Therefore, this study attempted to investigate the clinical characteristics, risk factors and outcomes of KP-pneumonia/KP-BSI.
Methods
A retrospective observational study was conducted at a tertiary hospital between January 1, 2018, and December 31, 2020. The patients were divided into groups of KP pneumonia alone and KP pneumonia/KP-BSI, and the clinical information were collected from medical records electronic system.
Results
A total of 409 patients were finally recruited. According to the multivariate logistic regression analysis, male sex (adjusted odds ratio [aOR] 3.7; 95% CI, 1.44–9.5), immunosuppression (aOR, 13.52; 95% CI, 2.53,72.22), APACHE II score higher than 21 (aOR, 3.39; 95% CI, 1.41–8.12), serum procalcitonin (PCT) levels above 1.8 ng/ml (aOR, 6.37; 95% CI, 2.67–15.27), ICU stay of more than 2.5 days before pneumonia onset (aOR, 1.09; 95% CI, 1.02,1.17), mechanical ventilation (aOR, 4.96; 95% CI, 1.2,20.5), Klebsiella pneumoniae isolates producing extended spectrum β-lactamase (ESBL-positive KP) (aOR, 12.93; 95% CI, 5.26–31.76), and inappropriate antibacterial therapy (aOR, 12.38; 95% CI, 5.36–28.58) were independent factors of KP pneumonia/KP BSI. In comparison with the patients with KP pneumonia alone, the patients with KP pneumonia/KP BSI showed an almost 3 times higher incidence of septic shock (64.4% vs. 20.1%, p < 0.01), a longer duration of mechanical ventilation, and longer lengths of ICU stay and total hospital stay (median days, 15 vs. 4,19 vs. 6, 34 vs. 17, respectively, both p < 0.01). Additionally, the overall in-hospital crude mortality rate in the patients with KP-pneumonia/KP-BSI was more than two times higher than that in those with KP pneumonia alone (61.5% vs. 27.4%, p < 0.01).
Conclusion
Factors including male sex, immunosuppression, APACHE II score higher than 21, serum PCT levels above 1.8 ng/ml, ICU stay of more than 2.5 days before pneumonia onset, mechanical ventilation, ESBL-positive KP, and inappropriate antibacterial therapy are independent risk factors for KP pneumonia/KP-BSI. Of note, the outcomes in patients with KP pneumonia worsen once they develop secondary KP-BSI, which merits more attention.
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Eichenberger EM, Troy J, Ruffin F, Dagher M, Thaden JT, Ford ML, Fowler VG. Gram-negative bacteremia in solid organ transplant recipients: Clinical characteristics and outcomes as compared to immunocompetent non-transplant recipients. Transpl Infect Dis 2022; 24:e13969. [PMID: 36411527 PMCID: PMC9780155 DOI: 10.1111/tid.13969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/19/2022] [Accepted: 08/04/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Outcomes from Gram-negative bacteremia (GNB) in solid organ transplant (SOT) recipients are poorly understood. METHODS This is a single center prospective cohort study comparing the clinical characteristics and outcomes of SOT recipients with GNB to immunocompetent non-SOT patients with GNB between 1/1/2002 through 12/31/2018. Outcomes of interest included incidence of septic shock, respiratory failure, and time to death. A multivariable logistic regression model was used to determine factors associated with incidence of septic shock and respiratory failure. Time to death was evaluated using Cox proportional hazard models. RESULTS A total of 297 SOT and 1245 immunocompetent non-SOT patients were included. Incidence of septic shock did not significantly differ between the groups (SOT 25.3% vs. non-SOT 24.6%, p = .8225). Overall survival did not significantly differ by transplant status (30-day survival: SOT 76%, 95% confidence interval [CI] 70, 92, non-SOT 74%, 95% CI 71, 77: log rank: p = .76). SOT recipients taking three immunosuppressive medications had significantly lower odds of developing septic shock or respiratory failure requiring intubation and mechanical ventilation than those taking ≤1 agent (shock: adjusted odds ratio [aOR] 0.29, 95% CI 0.09, 0.90, p = .0316; respiratory failure: aOR 0.14, 95% CI: 0.04, 0.49, p = .0020). CONCLUSIONS SOT recipients with GNB do not experience higher rates of septic shock, respiratory failure, or mortality than immnon-SOT recipients with GNB. Among SOT recipients, a greater number of immunosuppressive medications may be associated with improved outcomes during GNB. Future studies are needed to understand the potential relationship between levels of immunosuppression and clinical outcome in SOT recipients with GNB.
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Affiliation(s)
- Emily M Eichenberger
- Department of Medicine, Division of Infectious Disease, Duke University Medical Center
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine
| | - Jesse Troy
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine
| | - Felicia Ruffin
- Department of Medicine, Division of Infectious Disease, Duke University Medical Center
| | - Michael Dagher
- Department of Medicine, Division of Infectious Disease, Duke University Medical Center
| | - Joshua T Thaden
- Department of Medicine, Division of Infectious Disease, Duke University Medical Center
| | - Mandy L Ford
- Department of Surgery, Division of Transplant, Emory University School of Medicine
| | - Vance G Fowler
- Department of Medicine, Division of Infectious Disease, Duke University Medical Center
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Tran-Dinh A, Guiot M, Tanaka S, Lortat-Jacob B, Atchade E, Zappella N, Mordant P, Castier Y, Mal H, Weisenburger G, Messika J, Grall N, Montravers P. Bacteraemia Is Associated with Increased ICU Mortality in the Postoperative Course of Lung Transplantation. Antibiotics (Basel) 2022; 11:antibiotics11101405. [PMID: 36290063 PMCID: PMC9598225 DOI: 10.3390/antibiotics11101405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to describe the prevalence, risk factors, morbidity and mortality associated with the occurrence of bacteraemia during the postoperative ICU stay after lung transplantation (LT). We conducted a retrospective single-centre study that included all consecutive patients who underwent LT between January 2015 and October 2021. We analysed all the blood cultures drawn during the postoperative ICU stay, as well as samples from suspected infectious sources in case of bacteraemia. Forty-six bacteria were isolated from 45 bacteraemic patients in 33/303 (10.9%) patients during the postoperative ICU stay. Staphylococcus aureus (17.8%) was the most frequent bacteria, followed by Pseudomonas aeruginosa (15.6%) and Enterococcus faecium (15.6%). Multidrug-resistant bacteria accounted for 8/46 (17.8%) of the isolates. The most common source of bacteraemia was pneumonia (38.3%). No pre- or intraoperative risk factor for bacteraemia was identified. Recipients who experienced bacteraemia required more renal replacement therapy, invasive mechanical ventilation, norepinephrine support, tracheotomy and more days of hospitalization during the ICU stay. After adjustment for age, sex, type of LT procedure and the need for intraoperative ECMO, the occurrence of bacteraemia was associated with a higher mortality rate in the ICU (aOR = 3.55, 95% CI [1.56–8.08], p = 0.003). Bacteraemia is a major source of concern for lung transplant recipients.
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Affiliation(s)
- Alexy Tran-Dinh
- Département d’Anesthésie-Réanimation, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
- INSERM UMR 1148 LVTS, Université Paris Cité, 75018 Paris, France
- Correspondence: ; Tel.: +33-1-40-25-83-55
| | - Marion Guiot
- Département d’Anesthésie-Réanimation, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
| | - Sébastien Tanaka
- Département d’Anesthésie-Réanimation, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
- INSERM U1188 Diabetes Atherothrombosis Réunion Indian OCean (DéTROI), CYROI Plateform, Réunion Island University, 97744 Saint-Denis de la Réunion, France
| | - Brice Lortat-Jacob
- Département d’Anesthésie-Réanimation, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
| | - Enora Atchade
- Département d’Anesthésie-Réanimation, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
| | - Nathalie Zappella
- Département d’Anesthésie-Réanimation, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
| | - Pierre Mordant
- Service de Chirurgie Vasculaire, Thoracique et Transplantation Pulmonaire, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
- INSERM UMR 1152 PHERE, Université Paris Cité, 75018 Paris, France
| | - Yves Castier
- Service de Chirurgie Vasculaire, Thoracique et Transplantation Pulmonaire, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
- INSERM UMR 1152 PHERE, Université Paris Cité, 75018 Paris, France
| | - Hervé Mal
- INSERM UMR 1152 PHERE, Université Paris Cité, 75018 Paris, France
- Pneumologie B et Transplantation Pulmonaire, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
| | - Gaelle Weisenburger
- INSERM UMR 1152 PHERE, Université Paris Cité, 75018 Paris, France
- Pneumologie B et Transplantation Pulmonaire, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
| | - Jonathan Messika
- INSERM UMR 1152 PHERE, Université Paris Cité, 75018 Paris, France
- Pneumologie B et Transplantation Pulmonaire, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
- Paris Transplant Group, 75018 Paris, France
| | - Nathalie Grall
- Service de Bactériologie, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
- INSERM UMR 1137 IAME, Université Paris Cité, 75018 Paris, France
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, Hôpital Bichat Claude Bernard, AP-HP, Université Paris Cité, 75018 Paris, France
- INSERM UMR 1152 PHERE, Université Paris Cité, 75018 Paris, France
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Pióro A, Latos M, Urlik M, Stącel T, Zawadzki F, Gawęda M, Pandel A, Przybyłowski P, Knapik P, Ochman M. Various Aspects of Bacterial Infections in the Early Postoperative Stage Among Lung Transplant Recipients on Broad-Spectrum Antibiotics: A Single Center Study. Transplant Proc 2022; 54:1097-1103. [DOI: 10.1016/j.transproceed.2022.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/18/2022] [Indexed: 11/16/2022]
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Bezinover D, Biancofiore G, Falcone M, Karvellas C, Husain S, Saner FH. Multidrug-resistant infections in solid organ transplant recipients: a focus on risk factors, prevention and treatment strategies. Minerva Anestesiol 2022; 88:735-747. [PMID: 35315621 DOI: 10.23736/s0375-9393.22.16124-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Solid organ transplantation is the best therapeutic option for patients with end-stage organ disease and, according to the data from international registries, there has been a steady increase in numbers and results. However, post-transplant infections remain a fearsome complication with, in the last decade, an increasing incidence of episodes due to antibiotic-resistant bacteria and opportunistic agents. In this paper, we summarize the most relevant and updated knowledge concerning infections from multidrug-resistant germs in solid organ transplant recipients, focusing on risk factors, treatment and prevention strategies, and antimicrobial pharmacokinetics relevant to this particular population of patients.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Gianni Biancofiore
