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Singlar MM, Xhemali X, Brizendine KD, Eckardt J, Ward J, Palm N. Evaluation of a Perioperative Fungal Prophylaxis Protocol Change in Orthotopic Liver Transplant. Ann Pharmacother 2025:10600280251314018. [PMID: 39910443 DOI: 10.1177/10600280251314018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2025] Open
Abstract
BACKGROUND Orthotopic liver transplant (OLT) carries a risk for invasive fungal infections (IFI). A targeted antifungal prophylaxis protocol can identify OLT patients who warrant antifungal prophylaxis. The optimal protocol and appropriate risk factors have yet to be confirmed. OBJECTIVE This study aimed to describe the impact of a targeted antifungal prophylaxis protocol post OLT on rates of IFI and protocol adherence. METHODS This was a retrospective observational cohort study of patients ≥18 years old with an OLT at Cleveland Clinic. Pre-protocol was defined as June 1, 2019 to May 31, 2020 and post-protocol was June 1, 2021 to May 31, 2022. The primary objective was to determine adherence to the prophylaxis protocol on postoperative day (POD) 0. Secondary objectives included comparing the 90-day incidence of proven or probable IFI post-OLT between groups. RESULTS The pre-protocol group included 134 patients, whereas the post-protocol group included 166. Prior to protocol implementation, 73% received clotrimazole, 13% fluconazole, 13% micafungin, and 1% nystatin. After protocol implementation, 63% received clotrimazole, 16% fluconazole, and 21% micafungin. Adherence to the protocol was 66% on POD0 and increased to 84% over the duration of prophylaxis. Rates of IFI development decreased to 3.6% after implementation from 6.7% prior to the protocol (P = 0.22). Median time to IFI was 8 days (interquartile range [IQR] = 2-19) pre-protocol and 15 days (IQR = 6-17) post-protocol. CONCLUSIONS AND RELEVANCE The implementation of a post-OLT-targeted antifungal prophylaxis protocol can promote consistency in antifungal prophylaxis. This study showed an 84% adherence rate to the implemented protocol, with numerically lower rates of IFIs post-protocol compared with pre-protocol.
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Affiliation(s)
- Megan M Singlar
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
- Trinity Health Ann Arbor Hospital, Ypsilanti, MI, USA
| | - Xhilda Xhemali
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Kyle D Brizendine
- Department of Infectious Disease, Cleveland Clinic, Cleveland, OH, USA
| | - Jamie Eckardt
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Jessica Ward
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Nicole Palm
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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2
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Aufhauser DD, Stalter L, Marka N, Leverson G, Al-Adra DP, Foley DP. Detrimental impact of early biopsy-proven rejection in liver transplantation. Clin Transplant 2024; 38:e15206. [PMID: 38041491 PMCID: PMC10843795 DOI: 10.1111/ctr.15206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/07/2023] [Accepted: 11/19/2023] [Indexed: 12/03/2023]
Abstract
Existing literature offers conflicting conclusions about whether early acute cellular rejection influences long-term outcomes in liver transplantation. We retrospectively collected donor and recipient data on all adult, first-time liver transplants performed at a single center between 2008 and 2020. We divided this population into two cohorts based on the presence of early biopsy-proven acute cellular rejection (EBPR) within the first 90 days post-transplant and compared outcomes between the groups. There were 896 liver transplants that met inclusion criteria with 112 cases (12.5%) of EBPR. Recipients who developed EBPR had higher biochemical Model for End-Stage Liver Disease scores (28 vs. 24, p < .01), but other donor and recipient characteristics were similar. Recipients with EBPR had similar overall survival compared to patients without EBPR (p = .09) but had decreased graft survival (p < .05). EBPR was also associated with decreased time to first episode of late (> 90 days post-transplant) rejection (p < .0001) and increased vulnerability to bacterial and viral infection (p < .05). In subgroup analysis of recipients with autoimmune indications for liver transplantation, EBPR had a more pronounced association with patient death (hazard ratio [HR] 3.9, p < .05) and graft loss (HR 4.0, p < .01). EBPR after liver transplant is associated with inferior graft survival, increased susceptibility to late rejections, and increased vulnerability to infection.