- Department of Transplant Anesthesia and Critical Care, AOU Pisana, University of Pisa, Pisa, Italy -
| | - Marco Falcone
- Unit of Infectious Diseases, AOU Pisana, University of Pisa, Pisa, Italy
| | - Costantine Karvellas
- Department of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, Canada
| | - Shaid Husain
- Department of Infectious Diseases, Toronto General Hospital Research Institute, Toronto University, Toronto, ON, Canada
| | - Fuat H Saner
- Department of General- and Visceral- and Transplant Surgery, Essen University Medical Center, Essen, Germany
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McCort M, MacKenzie E, Pursell K, Pitrak D. Bacterial infections in lung transplantation. J Thorac Dis 2022; 13:6654-6672. [PMID: 34992843 PMCID: PMC8662486 DOI: 10.21037/jtd-2021-12] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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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Eichenberger EM, Ruffin F, Sharma-Kuinkel B, Dagher M, Park L, Kohler C, Sinclair MR, Maskarinec SA, Fowler VG. Bacterial genotype and clinical outcomes in solid organ transplant recipients with Staphylococcus aureus bacteremia. Transpl Infect Dis 2021; 23:e13730. [PMID: 34500502 PMCID: PMC8785702 DOI: 10.1111/tid.13730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/26/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Outcomes from Staphylococcus aureus bacteremia (SAB) in solid organ transplant (SOT) recipients are poorly understood. METHODS This is a prospective cohort study comparing the bacterial genotype and clinical outcomes of SAB among SOT and non-transplant (non-SOT) recipients from 2005 to 2019. Each subject's initial S. aureus bloodstream isolate was genotyped using spa typing and assigned to a clonal complex. RESULTS A total of 103 SOT and 1783 non-SOT recipients with SAB were included. Bacterial genotype did not differ significantly between SOT and non-SOT recipients (p = .4673), including the proportion of SAB caused by USA300 (13.2% vs. 16.0%, p = .2680). Transplant status was not significantly associated with 90-day mortality (18.4% vs. 29.5%; adjusted odds ratio [aOR] 0.74; 95% confidence interval [CI]: 0.44, 1.25), but was associated with increased risk for septic shock (50.0% vs. 21.8%; aOR 2.31; 95% CI: 1.48, 3.61) and acute respiratory distress syndrome (21.4% vs. 13.7%; aOR 2.03; 95% CI: 1.22, 3.37), and a significantly lower risk of metastatic complications (33.0% vs. 45.5%; aOR 0.49; 95% CI: 0.32, 0.76). No association was found between bacterial genotype and 90-day mortality (p = .6222) or septic shock (p = .5080) in SOT recipients with SAB. CONCLUSIONS SOT recipients with SAB do not experience greater mortality than non-SOT recipients. The genotype of S. aureus bloodstream isolates in SOT recipients is similar to that of non-SOT recipients, and does not appear to be an important determinant of outcome in SOT recipients with SAB.
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Affiliation(s)
- Emily M Eichenberger
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Felicia Ruffin
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Batu Sharma-Kuinkel
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Michael Dagher
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Lawrence Park
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Celia Kohler
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Matthew R Sinclair
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States of America
| | - Stacey A Maskarinec
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
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Andreoni M, Sticchi L, Nozza S, Sarmati L, Gori A, Tavio M. Recommendations of the Italian society for infectious and tropical diseases (SIMIT) for adult vaccinations. Hum Vaccin Immunother 2021; 17:4265-4282. [PMID: 34524945 PMCID: PMC8828129 DOI: 10.1080/21645515.2021.1971473] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/30/2021] [Accepted: 08/18/2021] [Indexed: 12/14/2022] Open
Abstract
Vaccination prevents 2-3 million deaths worldwide every year. Nevertheless, vaccine-preventable diseases (VPDs) still cause a considerable number of deaths especially in subjects belonging to "risk groups." These are represented by older adults, immunocompromised individuals and all subjects with underlying chronic medical conditions (cardiovascular, pulmonary, renal and liver chronic diseases, diabetes, immunodeficiency disorders). They have a weaker immune system and, if infected, are more likely to develop severe complications of their condition or of the preventable-infectious disease. This document summarizes the recommendations for vaccination of the main Global Institutional Organizations and analyses the risks of comorbidities associated with infectious disease and the benefits of vaccination for each specific group. The document provides a clear, practical and authoritative guide to adult vaccination.
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Affiliation(s)
- Massimo Andreoni
- UOC Infectious diseases Tor Vergata Polyclinic, University Hospital Viale, Rome, Italy
| | - Laura Sticchi
- Hygiene Unit, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Silvia Nozza
- Medical Director, San Raffaele Hospital, Milan, Italy
| | - Loredana Sarmati
- UOC Infectious diseases Tor Vergata Polyclinic, University Hospital Viale, Rome, Italy
| | - Andrea Gori
- UOC Infectious Diseases, Irccs Ca’Granda Foundation, Maggiore Policlinico Hospital, Milan, Italy
| | - Marcello Tavio
- UOC Division of Emerging Infectious Diseases and Immunosuppressed, AOU Ospedali Riuniti of Ancona, Ancona, Italy
| | - Society for Infectious and Tropical Diseases (SIMIT)
- UOC Infectious diseases Tor Vergata Polyclinic, University Hospital Viale, Rome, Italy
- Hygiene Unit, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
- Medical Director, San Raffaele Hospital, Milan, Italy
- UOC Infectious Diseases, Irccs Ca’Granda Foundation, Maggiore Policlinico Hospital, Milan, Italy
- UOC Division of Emerging Infectious Diseases and Immunosuppressed, AOU Ospedali Riuniti of Ancona, Ancona, Italy
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Møller DL, Sørensen SS, Perch M, Gustafsson F, Rezahosseini O, Knudsen AD, Scheike T, Knudsen JD, Lundgren J, Rasmussen A, Nielsen SD. Bacterial and fungal bloodstream infections in solid organ transplant recipients: results from a Danish cohort with nationwide follow-up. Clin Microbiol Infect 2021; 28:391-397. [PMID: 34325067 DOI: 10.1016/j.cmi.2021.07.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/08/2021] [Accepted: 07/18/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Bloodstream infections (BSI) are prevalent after solid organ transplantation (SOT). In this study, we aimed to investigate the incidence and risk factors for BSI in the first 5 years post-transplantation. METHODS The study included 1322 SOT (kidney, liver, lung and heart) recipients transplanted from 2010 to 2017 with a total of 5616 years of follow-up. Clinical characteristics and microbiology were obtained from the Centre of Excellence for Personalized Medicine of Infectious Complications in Immune Deficiency (PERSIMUNE) data repository with nationwide follow-up. Incidence was investigated in the different SOT groups. Risk factors associated with BSI were assed in the combined group in time-updated multivariable Cox regressions. RESULTS The cumulative incidence of first BSI in the first 5 years post-transplantation differed in the SOT groups with a lower incidence in heart transplant recipients than in the other SOT groups (heart: 4.4%, CI 0.0-9.7%, vs. kidney: 24.6%, CI 20.9-28.2%, liver: 24.7%, CI 19.4-29.9%, and lung: 19.6%, CI 14.5-24.8%, p <0.001). Age above 55 years (HR 1.71, CI 1.2-2.4, p=0.002) and higher Charlson comorbidity index score (HR per unit increase: 1.25, CI 1.1-1.4, p<0.001) at transplantation, current cytomegalovirus (CMV) infection (HR 4.5, CI 2.6-7.9, p<0.001) and current leucopenia (HR 13.3, CI 3.7-47.9, p<0.001) were all associated with an increased risk of BSI. CONCLUSION In SOT recipients, the incidence of BSI differed with the type of transplanted organ. Risk of BSI was higher in older recipients and in recipients with comorbidity, current CMV infection or leucopenia. Thus, increased attention towards BSI in recipients with these characteristics is warranted.
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Affiliation(s)
- Dina Leth Møller
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Søren Schwartz Sørensen
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael Perch
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Omid Rezahosseini
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Dehlbæk Knudsen
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Scheike
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Jenny Dahl Knudsen
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens Lundgren
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Centre of Excellence for Health, Immunity, and Infections, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Dam Nielsen
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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12
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Okamoto K, Santos CAQ. Management and prophylaxis of bacterial and mycobacterial infections among lung transplant recipients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:413. [PMID: 32355857 PMCID: PMC7186743 DOI: 10.21037/atm.2020.01.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Bacterial and mycobacterial infections are associated with morbidity and mortality in lung transplant recipients. Infectious complications are categorized by timing post-transplant: <1, 1–6, and >6 months. The first month post-transplant is associated with the highest risk of infection. During this period, infections are most commonly healthcare-associated, and include infections related to surgical complications. The lungs and bloodstream are common sites of infections. Common healthcare-associated organisms include methicillin-resistant Staphylococcus aureus (MRSA), Gram-negative bacilli such as Pseudomonas aeruginosa, and Clostridioides difficile. More than 1-month post-transplant, opportunistic infections can occur. Tuberculosis occurs in 0.8–10% of lung transplant recipients which reflects variation in background prevalence. The majority of post-transplant tuberculosis stems from reactivation of untreated or undiagnosed latent tuberculosis. Most post-transplant tuberculosis occurs in the lungs and develops within a year of transplant. Non-tuberculous mycobacteria commonly colonize the lungs of lung transplant candidates and are often hard to eradicate even with prolonged courses of antimycobacterial agents. Drug interactions between antimycobacterial agents and calcineurin and mTOR inhibitors also complicates treatment post-transplant. Given that infection adversely impacts outcomes after lung transplant, and that anti-infective therapy is often less effective after transplant, infection prevention is key to long-term success. A comprehensive approach that includes pre-transplant evaluation, perioperative prophylaxis, long-term antimicrobial prophylaxis, immunization, and safer living at home and in the community, should be employed to minimize the risk of infection.