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Affiliation(s)
- David D Aufhauser
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Lily Stalter
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Nicholas Marka
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - David P Al-Adra
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - David P Foley
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
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3
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Barros N, Rosenblatt RE, Phipps MM, Fomin V, Mansour MK. Invasive fungal infections in liver diseases. Hepatol Commun 2023; 7:e0216. [PMID: 37639701 PMCID: PMC10462082 DOI: 10.1097/hc9.0000000000000216] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/07/2023] [Indexed: 08/31/2023] Open
Abstract
Patients with liver diseases, including decompensated cirrhosis, alcohol-associated hepatitis, and liver transplant recipients are at increased risk of acquiring invasive fungal infections (IFIs). These infections carry high morbidity and mortality. Multiple factors, including host immune dysfunction, barrier failures, malnutrition, and microbiome alterations, increase the risk of developing IFI. Candida remains the most common fungal pathogen causing IFI. However, other pathogens, including Aspergillus, Cryptococcus, Pneumocystis, and endemic mycoses, are being increasingly recognized. The diagnosis of IFIs can be ascertained by the direct observation or isolation of the pathogen (culture, histopathology, and cytopathology) or by detecting antigens, antibodies, or nucleic acid. Here, we provide an update on the epidemiology, pathogenesis, diagnosis, and management of IFI in patients with liver disease and liver transplantation.
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Affiliation(s)
- Nicolas Barros
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Division of Infectious Diseases, Department of Medicine, Indiana University Health, Indianapolis, Indiana, USA
| | - Russell E. Rosenblatt
- Department of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Meaghan M. Phipps
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Vladislav Fomin
- Department of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Michael K. Mansour
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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So M, Tsai H, Swaminathan N, Bartash R. Bring it on: Top five antimicrobial stewardship challenges in transplant infectious diseases and practical strategies to address them. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e72. [PMID: 36483373 PMCID: PMC9726551 DOI: 10.1017/ash.2022.53] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 06/17/2023]
Abstract
Antimicrobial therapies are essential tools for transplant recipients who are at high risk for infectious complications. However, judicious use of antimicrobials is critical to preventing the development of antimicrobial resistance. Treatment of multidrug-resistant organisms is challenging and potentially leads to therapies with higher toxicities, intravenous access, and intensive drug monitoring for interactions. Antimicrobial stewardship programs are crucial in the prevention of antimicrobial resistance, though balancing these strategies with the need for early and frequent antibiotic therapy in these immunocompromised patients can be challenging. In this review, we summarize 5 frequently encountered transplant infectious disease stewardship challenges, and we suggest strategies to improve practices for each clinical syndrome. These 5 challenging areas are: asymptomatic bacteriuria in kidney transplant recipients, febrile neutropenia in hematopoietic stem cell transplantation, antifungal prophylaxis in liver and lung transplantation, treatment of left-ventricular assist device infections, and Clostridioides difficile infection in solid-organ and hematopoietic stem-cell transplant recipients. Common themes contributing to these challenges include limited data specific to transplant patients, shortcomings in diagnostic testing, and uncertainties in pharmacotherapy.
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Affiliation(s)
- Miranda So
- Sinai Health-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Helen Tsai
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Neeraja Swaminathan
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Rachel Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
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5
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Khalid M, Neupane R, Anjum H, Surani S. Fungal infections following liver transplantation. World J Hepatol 2021; 13:1653-1662. [PMID: 34904035 PMCID: PMC8637669 DOI: 10.4254/wjh.v13.i11.1653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/24/2021] [Accepted: 08/30/2021] [Indexed: 02/06/2023] Open
Abstract
With increasing morbidity and mortality from chronic liver disease and acute liver failure, the need for liver transplantation is on the rise. Most of these patients are extremely vulnerable to infections as they are immune-compromised and have other chronic co-morbid conditions. Despite the recent advances in practice and improvement in diagnostic surveillance and treatment modalities, a major portion of these patients continue to be affected by post-transplant infections. Of these, fungal infections are particularly notorious given their vague and insidious onset and are very challenging to diagnose. This mini-review aims to discuss the incidence of fungal infections following liver transplantation, the different fungi involved, the risk factors, which predispose these patients to such infections, associated diagnostic challenges, and the role of prophylaxis. The population at risk is increasingly old and frail, suffering from various other co-morbid conditions, and needs special attention. To improve care and to decrease the burden of such infections, we need to identify the at-risk population with more robust clinical and diagnostic parameters. A more robust global consensus and stringent guidelines are needed to fight against resistant microbes and maintain the longevity of current antimicrobial therapies.
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Affiliation(s)
- Madiha Khalid
- Department of Medicine, Orlando Health Medical Center, Orlando, FL 32806, United States
| | - Ritesh Neupane
- Department of Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA 17033, United States
| | - Humayun Anjum
- Department of Medicine, University of North Texas, Denton, TX 76203, United States
| | - Salim Surani
- Department of Pulmonary Critical Care and Sleep Medicine, Texas A&M Health Science Center, Corpus Christi, TX 78405, United States.
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6
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Invasive Candidiasis in Liver Transplant Recipients: A Review. CURRENT FUNGAL INFECTION REPORTS 2021. [DOI: 10.1007/s12281-021-00426-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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7
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Liu M, Zhu Z, Sun L. Risk Factors of Invasive Fungal Infection in Recipients After Liver Transplantation: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:687028. [PMID: 34671611 PMCID: PMC8522940 DOI: 10.3389/fmed.2021.687028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/31/2021] [Indexed: 12/30/2022] Open
Abstract
Objectives: Invasive fungal infection (IFI) remains an important cause of mortality in liver transplantation (LT). The objective of this meta-analysis was to identify the risk factors for IFI after LT. Methods: We searched for relevant studies published up to June 2020 from PubMed, Web of Science, Embase, and the Cochrane Library. Odds ratios (ORs) and their corresponding 95% CIs were used to identify significant differences in the risk factors. Heterogeneity between studies was evaluated by the I2 test, and potential publication bias was assessed with Egger's test. The quality of included studies was evaluated with the Newcastle-Ottawa Scale (NOS). Results: A total of 14 studies enrolling 4,284 recipients were included in the meta-analysis. Reoperation (OR = 2.18, 95% CI: 1.61–2.94), posttransplantation dialysis (OR = 2.03, 95% CI: 1.52–2.72), bacterial infection (OR = 1.81, 95% CI: 1.33–2.46), live donor (OR = 1.78, 95% CI: 1.20–2.63), retransplantation (OR = 2.45, 95% CI: 1.54–3.89), and fungal colonization (OR = 2.60, 95% CI: 1.99–3.42) were associated with the risk factors of IFI after LT. Conclusions: Despite some risk factors that have been identified as significant factors for IFI post-LT, which may inform prevention recommendations, rigorous and well-designed studies with adequate sample sizes should be conducted to solve the limitations of this study.
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Affiliation(s)
- Min Liu
- Department of Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhijun Zhu
- Department of Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Liying Sun
- Department of Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Centre for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Department of Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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8
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Fungal Infection and Prevention in Lung Transplant. CURRENT FUNGAL INFECTION REPORTS 2021. [DOI: 10.1007/s12281-021-00424-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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9
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Fungal Infections in Liver Transplant Recipients. J Fungi (Basel) 2021; 7:jof7070524. [PMID: 34210106 PMCID: PMC8304186 DOI: 10.3390/jof7070524] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/25/2021] [Accepted: 06/21/2021] [Indexed: 01/03/2023] Open
Abstract
Invasive fungal infections (IFIs) are one of the most feared complications associated with liver transplantation, with high rates of morbidity and mortality. We discuss the most common invasive fungal infections in the setting of liver transplant, including Candida, Aspergillus, and Cryptococcal infections, and some less frequent but devastating mold infections. Further, we evaluate the use of prophylaxis to prevent invasive fungal infection in this population as a promising mechanism to reduce risks to patients after liver transplant.