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Affiliation(s)
- Koh Okamoto
- Department of Infectious Diseases, University of Tokyo Hospital, Tokyo, Japan.,Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Carlos A Q Santos
- Department of Infectious Diseases, University of Tokyo Hospital, Tokyo, Japan.,Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
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13
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Chen W, Sun L, Guo L, Cao B, Liu Y, Zhao L, Lu B, Li B, Chen J, Wang C. Clinical outcomes of ceftazidime-avibactam in lung transplant recipients with infections caused by extensively drug-resistant gram-negative bacilli. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:39. [PMID: 32154284 DOI: 10.21037/atm.2019.10.40] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Infections produced by extensively drug-resistant (XDR) gram-negative bacilli (GNB) in solid organ transplant (SOT) are an important cause of morbidity and mortality. Ceftazidime/avibactam (CAZ-AVI) is a novel β-lactam/β-lactamase combination antibiotic with anti-GNB activity, but experience in real clinical practice with CAZ-AVI in lung transplant (LT) recipients is limited. Methods We conducted a retrospective study of patients with XDR-GNB infection who received at least 3 days of CAZ-AVI in the Department of Lung Transplantation Between December 2017 and December 2018 at China-Japan friendship hospital (CJFH). The general information, clinical manifestations, laboratory examinations, treatment course, and outcomes were summarized. Results A total of 10 patients who underwent LT at our center were included. They were all males with a mean age 51 years. Infections after LT included pneumonia and/or tracheobronchitis [n=9; 90% (9/10)], cholecystitis and blood stream infection (BSI) (n=1, patient 8). In these 10 LT recipients, the incidence of various airway complications was 70% (7/10). Carbapenem-resistant Klebsialla pneumoniae (CRKP) was the predominant pathogen, being detected in 9 patients. Multilocus sequence typing (MLST) analysis showed that all 9 CRKP isolates belonged to ST11. Six patients (6/10, 60%) started CAZ-AVI as salvage therapy after a first-line treatment with other antimicrobials. CAZ-AVI was administered as monotherapy or in combination regimens in 20% (2/10) and 80% (8/10) of patients respectively. There were no difference in temperature before and after CAZ-AVI treatment (P>0.05). White blood cell (WBC) at 7 days, and procalcitonin (PCT) at 7 days and 14 days significantly dropped (P<0.05). After 7-14 days of CAZ-AVI treatment, the PaO2/FiO2ratio (P/F ratio) significantly improved (P<0.05). Nine patients (9/10, 90%) obtained negative microbiologic culture of CRKP/CRPA, with a median time to was 6.7 days (range, 1-15 days). However, 5 patients (5/10, 50%) had relapse of CRKP/CRPA infections in the respiratory tract regardless of whether negative microbiologic culture was obtained or not. The 30-day survival rate was 100%, and the 90-day survival rate was 90% (1/10). No severe adverse events related to CAZ-AVI occurred. Conclusions CAZ-AVI treatment of CRKP/ CRPA infection in LT recipients was associated with high rates of clinical success, survival, and safety, but recurrent CRKP/CRPA infections in the respiratory tract did occur.
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Affiliation(s)
- Wenhui Chen
- Department of Lung Transplantation, Centre for Lung Transplantation, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Lingxiao Sun
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Capital Medical University, Beijing 100029, China
| | - Lijuan Guo
- Department of Lung Transplantation, Centre for Lung Transplantation, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Bin Cao
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Capital Medical University, Beijing 100029, China.,Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, China.,Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Yingmei Liu
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Li Zhao
- Department of Lung Transplantation, Centre for Lung Transplantation, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Binghuai Lu
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Binbin Li
- Laboratory of Clinical Microbiology and Infectious Diseases, Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jingyu Chen
- Department of Lung Transplantation, Centre for Lung Transplantation, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Chen Wang
- Department of Lung Transplantation, Centre for Lung Transplantation, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, China.,Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, China.,National Clinical Research Center for Respiratory Diseases, Beijing 100730, China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.,Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China.,WHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing 100029, China
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14
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Abstract
Despite advances in surgical technique, lung transplantation is associated with worse survival when compared with other solid organ transplantations. Graft dysfunction and infection are the leading causes of mortality in the first 30 days following transplantation. Primary graft dysfunction (PGD) is a form of reperfusion injury that occurs early after transplantation. Management of PGD is mainly supportive with use of lung protective ventilation. Inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation may be used in severe cases. Bacterial pneumonias are the most common infectious complication in the immediate post transplant period, but invasive fungal infections may also occur. Other potential complications in the postoperative period include atrial arrhythmias and neurologic complications such as stroke. There is a lack of multicenter, randomized trials to guide ventilation strategies, infection prophylaxis, and treatment of atrial arrhythmias, therefore prevention and management of post-transplant complications vary by transplant center.
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Affiliation(s)
- Christina C Kao
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Amit D Parulekar
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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15
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Hamandi B, Law N, Alghamdi A, Husain S, Papadimitropoulos EA. Clinical and economic burden of infections in hospitalized solid organ transplant recipients compared with the general population in Canada - a retrospective cohort study. Transpl Int 2019; 32:1095-1105. [PMID: 31144787 DOI: 10.1111/tri.13467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/05/2019] [Accepted: 05/25/2019] [Indexed: 12/16/2022]
Abstract
Infections continue to be a major cause of post-transplant morbidity and mortality, requiring increased health services utilization. Estimates on the magnitude of this impact are relatively unknown. Using national administrative databases, we compared mortality, acute care health services utilization, and costs in solid organ transplant (SOT) recipients to nontransplant patients using a retrospective cohort of hospitalizations in Canada (excluding Manitoba/Quebec) between April-2009 and March-2014, with a diagnosis of pneumonia, urinary tract infection (UTI), or sepsis. Costs were analyzed using multivariable linear regression. We examined 816 324 admissions in total: 408 352 pneumonia; 328 066 UTI's; and 128 275 sepsis. Unadjusted mean costs were greater in SOT compared to non-SOT patients with pneumonia [(C$14 923 ± C$29 147) vs. (C$11 274 ± C$18 284)] and sepsis [(C$23 434 ± C$39 685) vs. (C$20 849 ± C$36 257)]. Mortality (7.6% vs. 12.5%; P < 0.001), long-term care transfer (5.3% vs. 16.5%; P < 0.001), and mean length of stay (11.0 ± 17.7 days vs. 13.1 ± 24.9 days; P < 0.001) were lower in SOT. More SOT patients could be discharged home (63.2% vs. 44.3%; P < 0.001), but required more specialized care (23.5% vs. 16.1%; P < 0.001). Adjusting for age and comorbidities, hospitalization costs for SOT patients were 10% (95% CI: 8-12%) lower compared to non-SOT patients. Increased absolute hospitalization costs for these infections are tempered by lower adjusted costs and favorable clinical outcomes.
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Affiliation(s)
- Bassem Hamandi
- Department of Pharmacy, University Health Network, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Nancy Law
- Division of Infectious Diseases, Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, ON, Canada
| | - Ali Alghamdi
- Division of Infectious Diseases, Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, ON, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, ON, Canada
| | - Emmanuel A Papadimitropoulos
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Eli Lilly & Company, Toronto, ON, Canada
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16
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Abstract
Infections in heart and lung transplant recipients are complex and heterogeneous. This article reviews the epidemiology, risk factors, specific clinical syndromes, and most frequent opportunistic infections in heart and/or lung transplant recipients that will be encountered in the intensive care unit and will provide a practical approach of empirical management.
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Affiliation(s)
- Mohammed Alsaeed
- Division of Infectious Diseases, Multi-Organ Transplant Program, Department of Medicine, University of Toronto, University Health Network, 585 University Avenue, 11 PMB 138, Toronto, Ontario M5G 2N2, Canada; Division of Infectious Diseases, Department of Medicine, Prince Sultan Military Medical City, Makkah Al Mukarramah Road, As Sulimaniyah, Riyadh 12233, Saudi Arabia
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, Department of Medicine, University of Toronto, University Health Network, 585 University Avenue, 11 PMB 138, Toronto, Ontario M5G 2N2, Canada.
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17
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Multidrug-Resistant Bacterial Infections in Solid Organ Transplant Candidates and Recipients. Infect Dis Clin North Am 2018; 32:551-580. [DOI: 10.1016/j.idc.2018.04.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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18
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Hamandi B, Fegbeutel C, Silveira FP, Verschuuren EA, Younus M, Mo J, Yan J, Ussetti P, Chin-Hong PV, Solé A, Holmes-Liew CL, Billaud EM, Grossi PA, Manuel O, Levine DJ, Barbers RG, Hadjiliadis D, Aram J, Singer LG, Husain S. Voriconazole and squamous cell carcinoma after lung transplantation: A multicenter study. Am J Transplant 2018; 18:113-124. [PMID: 28898527 DOI: 10.1111/ajt.14500] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/04/2017] [Accepted: 08/30/2017] [Indexed: 01/25/2023]
Abstract
This study evaluated the independent contribution of voriconazole to the development of squamous cell carcinoma (SCC) in lung transplant recipients, by attempting to account for important confounding factors, particularly immunosuppression. This international, multicenter, retrospective, cohort study included adult patients who underwent lung transplantation during 2005-2008. Cox regression analysis was used to assess the effects of voriconazole and other azoles, analyzed as time-dependent variables, on the risk of developing biopsy-confirmed SCC. Nine hundred lung transplant recipients were included. Median follow-up time from transplantation to end of follow-up was 3.51 years. In a Cox regression model, exposure to voriconazole alone (adjusted hazard ratio 2.39, 95% confidence interval 1.31-4.37) and exposure to voriconazole and other azole(s) (adjusted hazard ratio 3.45, 95% confidence interval 1.07-11.06) were associated with SCC compared with those unexposed after controlling for important confounders including immunosuppressants. Exposure to voriconazole was associated with increased risk of SCC of the skin in lung transplant recipients. Residual confounding could not be ruled out because of the use of proxy variables to control for some confounders. Benefits of voriconazole use when prescribed to lung transplant recipients should be carefully weighed versus the potential risk of SCC. EU PAS registration number: EUPAS5269.