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10
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Jorgenson MR, Gracon AS, Hanlon B, Leverson GE, Parajuli S, Smith JA, Al-Adra DP. Pre-transplant bariatric surgery is associated with increased fungal infection after liver transplant. Transpl Infect Dis 2021; 23:e13484. [PMID: 33012079 DOI: 10.1111/tid.13484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/18/2020] [Accepted: 09/26/2020] [Indexed: 01/11/2023]
Abstract
AIM The impact of pre-transplant (pre-TXP) bariatric surgery (BS) on outcomes after liver transplant (LTX) has not been completely elucidated. Roux-en Y gastric bypass (RYGB) is one of the most common BS procedures. The primary objective of this study was to identify the risk of infection in LTX recipients with pre-TXP RYGB. METHODS Adult patients with LTX between 1/1/2001 and 9/30/2018 at our center were screened for pre-TXP RYGB; patients with gastrectomy via sleeve or banding were excluded. Patients with no history of BS pre- or post-transplant were placed in a comparator group, matched 2:1 via incidence density sampling on age epoch. RESULTS There were 16 LTX recipients with pre-TXP RYGB matched to 32 controls. Median time from RYGB to transplant was 11.7 years. Mean weight loss was 66 ± 19 kg. There were significantly more women with pre-TXP RYGB than in the matched control (RYGB:68.8% vs control:25%, P = .009). Demographics were otherwise similar between groups. Pre-TXP RYGB did not significantly increase hospital or ICU length of stay (P = .5, P = .3) but was associated with a significantly increased rate of fungal infection at 1 year (RYGB:33.4% vs control:9.7%, P = .01), and a numerical trend to increased bacterial infection (RYGB:56.2% vs control:32.2%, P = .09). CONCLUSION Despite the substantial weight loss attributed to BS, patients with pre-TXP RYGB demonstrated increased rates of fungal infection after transplant and trended toward increased bacterial infection. While the anatomical complexity associated with LTX surgery after RYGB did not appear to significantly affect ICU or hospital length of stay, it may have contributed to overall infectious risk, and possibly to impaired survival. Additionally, bypass of the host natural barrier defenses of the stomach could also have contributed to infectious risk. Our findings highlight the complexity of this patient population. Future prospective studies are needed to investigate risk of infection after LTX in the setting of pre-Txp BS. Potential modification in fungal prophylaxis protocols to include pre-TXP RYGB may be warranted.
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Affiliation(s)
- Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Adam S Gracon
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Bret Hanlon
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Glen E Leverson
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Jeannina A Smith
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - David P Al-Adra
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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Ferrarese A, Cattelan A, Cillo U, Gringeri E, Russo FP, Germani G, Gambato M, Burra P, Senzolo M. Invasive fungal infection before and after liver transplantation. World J Gastroenterol 2020; 26:7485-7496. [PMID: 33384549 PMCID: PMC7754548 DOI: 10.3748/wjg.v26.i47.7485] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/15/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
Invasive infections are a major complication before liver transplantation (LT) and in the early phase after surgery. There has been an increasing prevalence of invasive fungal disease (IFD), especially among the sickest patients with decompensated cirrhosis and acute-on-chronic liver failure, who suffer from a profound state of immune dysfunction and receive intensive care management. In such patients, who are listed for LT, development of an IFD often worsens hepatic and extra-hepatic organ dysfunction, requiring a careful evaluation before surgery. In the post-transplant setting, the burden of IFD has been reduced after the clinical advent of antifungal prophylaxis, even if several major issues still remain, such as duration, target population and drug type(s). Nevertheless, the development of IFD in the early phase after surgery significantly impairs graft and patient survival. This review outlines presentation, prophylactic and therapeutic strategies, and outcomes of IFD in LT candidates and recipients, providing specific considerations for clinical practice.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Padua University Hospital, Padua 35128, Italy
| | - Annamaria Cattelan
- Tropical and Infectious Disease Unit, Padua University Hospital, Padua 35128, Italy
| | - Umberto Cillo
- Padua University Hospital, Hepatobiliary Surgery and Liver Transplant Center, Padua 35128, Italy
| | - Enrico Gringeri
- Padua University Hospital, Hepatobiliary Surgery and Liver Transplant Center, Padua 35128, Italy
| | | | - Giacomo Germani
- Multivisceral Transplant Unit, Padua University Hospital, Padua 35128, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Padua University Hospital, Padua 35128, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Padua University Hospital, Padua 35128, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Padua University Hospital, Padua 35128, Italy
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