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Affiliation(s)
- B Hamandi
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
| | - C Fegbeutel
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - F P Silveira
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - E A Verschuuren
- Department of Pulmonary Diseases, University Hospital Groningen, Groningen, the Netherlands
| | | | - J Mo
- Pfizer Inc., New York, NY, USA
| | - J Yan
- Pfizer Inc., New York, NY, USA
| | - P Ussetti
- Respiratory Department, Hospital Puerta de Hierro, Madrid, Spain
| | - P V Chin-Hong
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - A Solé
- Respiratory Department, University and Polytechnic Hospital La Fe, Universidad de Valencia, Valencia, Spain
| | - C L Holmes-Liew
- Lung Research, Hanson Institute, and Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, Australia
| | - E M Billaud
- Service de Pharmacologie, AP-HP, Hôpital Européen G Pompidou, Paris, France
| | - P A Grossi
- Infectious Diseases Department, University of Insubria, Varese, Italy
| | - O Manuel
- Infectious Diseases Service and Transplantation Center, University Hospital of Lausanne, Lausanne, Switzerland
| | - D J Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - R G Barbers
- Division of Pulmonary and Critical Care, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - D Hadjiliadis
- Department of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - J Aram
- Pfizer Inc., New York, NY, USA
| | - L G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - S Husain
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
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19
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Calik Basaran N, Ascioglu S. Epidemiology and management of healthcare-associated bloodstream infections in non-neutropenic immunosuppressed patients: a review of the literature. Ther Adv Infect Dis 2017; 4:171-191. [PMID: 29662673 DOI: 10.1177/2049936117733394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Advancements in medicine have led to a considerable increase in the proportion of patients living with severe chronic diseases, malignancies, and HIV infections. Most of these conditions are associated with acquired immune-deficient states and treatment-related immunosuppression. Although infections as a result of neutropenia have long been recognized and strategies for management were developed, non-neutropenic immunosuppression has been overlooked. Recently, community-acquired infections in patients with frequent, significant exposure to healthcare settings and procedures have been classified as 'healthcare-associated infections' since they are more similar to hospital-acquired infections. Most of the non-neutropenic immunosuppressed patients have frequent contact with the healthcare system due to their chronic and severe diseases. In this review, we focus on the healthcare-associated bloodstream infections in the most common non-neutropenic immunosuppressive states and provide an update of the recent evidence for the management of these infections.
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Affiliation(s)
- Nursel Calik Basaran
- Department of Internal Medicine, Hacettepe University Medical School, Ankara, Turkey
| | - Sibel Ascioglu
- Department of Infectious Diseases and Microbiology, Hacettepe University Medical School, Ankara, Turkey; GlaxoSmithKline Pte Ltd., Singapore
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20
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Management of multidrug resistant Gram-negative bacilli infections in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations. Transplant Rev (Orlando) 2017; 32:36-57. [PMID: 28811074 DOI: 10.1016/j.trre.2017.07.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/02/2017] [Indexed: 12/17/2022]
Abstract
Solid organ transplant (SOT) recipients are especially at risk of developing infections by multidrug resistant (MDR) Gram-negative bacilli (GNB), as they are frequently exposed to antibiotics and the healthcare setting, and are regulary subject to invasive procedures. Nevertheless, no recommendations concerning prevention and treatment are available. A panel of experts revised the available evidence; this document summarizes their recommendations: (1) it is important to characterize the isolate's phenotypic and genotypic resistance profile; (2) overall, donor colonization should not constitute a contraindication to transplantation, although active infected kidney and lung grafts should be avoided; (3) recipient colonization is associated with an increased risk of infection, but is not a contraindication to transplantation; (4) different surgical prophylaxis regimens are not recommended for patients colonized with carbapenem-resistant GNB; (5) timely detection of carriers, contact isolation precautions, hand hygiene compliance and antibiotic control policies are important preventive measures; (6) there is not sufficient data to recommend intestinal decolonization; (7) colonized lung transplant recipients could benefit from prophylactic inhaled antibiotics, specially for Pseudomonas aeruginosa; (8) colonized SOT recipients should receive an empirical treatment which includes active antibiotics, and directed therapy should be adjusted according to susceptibility study results and the severity of the infection.
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21
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Costa J, Benvenuto LJ, Sonett JR. Long-term outcomes and management of lung transplant recipients. Best Pract Res Clin Anaesthesiol 2017; 31:285-297. [PMID: 29110800 DOI: 10.1016/j.bpa.2017.05.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 05/23/2017] [Indexed: 12/11/2022]
Abstract
Lung transplantation is an established treatment for patients with end-stage lung disease. Improvements in immunosuppression and therapeutic management of infections have resulted in improved long-term survival and a decline in allograft rejection. Allograft rejection continues to be a serious complication following lung transplantation, thereby leading to acute graft failure and, subsequently, chronic lung allograft dysfunction (CLAD). Bronchiolitis obliterans syndrome (BOS), the most common phenotype of CLAD, is the leading cause of late mortality and morbidity in lung recipients, with 50% having developed BOS within 5 years of lung transplantation. Infections in lung transplant recipients are also a significant complication and represent the most common cause of death within the first year. The success of lung transplantation depends on careful management of immunosuppressive regimens to reduce the rate of rejection, while monitoring recipients for infections and complications to help identify problems early. The long-term outcomes and management of lung transplant recipients are critically based on modulating natural immune response of the recipient to prevent acute and chronic rejection. Understanding the immune mechanisms and temporal correlation of acute and chronic rejection is thus critical in the long-term management of lung recipients.
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Affiliation(s)
- Joseph Costa
- Columbia University College of Physicians and Surgeons, Columbia University Medical Center, 622 West 168th St, PH 14, Room 108, New York, NY 10032, USA.
| | - Luke J Benvenuto
- Columbia University College of Physicians and Surgeons, Division Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, 622 West 168th St, PH 14, Room 104, New York, NY 10032, USA.
| | - Joshua R Sonett
- The Price Family Center for Comprehensive Chest Care, Columbia University College of Physicians and Surgeons, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY 10032, USA.
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22
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Hamandi B, Husain S, Grootendorst P, Papadimitropoulos EA. Clinical and microbiological epidemiology of early and late infectious complications among solid-organ transplant recipients requiring hospitalization. Transpl Int 2016; 29:1029-38. [PMID: 27284994 DOI: 10.1111/tri.12808] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 03/14/2016] [Accepted: 06/06/2016] [Indexed: 12/17/2022]
Abstract
There is limited literature describing the clinical and microbiological characteristics of solid-organ transplant recipients requiring hospitalization for infectious complications. This study reports on the rate and timing of these syndromes and describes the associated microbiological epidemiology. This prevalence cohort study evaluated solid-organ transplant recipients requiring hospitalization during 2007-2011. We reported infectious complications requiring hospitalization in 603 of 1414 readmissions at a rate of 0.43 episodes per 1000 transplant-days (95% CI, 0.40-0.47), with 85% occurring >6 months post-transplantation. The most frequent infectious complications were as follows: respiratory (27%), sepsis or bacteremia (13%), liver or biliary tract (12%), genitourinary (12%), and cytomegalovirus related (9%). Approximately 53% presented without fever, 45% had no pathogen isolated, and multidrug-resistant organisms were isolated in 27% of those with an identified microbiological etiology. Infectious-related complications continue to pose a high clinical burden on our acute care center, with the majority occurring in the late transplant period. Clinicians are faced with the difficult task of prescribing adequate antimicrobial therapy.
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Affiliation(s)
- Bassem Hamandi
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Pharmacy, University Health Network, Toronto, ON, Canada
| | - Shahid Husain
- Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Paul Grootendorst
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Emmanuel A Papadimitropoulos
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Eli Lilly & Company, Toronto, ON, Canada
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23
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So M, Yang DY, Bell C, Humar A, Morris A, Husain S. Solid organ transplant patients: are there opportunities for antimicrobial stewardship? Clin Transplant 2016; 30:659-68. [PMID: 26992472 DOI: 10.1111/ctr.12733] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Rising incidence of Clostridium difficile and multidrug-resistant organisms' infections and a dwindling development of new antimicrobials are an impetus for antimicrobial stewardship in organ transplant recipients. We sought to understand antimicrobial prescribing practices and identify opportunities for interdisciplinary collaboration among the transplant, antimicrobial stewardship, and infectious diseases teams. METHODS In 2013, two assessors conducted four real-time audits on all antimicrobial therapy in transplant patients, assessing each regimen against stewardship principles established by the Centers for Disease Prevention and Control, supplemented by applicable transplant-specific infection guidelines. Chi-square test was used to compare stewardship-concordant and stewardship-discordant audit results relative to transplant infectious diseases consultation. RESULTS Analysis was performed on 176 audits. Fifty-eight percent (103/176) received at least one antimicrobial, of which 69.9% (72/103) were stewardship-concordant. Infections were confirmed or suspected in 52.3% (92/176). Of those, 98.9% (91/92) received antimicrobials, and 41.8% (38/91) were prescribed by transplant clinicians. Infectious diseases consultation was associated with more stewardship-concordant prescriptions (78.5% vs. 59.6%, p = 0.03). The most common stewardship-discordant categories were lack of de-escalation, empiric antimicrobial spectrum being too broad, and therapy duration being too long. CONCLUSIONS Opportunities exist for antimicrobial stewardship in transplant recipients, especially those who do not require infectious diseases consultation.
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Affiliation(s)
- Miranda So
- University Health Network, 585 University Avenue, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada
| | - Daisy Yu Yang
- Baycrest Health Sciences Centre, Toronto, ON, Canada
| | - Chaim Bell
- Mount Sinai Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Atul Humar
- University Health Network, 585 University Avenue, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrew Morris
- University Health Network, 585 University Avenue, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shahid Husain
- University Health Network, 585 University Avenue, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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Luo A, Zhong Z, Wan Q, Ye Q. The Distribution and Resistance of Pathogens Among Solid Organ Transplant Recipients with Pseudomonas aeruginosa Infections. Med Sci Monit 2016; 22:1124-30. [PMID: 27045418 PMCID: PMC4824462 DOI: 10.12659/msm.896026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Pseudomonas aeruginosa infection remains a life-threatening complication after solid organ transplantation (SOT). We aimed to investigate the distribution and drug susceptibility of pathogens, and clinical characteristics of SOT recipients with Pseudomonas aeruginosa infections. Material/Methods A total of 55 SOT recipients who developed 61 episodes of Pseudomonas aeruginosa infections between January 1, 2003 and July 31, 2015 were retrospectively analyzed. The distribution and the drug susceptibility of Pseudomonas aeruginosa were reviewed. Results The most common site from which 61 Pseudomonas aeruginosa rods were isolated were the lungs (57.4%, n=37), followed by the blood (27.9%, n=17). There were 35, 18, and 9 recipients accompanied with a serum creatinine level of >1.5 mg/dL, lymphocyte count of <300/mm3, and a serum albumin level of <30 g/L, respectively. Seven patients each presented with white blood cell count of >15 000/mm3 and platelet count of <50 000/mm3. There were 6 (10.9%) cases of septic shocks and 18 (32.7%) deaths. Antibiotic resistance rate of all Pseudomonas aeruginosa to 4 of 10 antibiotics investigated was more than 50%. Of these 61 Pseudomonas aeruginosa isolates, 47.5% were carbapenem-resistant. The rods were relatively sensitive to piperacillin-tazobactam, levofloxacin, amikacin, and cefoperazone-sulbactam (resistance rate <40%). Conclusions The clinical presentation of Pseudomonas aeruginosa infections included high body temperature, decreased platelet count, elevated white blood cell count, a high nosocomial origin and mortality, and onset in the late period after transplantation. According to our findings, piperacillin-tazobactam, levofloxacin, amikacin, and cefoperazone-sulbactam, alone or combination, are recommended to treat SOT recipients with Pseudomonas aeruginosa infections.
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Affiliation(s)
- Aijing Luo
- Key Laboratory of Medical Information Research (Central South University), College ofHunan Province, Changsha, China (mainland)
| | - Zhuqing Zhong
- Department of nursing, The Third Xiangya Hospital, Central South University, Changsha, China (mainland)
| | - Qiquan Wan
- Department of Transplant Surgery, the Third Xiangya Hospital, Central South University, Changsha, China (mainland)
| | - Qifa Ye
- Department of Transplant Surgery, The Third Xiangya Hospital, Central South University, Changsha, China (mainland)
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Abstract
Solid-organ transplantation (SOT) has become the preferred strategy to treat a number of end-stage organ disease, because a continuous improvement in survival and quality of life. While preventive strategies has decreased the risk for classical opportunistic infections (such as viral, fungal and parasite infections), bacterial infections, and particularly bloodstream infections (BSIs) remain the most common and life-threatening complications in SOT recipients. The source of BSI after transplant depends on the type of transplantation, being urinary tract infection, pneumonia, and intraabdominal infections the most common infections occurring after kidney, lung and liver transplantation, respectively. The risk for candidemia is higher in abdominal-organ than in thoracic-organ transplantation. Currently, the increasing prevalence of multi-drug resistant (MDR) Gram-negative pathogens, such as extended-spectrum betalactamase-producing Enterobacteriaciae and carbapenem-resistant Klebsiella pneumoniae, is causing particular concerns in SOT recipients, a population which presents several risk factors for developing infections due to MDR organisms. The application of strict preventive policies to reduce the incidence of post transplant BSIs and to control the spread of MDR organisms, including the implementation of specific stewardship programs to avoid the overuse of antibiotics and antifungal drugs, are essential steps to reduce the impact of post transplant infections on allograft and patient outcomes.
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Affiliation(s)
- Antonios Kritikos
- a Infectious Diseases Service, University Hospital and University of Lausanne , Lausanne , Switzerland
| | - Oriol Manuel
- a Infectious Diseases Service, University Hospital and University of Lausanne , Lausanne , Switzerland.,b Transplantation Center, University Hospital and University of Lausanne , Lausanne , Switzerland
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26
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Risks and Epidemiology of Infections After Lung or Heart–Lung Transplantation. TRANSPLANT INFECTIONS 2016. [PMCID: PMC7123746 DOI: 10.1007/978-3-319-28797-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Nowadays, lung transplantation is an established treatment option of end-stage pulmonary parenchymal and vascular disease. Post-transplant infections are a significant contributor to overall morbidity and mortality in the lung transplant recipient that, in turn, are higher than in other solid organ transplant recipients. This is likely due to several specific factors such as the constant exposure to the outside environment and the colonized native airway, and the disruption of usual mechanisms of defense including the cough reflex, bronchial circulation, and lymphatic drainage. This chapter will review the common infections that develop in the lung or heart–lung transplant recipient, including the general risk factors for infection in this population, and specific features of prophylaxis and treatment for the most frequent bacterial, viral, and fungal infections. The effects of infection on lung transplant rejection will also be discussed.
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Wan Q, Luo A, Ye Q, Liu S, Zhou J. Predictors of shock and mortality in solid organ transplant recipients with bacteremia caused by non-lactose-fermenting gram-negative bacilli. Infect Dis (Lond) 2015; 48:32-9. [PMID: 26329287 DOI: 10.3109/23744235.2015.1051106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND More data on bacteremia due to non-lactose fermenting gram-negative bacilli (NLF GNB) in solid organ transplant (SOT) recipients are needed. We aimed to investigate the epidemiology, microbiology, and risk factors for mortality and septic shock due to NLF GNB bacteremia in SOT recipients. METHODS We performed a retrospective, double-center study over a 12-year study period. The risk factors for mortality and septic shock in SOT recipients with NLF GNB bacteremia were assessed with multivariate logistic regression analysis. RESULTS A total of 230 episodes of bloodstream infections (BSIs) occurred in 159 SOT recipients. Fifty episodes of NLF GNB bacteremia were detected in 47 SOT recipients, with a predominance of Acinetobacter baumanii (27 isolates, 54.0%). The antibiotic resistance rate of all NLF GNB to 10 of 12 antibiotics investigated was more than 50%. The independent risk factors associated with septic shock were platelet count < 50 000/mm(3) (odds ratio (OR) = 14.41, 95% confidence interval (CI) = 2.64-78.71, p = 0.002) and late-onset bacteremia (time of onset more than 2 months post-transplant) (OR = 10.87, 95% CI = 1.79-65.89, p = 0.009). Lung focus (OR = 32.91, 95% CI = 2.56-423.18, p = 0.007) and septic shock (OR = 70.38, 95% CI = 4.21-1176.21, p = 0.003) were risk factors for bacteremia-related mortality. CONCLUSIONS The drug resistance of the pathogens and the morbidity and mortality rates of NLF GNB bacteremia were high in SOT recipients. For septic shock, associated risk factors were thrombocytopenia and late-onset bacteremia. The risk factors significantly associated with mortality were lung focus and septic shock.
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Wan Q, Ye Q, Huang F. The Bacteremia Caused by Non-Lactose Fermenting Gram-Negative Bacilli in Solid Organ Transplant Recipients. Surg Infect (Larchmt) 2015; 16:479-89. [PMID: 26181230 DOI: 10.1089/sur.2015.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Blood stream infections (BSIs) remain as a serious life-threatening condition after solid organ transplant (SOT). In recent years, a progressive growth in the incidence of bacteremia caused by non-lactose fermenting gram-negative bacilli (NLF GNB) has been observed. NLF GNB led to high mortality among SOT recipients with bacteremia and were difficult to treat because of their high drug resistance to commonly used antibiotics. METHODS Two electronic databases, PUBMED and EMBASE, were searched for relevant literature published up to January 2015, to better understand the characteristics of bacteremia because of NLF GNB. RESULTS The morbidity and mortality rates of bacteremia because of NLF GNB depend on the types of organisms and transplantation. Multi-drug resistant NLF GNB ranged from 9.8% to 12.5% of all NLF GNB causing BSIs among SOT recipients. Certain factors can predispose SOT recipients to NLF GNB bacteremia, which included previous transplantation, hospital-acquired BSIs, and prior intensive care unit admission. Combination therapy may be beneficial in the treatment of NLF GNB bacteremia to enhance antimicrobial activity, provide synergistic interactions, relieve side effects, and minimize superinfections. CONCLUSIONS Prevention is pivotal in minimizing the morbidity and mortality associated with NLF GNB bacteremia after SOT. To improve the outcomes of SOT recipients with NLF GNB bacteremia, prevention is pivotal, and combination therapy of antibiotics may be beneficial.
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Affiliation(s)
- Qiquan Wan
- 1 Department of Transplant Surgery, The Third Xiangya Hospital, Central South University , Changsha, Hunan, China
| | - Qifa Ye
- 1 Department of Transplant Surgery, The Third Xiangya Hospital, Central South University , Changsha, Hunan, China .,2 Department of Transplant Surgery, Zhongnan Hospital, Wuhan University , Wuhan, China
| | - Feizhou Huang
- 3 Department of General Surgery, The Third Xiangya Hospital, Central South University , Changsha, China
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Infections in Solid-Organ Transplant Recipients. MANDELL, DOUGLAS, AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES 2015. [PMCID: PMC7151835 DOI: 10.1016/b978-1-4557-4801-3.00313-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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30
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Riera J, Caralt B, López I, Augustin S, Roman A, Gavalda J, Rello J. Ventilator-associated respiratory infection following lung transplantation. Eur Respir J 2014; 45:726-37. [PMID: 25359351 DOI: 10.1183/09031936.00095214] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The medical records of 170 adult patients who underwent lung transplantation between January 2010 and December 2012 were reviewed to assess the incidence, causative organisms, risk factors and outcomes of post-operative pneumonia and tracheobronchitis. 20 (12%) patients suffered 24 episodes of ventilator-associated pneumonia. The condition was associated with mean increases of 43 days in mechanical ventilation and of 35 days in hospital stay, and significantly higher hospital mortality (OR 9.0, 95% CI 3.2-25.1). Pseudomonas aeruginosa (eight out of 12 patients were multidrug-resistant) was the most common pathogen, followed by Enterobacteriaceae (one out of five patients produced extended-spectrum β-lactamases). Gastroparesis occurred in 55 (32%) patients and was significantly associated with pneumonia (OR 6.2, 95% CI 2.2-17.2). Ventilator-associated tracheobronchitis was associated with a mean increase of 28 days in mechanical ventilation and 30.5 days in hospital stay, but was not associated with higher mortality (OR 1.2, 95% CI 0.4-3.2). Pseudomonas aeruginosa (six out of 16 patients were multidrug resistant) was the most common pathogen, followed by Enterobacteriaceae (three out of 14 patients produced extended-spectrum β-lactamase). Patients with gastroparesis also had more episodes of ventilator-associated tracheobronchitis (40% versus 12%, p<0.001). In conclusion, ventilator-associated pneumonia following lung transplantation increased mortality. Preventing gastroparesis probably decreases the risk of pneumonia and tracheobronchitis. Multidrug-resistant bacteria frequently cause post-lung-transplantation pneumonia and tracheobronchitis.
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Affiliation(s)
- Jordi Riera
- Dept of Critical Care, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Berta Caralt
- Dept of Critical Care, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Iker López
- Dept of Thoracic Surgery, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Salvador Augustin
- Liver Unit, Dept of Internal Medicine, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Roman
- Dept of Pneumology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Joan Gavalda
- Dept of Infectious Diseases, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain Red Española de Investigación de Patologías Infecciosas (REIPI), Instituto de Salud Carlos III, Madrid, Spain
| | - Jordi Rello
- Dept of Critical Care, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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Shao M, Wan Q, Xie W, Ye Q. Bloodstream infections among solid organ transplant recipients: Epidemiology, microbiology, associated risk factors for morbility and mortality. Transplant Rev (Orlando) 2014; 28:176-81. [PMID: 24630890 DOI: 10.1016/j.trre.2014.02.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 09/26/2013] [Accepted: 02/09/2014] [Indexed: 12/15/2022]
Abstract
Bloodstream infections (BSIs) remain important causes of morbidity and mortality among solid organ transplant (SOT) recipients and still threaten the success of SOT. In general, among SOT recipients, risk factors for BSIs are associated with prior ICU admission, catheterization, older recipient or donor age…etc. Pulmonary focus, nosocomial source of BSIs, lack of appropriate antibiotic therapy and other variables have significant impacts on BSIs-related mortality in SOT. Most of BSIs in SOT are caused by gram-negative bacteria. However, all aspects including microbiological spectrum, morbidity and mortality rates, risk factors of BSIs and BSIs-related death depend on the type of transplantation. The purpose of this review is to summarize the epidemiology, microbiologic features including antimicrobial resistance of organisms, and associated risk factors for morbidity and mortality of BSIs according to different type of transplantation to better understand the characteristics of BSIs and improve the outcomes after SOT.
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Lederer DJ, Philip N, Rybak D, Arcasoy SM, Kawut SM. Intravenous immunoglobulin for hypogammaglobulinemia after lung transplantation: a randomized crossover trial. PLoS One 2014; 9:e103908. [PMID: 25090414 PMCID: PMC4121238 DOI: 10.1371/journal.pone.0103908] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 07/03/2014] [Indexed: 11/18/2022] Open
Abstract
Background We aimed to determine the effects of treatment with intravenous immunoglobulin on bacterial infections in patients with hypogammaglobulinemia (HGG) after lung transplantation. Methods We performed a randomized, double-blind, placebo-controlled two-period crossover trial of immune globulin intravenous (IVIG), 10% Purified (Gamunex, Bayer, Elkhart, IN) monthly in eleven adults who had undergone lung transplantation more than three months previously. We randomized study participants to three doses of IVIG (or 0.1% albumin solution (placebo)) given four weeks apart followed by a twelve week washout and then three doses of placebo (or IVIG). The primary outcome was the number of bacterial infections within each treatment period. Results IVIG had no effect on the number of bacterial infections during the treatment period (3 during IVIG and 1 during placebo; odds ratio 3.5, 95% confidence interval 0.4 to 27.6, p = 0.24). There were no effects on other infections, use of antibiotics, or lung function. IVIG significantly increased trough IgG levels at all time points (least square means, 765.3 mg/dl during IVIG and 486.3 mg/dl during placebo, p<0.001). Four serious adverse events (resulting in hospitalization) occurred during the treatment periods (3 during active treatment and 1 during the placebo period, p = 0.37). Chills, flushing, and nausea occurred during one infusion of IVIG. Conclusions Treatment with IVIG did not reduce the short-term risk of bacterial infection in patients with HGG after lung transplantation. The clinical efficacy of immunoglobulin supplementation in HGG related to lung transplantation over the long term or with recurrent infections is unknown. Trial Registration Clinicaltrials.gov NCT00115778
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Affiliation(s)
- David J. Lederer
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York City, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, New York, United States of America
| | - Nisha Philip
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York City, New York, United States of America
| | - Debbie Rybak
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York City, New York, United States of America
| | - Selim M. Arcasoy
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York City, New York, United States of America
| | - Steven M. Kawut
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- * E-mail:
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Abstract
Lung transplantation is the only established therapeutic option for several end-stage respiratory diseases. Limited mostly by lack of suitable allografts, the results have measurably improved over the last decade. Numerous surgical and pharmaceutical improvements have had positive impact on outcomes. The potential for critical care issues and the need for interdisciplinary management remains paramount. Cardiac, renal, and metabolic complications are frequently encountered in the acute postoperative phase. Allograft rejection and infectious diseases as well as problems related to immunosuppressive regimen are seen later after lung transplantation. Neurologic manifestations with a range of etiologies are discussed here in this context.
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Affiliation(s)
- Christopher H Wigfield
- Department of Surgery, Section of Cardiac & Thoracic Surgery, University of Chicago, Chicago, IL, USA.
| | - Robert B Love
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaulkee, Wi, USA
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Esguerra-Gonzalez A, Ilagan-Honorio M, Fraschilla S, Kehoe P, Lee AJ, Marcarian T, Mayol-Ngo K, Miller PS, Onga J, Rodman B, Ross D, Sommer S, Takayanagi S, Toyama J, Villamor F, Weigt SS, Gawlinski A. CNE article: pain after lung transplant: high-frequency chest wall oscillation vs chest physiotherapy. Am J Crit Care 2013; 22:115-24. [PMID: 23455861 DOI: 10.4037/ajcc2013869] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background Chest physiotherapy and high-frequency chest wall oscillation (HFCWO) are routinely used after lung transplant to facilitate removal of secretions. To date, no studies have been done to investigate which therapy is more comfortable and preferred by lung transplant recipients. Patients who have less pain may mobilize secretions, heal, and recover faster. Objectives To compare effects of HFCWO versus chest physiotherapy on pain and preference in lung transplant recipients. Methods In a 2-group experimental, repeated-measures design, 45 lung transplant recipients (27 single lung, 18 bilateral) were randomized to chest physiotherapy (10 AM, 2 PM) followed by HFCWO (6 PM, 10 PM; group 1, n=22) or vice versa (group 2, n=23) on postoperative day 3. A verbal numeric rating scale was used to measure pain before and after treatment. At the end of the treatment sequence, a 4-item patient survey was administered to assess treatment preference, pain, and effectiveness. Data were analyzed with χ(2) and t tests and repeated-measures analysis of variance. Results A significant interaction was found between mean difference in pain scores from before to after treatment and treatment method; pain scores decreased more when HFCWO was done at 10 AM and 6 PM (P =.04). Bilateral transplant recipients showed a significant preference for HFCWO over chest physiotherapy (11 [85%] vs 2 [15%], P=.01). However, single lung recipients showed no significant difference in preference between the 2 treatments (11 [42%] vs 14 [54%]). Conclusions HFCWO seems to provide greater decreases in pain scores than does chest physiotherapy. Bilateral lung transplant recipients preferred HFCWO to chest physiotherapy. HFCWO may be an effective, feasible alternative to chest physiotherapy. (American Journal of Critical Care. 2013;22:115-125).
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Affiliation(s)
- Angeli Esguerra-Gonzalez
- Angeli Esguerra-Gonzalez, Monina Ilagan-Honorio, Ai Jin Lee, Taline Marcarian, Kristina Mayol-Ngo, Betty Rodman, Susan Sommer, and Filma Villamor are nurses in the cardiothoracic intensive care unit at Ronald Reagan University of California Los Angeles Medical Center
| | - Monina Ilagan-Honorio
- Angeli Esguerra-Gonzalez, Monina Ilagan-Honorio, Ai Jin Lee, Taline Marcarian, Kristina Mayol-Ngo, Betty Rodman, Susan Sommer, and Filma Villamor are nurses in the cardiothoracic intensive care unit at Ronald Reagan University of California Los Angeles Medical Center
| | - Stephanie Fraschilla
- Stephanie Fraschilla and Jay Onga are transplant coordinators for the heart and lung transplant program at Ronald Reagan University of California Los Angeles Medical Center
| | - Priscilla Kehoe
- Priscilla Kehoe is the director of research and Sumiko Takayanagi is a senior statistician in the School of Nursing at the University of California Los Angeles
| | - Ai Jin Lee
- Angeli Esguerra-Gonzalez, Monina Ilagan-Honorio, Ai Jin Lee, Taline Marcarian, Kristina Mayol-Ngo, Betty Rodman, Susan Sommer, and Filma Villamor are nurses in the cardiothoracic intensive care unit at Ronald Reagan University of California Los Angeles Medical Center
| | - Taline Marcarian
- Angeli Esguerra-Gonzalez, Monina Ilagan-Honorio, Ai Jin Lee, Taline Marcarian, Kristina Mayol-Ngo, Betty Rodman, Susan Sommer, and Filma Villamor are nurses in the cardiothoracic intensive care unit at Ronald Reagan University of California Los Angeles Medical Center
| | - Kristina Mayol-Ngo
- Angeli Esguerra-Gonzalez, Monina Ilagan-Honorio, Ai Jin Lee, Taline Marcarian, Kristina Mayol-Ngo, Betty Rodman, Susan Sommer, and Filma Villamor are nurses in the cardiothoracic intensive care unit at Ronald Reagan University of California Los Angeles Medical Center
| | - Pamela S. Miller
- Pamela S. Miller is a postdoctoral scholar in the School of Nursing at the University of California San Francisco
| | - Jay Onga
- Stephanie Fraschilla and Jay Onga are transplant coordinators for the heart and lung transplant program at Ronald Reagan University of California Los Angeles Medical Center
| | - Betty Rodman
- Angeli Esguerra-Gonzalez, Monina Ilagan-Honorio, Ai Jin Lee, Taline Marcarian, Kristina Mayol-Ngo, Betty Rodman, Susan Sommer, and Filma Villamor are nurses in the cardiothoracic intensive care unit at Ronald Reagan University of California Los Angeles Medical Center
| | - David Ross
- David Ross is a physician, professor, and medical director of the lung and heart-lung transplant program and S. Samuel Weigt is a physician and assistant professor in the Division of Pulmonary and Critical Care Medicine at David Geffen School of Medicine at University of California Los Angeles Medical Center
| | - Susan Sommer
- Angeli Esguerra-Gonzalez, Monina Ilagan-Honorio, Ai Jin Lee, Taline Marcarian, Kristina Mayol-Ngo, Betty Rodman, Susan Sommer, and Filma Villamor are nurses in the cardiothoracic intensive care unit at Ronald Reagan University of California Los Angeles Medical Center
| | - Sumiko Takayanagi
- Priscilla Kehoe is the director of research and Sumiko Takayanagi is a senior statistician in the School of Nursing at the University of California Los Angeles
| | - Joy Toyama
- Joy Toyama is a DrPH student in the Department of Biostatistics and a graduate student researcher in the School of Nursing at the University of California Los Angeles
| | - Filma Villamor
- Angeli Esguerra-Gonzalez, Monina Ilagan-Honorio, Ai Jin Lee, Taline Marcarian, Kristina Mayol-Ngo, Betty Rodman, Susan Sommer, and Filma Villamor are nurses in the cardiothoracic intensive care unit at Ronald Reagan University of California Los Angeles Medical Center
| | - S. Samuel Weigt
- David Ross is a physician, professor, and medical director of the lung and heart-lung transplant program and S. Samuel Weigt is a physician and assistant professor in the Division of Pulmonary and Critical Care Medicine at David Geffen School of Medicine at University of California Los Angeles Medical Center
| | - Anna Gawlinski
- Anna Gawlinski is the director of research and evidence-based practice at Ronald Reagan University of California Los Angeles Medical Center and adjunct professor in the School of Nursing at the University of California Los Angeles
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van Duin D, van Delden C. Multidrug-resistant gram-negative bacteria infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:31-41. [PMID: 23464996 DOI: 10.1111/ajt.12096] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Kim SY, Shin JA, Cho EN, Byun MK, Kim HJ, Ahn CM, Haam SJ, Lee DY, Paik HC, Chang YS. Late respiratory infection after lung transplantation. Tuberc Respir Dis (Seoul) 2013; 74:63-9. [PMID: 23483760 PMCID: PMC3591540 DOI: 10.4046/trd.2013.74.2.63] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 01/03/2013] [Accepted: 01/17/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Aiming to improve outcome of lung transplantation (LTx) patients, we reviewed risk factors and treatment practices for the LTx recipients who experienced respiratory infection in the late post-LTx period (>1 month after LTx). METHODS We analyzed the clinical data of 48 recipients and donors from 61 LTx, who experienced late respiratory infections. Late respiratory infections were classified according to the etiology, time of occurrence, and frequency of donor-to-host transmission or colonization of the recipient prior to transplantation. RESULTS During the period of observation, 42 episodes of respiratory infections occurred. The organisms most frequently involved were gram (-) bacteria: Acinetobacter baumannii (n=13, 31.0%), Pseudomonas aeruginosa (n=7, 16.7%), and Klebsiella pneumoniae (n=4, 10.0%). Among the 42 episodes recorded, 14 occurred in the late post-LTx period. These were bacterial (n=6, 42.9%), fungal (n=2, 14.3%), viral (n=4, 28.5%), and mycobacterial (n=2, 14.3%) infections. Of 6 bacterial infections, 2 were from multidrug-resistant (MDR) A. baumannii and one from each of MDR P. aeruginosa, extended spectrum β-lactamase (+) K. pneumoniae, methicillin-resistant Staphylococcus aureus and Streptococcus pneumoniae. Infection-related death occurred in 6 of the 14 episodes (43%). CONCLUSION Although the frequency of respiratory infection decreased sharply in the late post-LTx period, respiratory infection was still a major cause of mortality. Gram (-) MDR bacteria were the agents most commonly identified in these infections.
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Affiliation(s)
- Sang Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Staphylococcus aureus bacteremia in solid organ transplant recipients: evidence for improved survival when compared with nontransplant patients. Transplantation 2012; 93:1045-50. [PMID: 22357175 DOI: 10.1097/tp.0b013e31824bf219] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Staphylococcus aureus bacteremia (SAB) is an important cause of morbidity and mortality. Herein, we describe the incidence, clinical characteristics, and outcomes of SAB after solid organ transplantation (SOT) and compare these features with non-SOT controls. METHODS In a single-center retrospective study, blood cultures positive for S. aureus were obtained from January 1, 2000, to December 31, 2008. Chart review was performed on all SOT recipients with SAB. The social security death index was used to determine all-cause mortality. RESULTS Seventy of 2959 patients with SAB were SOT recipients (26 lung, 19 liver, 18 kidney, and seven heart). The overall attack rate of SAB in SOT was 22.9/1000 transplant patients. Early-onset SAB (≤ 90 days) was more frequent in liver recipients (79%), when compared with kidney recipients (17%). All-cause 30-day and 1-year mortality rates were 6% and 28% in SOT, respectively. Pneumonia as a source was associated with an increased 30-day mortality (18% vs. 2%, P = 0.04). Comparing SOT versus non-SOT controls, methicillin resistance was more frequent (86% vs. 52%, P < 0.0001), and duration of bacteremia was longer (mean 3.8 vs. 1.6 days, P < 0.01). SOT status was independently associated with lower risk of 30-day mortality (risk ratio [RR]: 0.37, P = 0.02). CONCLUSIONS In our cohort of SOT recipients, SAB was less common than previously reported and surprisingly had lower 30-day mortality, when compared with non-SOT. In SOT recipients, pneumonia as a source of SAB in SOT is associated with an increased 30-day mortality.
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Alegre ML, Goldstein DR, Chong AS. Toll-like receptor signaling in transplantation. Curr Opin Organ Transplant 2012; 13:358-65. [PMID: 18685330 DOI: 10.1097/mot.0b013e3283061149] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW This review summarizes recent advances in the role of endogenous and exogenous Toll-like receptor ligands in the activation and inhibition of immune responses in transplantation. RECENT FINDINGS During an alloresponse, Toll-like receptors can be engaged by both damage-induced endogenous ligands or microbial-associated molecular patterns. The damage-induced molecule high mobility group box 1 protein and its binding to Toll-like receptor 4 have been identified as major initiators of antitumor and antitransplant immune responses. Type I interferon signaling plays an important role in the pro-rejection effect mediated by Toll-like receptor agonists and some bacteria. Similar pathways, however, in neonates can result in inhibition rather than activation of alloimmune responses. SUMMARY The consequences of Toll-like receptor engagement by endogenous and exogenous ligands in transplantation may depend on the relative induction of inflammatory and regulatory pathways and the stage of development of the immune system.
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Affiliation(s)
- Maria-Luisa Alegre
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA.
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Infections and organ transplantation: new challenges for prevention and treatment--a colloquium. Transplantation 2012; 93:S4-S39. [PMID: 22374265 DOI: 10.1097/tp.0b013e3182481347] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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40
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Abstract
The ICU period is only one time point among many in the complex, multidisciplinary postoperative management required for patient survival and improved QOL. The care required on step-down units and after discharge to home each has unique care aspects that impact successful patient outcomes.
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Affiliation(s)
- Elisabeth L George
- Advanced Practice Nurse Critical Care, Department of Nursing, University of Pittsburgh Medical Center-Presbyterian Shadyside, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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41
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Bloodstream infection after kidney transplantation: epidemiology, microbiology, associated risk factors, and outcome. Transplantation 2010; 90:581-7. [PMID: 20585281 DOI: 10.1097/tp.0b013e3181e8a680] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bloodstream infection (BSI) is associated with both relevant morbidity and mortality rates after kidney transplantation. METHODS From January 1, 2000 to January 31, 2006, all episodes of BSI were retrospectively assessed through the review of medical records in two tertiary teaching Hospitals in Sao Paulo, Brazil, where 3308 transplant procedures were performed during this period. Contaminants and polymicrobial infections were excluded. The main objectives of the study were to describe clinical and microbiologic aspects of BSI, as well as risk factors for both BSI and mortality from these infections in kidney transplant patients. RESULTS BSI was detected in 185 patients, with onset after a median of 235 days after transplantation; 62% occurred after 6 months. The primary source of infection was the urinary tract in 37.8%. The most prevalent pathogen overall was Escherichia coli (30.3%). Risk factors for early acquired BSI (first 6 months after transplantation) were acute rejection, ureteric stent placement, and receiving an organ from a deceased donor. For late BSI (after 6 months), associated risk factors were acute rejection, Charlson Comorbidity Score more than or equal to 3, and receiving an organ from a deceased donor. Risk factors related to 30-day mortality were Acute Physiology and Chronic Health Evaluation II Score more than or equal to 20, shock, and respiratory failure. CONCLUSIONS BSI is most frequently a consequence of urinary tract infection, with a high prevalence of gram-negative bacilli. Severity of disease was the main determinant of 30-day mortality after BSI, and based on the knowledge of risk factors, some interventions are suggested for reducing the rate of BSI after transplantation.
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Methicillin-resistant Staphylococcus aureus Infection After Lung Transplantation: 5-year Review of Clinical and Molecular Epidemiology. J Heart Lung Transplant 2009; 28:1231-6. [DOI: 10.1016/j.healun.2009.06.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 11/18/2022] Open
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Hamandi B, Holbrook AM, Humar A, Brunton J, Papadimitropoulos EA, Wong GG, Thabane L. Delay of adequate empiric antibiotic therapy is associated with increased mortality among solid-organ transplant patients. Am J Transplant 2009; 9:1657-65. [PMID: 19459798 DOI: 10.1111/j.1600-6143.2009.02664.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Empiric antibiotic therapy is often prescribed prior to the availability of bacterial culture results. In some cases, the organism isolated may not be susceptible to initial empiric therapy (inadequate empiric therapy or IET). In solid-organ transplant recipients, the overall incidence and clinical importance of IET is unknown. We performed a retrospective cohort study of patients admitted from 2002 to 2004. Multiple logistic regression analyses were conducted to determine associations between potential determinants and mortality. IET was administered in 169/312 (54%) patients, with a hospital mortality rate that was significantly greater than those receiving adequate therapy (24.9% vs. 7.0%; relative risk [RR] 3.55; 95% confidence interval [CI], 1.85-6.83; p < 0.001). Regression analysis demonstrated that an increasing duration of IET (adjusted odds ratio [OR] at 24 h: 1.33; 95% CI: 1.15-1.53; p < 0.001), ICU-associated infections (adjusted OR: 6.27; 95% CI: 2.79-14.09; p < 0.001), prior antibiotic use (adjusted OR: 3.56; 95% CI: 1.51-8.41; p = 0.004) and increasing APACHE-II scores (adjusted OR: 1.26; 95% CI: 1.16-1.34; p < 0.001) were independently correlated with hospital mortality. IET is common and appears to be associated with an increased hospital mortality rate in the solid-organ transplant population.
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Affiliation(s)
- B Hamandi
- Pharmaceutical Sciences, University of Toronto, Toronto, Ontario, Canada. mailto:
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Al-Hasan MN, Razonable RR, Eckel-Passow JE, Baddour LM. Incidence rate and outcome of Gram-negative bloodstream infection in solid organ transplant recipients. Am J Transplant 2009; 9:835-43. [PMID: 19344469 DOI: 10.1111/j.1600-6143.2009.02559.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Bacterial infections are common complications of solid organ transplantation (SOT). In this study, we defined the incidence, mortality and in vitro antimicrobial resistance rates of Gram-negative bloodstream infection (BSI) in SOT recipients. We identified 223 patients who developed Gram-negative BSI among a cohort of 3367 SOT recipients who were prospectively followed at the Mayo Clinic (Rochester, MN) from January 1, 1996 to December 31, 2007. The highest incidence rate (IR) of Gram-negative BSI was observed within the first month following SOT (210.3/1000 person-years [95% confidence interval (CI): 159.3-268.3]), with a sharp decline to 25.7 (95% CI: 20.1-32.1) and 8.2 (95% CI: 6.7-10.0) per 1000 person-years between 2 and 12 months and more than 12 months following SOT, respectively. Kidney recipients were more likely to develop Gram-negative BSI after 12 months following transplantation than were liver recipients (10.3 [95% CI: 7.9-13.1] vs. 5.2 [95% CI: 3.1-7.8] per 1000 person-years). The overall unadjusted 28-day all-cause mortality of Gram-negative BSI was 4.9% and was lower in kidney than in liver recipients (1.6% vs. 13.2%, p < 0.001). We observed a linear trend of increasing resistance among Escherichia coli isolates to fluoroquinolone antibiotics from 0% to 44% (p = 0.002) throughout the study period. This increase in antimicrobial resistance may influence the choice of empiric therapy.
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Affiliation(s)
- M N Al-Hasan
- Department of Medicine, Division of Infectious Diseases, University of Kentucky, Lexington, KY, USA.
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Johnson LE, D'Agata EMC, Paterson DL, Clarke L, Qureshi ZA, Potoski BA, Peleg AY. Pseudomonas aeruginosa bacteremia over a 10-year period: multidrug resistance and outcomes in transplant recipients. Transpl Infect Dis 2009; 11:227-34. [PMID: 19302282 DOI: 10.1111/j.1399-3062.2009.00380.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AIM Transplant recipients are at risk for hospital-acquired infections (HAIs), including those caused by Pseudomonas aeruginosa. Of all HAIs, bloodstream infection (BSI) remains one of the most life-threatening. METHODS Over a 10-year period, we studied 503 patients, including 149 transplant recipients, with pseudomonal BSI from the University of Pittsburgh Medical Center. Trends in antimicrobial susceptibility, risk factors for multidrug resistance (MDR), and outcomes were compared between transplant and non-transplant patients. RESULTS Resistance to all antibiotic classes was significantly greater in pseudomonal blood culture isolates from transplant compared with non-transplant patients (P<0.001). Of isolates from transplant recipients (n=207), 43% were MDR, compared with 18% of isolates from non-transplant patients (n=391) (odds ratio [OR] 3.47; 95% confidence interval [CI] 2.34-5.14, P<0.001). Among all patients, independent risk factors for MDR P. aeruginosa BSI included previous transplantation (OR 2.38; 95% CI 1.51-3.76, P<0.001), hospital-acquired BSI (OR 2.41; 95% CI 1.39-4.18, P=0.002), and prior intensive care unit (ICU) admission (OR 2.04; 95% CI 1.15-3.63, P=0.015). Mortality among transplant recipients was 42%, compared with 32% in non-transplant patients (OR 1.55; 95% CI 0.87-2.76, P=0.108). For transplant recipients, onset of BSI in the ICU was the only independent predictor of mortality (OR 8.00; 95% CI 1.71-37.42, P=0.008). CONCLUSIONS Transplant recipients are at greater risk of MDR P. aeruginosa BSI, with an appreciable mortality. Future management must concentrate on the implementation of effective preventative strategies.
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Affiliation(s)
- L E Johnson
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Zivković SA, Jumaa M, Barisić N, McCurry K. Neurologic complications following lung transplantation. J Neurol Sci 2009; 280:90-3. [PMID: 19249798 DOI: 10.1016/j.jns.2009.02.308] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Revised: 01/14/2009] [Accepted: 02/09/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neurologic complications are frequent after solid organ transplantation, but their spectrum in lung transplant recipients has not been characterized. METHODS Retrospective analysis of medical records of 132 consecutive adult lung allograft recipients transplanted at the University of Pittsburgh Medical Center between 2001 and 2003 with a follow-up until December 31, 2005. RESULT Neurologic complications were reported in 68% of lung transplant recipients. Most common complications were impairment of consciousness (25%), neuromuscular complications (21%) and headaches (20%). The presence of neurologic complications did not affect posttransplant survival. Neurologic complications were commonly related to immunosuppressant neurotoxicity (17%) and opportunistic infections (11%). There was a trend for an increased frequency of seizures and headaches in recipients with cystic fibrosis (p>0.05). CONCLUSIONS Neurologic complications are a significant source of morbidity in lung transplant recipients. High prevalence of immunosuppressant toxicity is attributable to higher immunosuppression needs for effective prevention of allograft rejection. Frequent opportunistic infections are associated with complications related to systemic and CNS infections and toxicity of antibiotics. Patients with cystic fibrosis may be at higher risk of neurologic complications, but larger studies are needed to corroborate this finding and fully characterize the spectrum of neurologic complications following lung transplantation.
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Campos S, Caramori M, Teixeira R, Afonso J, Carraro R, Strabelli T, Samano M, Pêgo-Fernandes P, Jatene F. Bacterial and Fungal Pneumonias After Lung Transplantation. Transplant Proc 2008; 40:822-4. [DOI: 10.1016/j.transproceed.2008.02.049] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Moreno A, Cervera C, Gavaldá J, Rovira M, de la Cámara R, Jarque I, Montejo M, de la Torre-Cisneros J, Miguel Cisneros J, Fortún J, López-Medrano F, Gurguí M, Muñoz P, Ramos A, Carratalá J. Bloodstream infections among transplant recipients: results of a nationwide surveillance in Spain. Am J Transplant 2007; 7:2579-86. [PMID: 17868067 DOI: 10.1111/j.1600-6143.2007.01964.x] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Bloodstream infections (BSIs) are a major cause of morbidity and mortality in transplant recipients. The aim of this study is to describe the incidence, microbiology and outcomes of BSIs in transplant recipients in Spain. The Spanish Network for Research on Infection in Transplantation (RESITRA) is formed by 16 centers with transplant program in Spain. The incidence and characteristics of BSIs in transplant patients were obtained prospectively from the cohort. We included 3926 transplant recipients (2935 solid organ and 991 hematopoietic stem cell transplants). Overall, 730 episodes of BSIs were recorded with an incidence rate ranging from 3 episodes per 10 000 transplant days in kidney recipients to 44 episodes per 10 000 transplant days in allogeneic hematopoietic stem cell transplantation (HSCT). The most frequent sources were intravascular catheters and the most frequent microorganisms isolated were coagulase-negative staphylococci. Crude mortality of BSIs was 7.8%, being highest in liver recipients (16%). Multidrug resistant nonfermentative gram-negative BSIs had significantly worse prognosis than those caused by their susceptible counterparts (p = 0.015), but no differences were found between resistant and susceptible gram-negative enteric bacilli, S. aureus or Candida spp. BSIs are still a major concern in transplant recipients. The increasing isolations of multiresistant microorganisms represent a challenge for the next years.
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Affiliation(s)
- A Moreno
- Hospital Clínic-IDIBAPS-University of Barcelona, Barcelona, Spain.
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