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Tsai H, Bartash R, Burack D, Swaminathan N, So M. Bring it on again: antimicrobial stewardship in transplant infectious diseases: updates and new challenges. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e3. [PMID: 38234416 PMCID: PMC10789986 DOI: 10.1017/ash.2023.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 01/19/2024]
Abstract
Advancement in solid organ transplantation and hematopoietic stem cell transplant continues to improve the health outcomes of patients and widens the number of eligible patients who can benefit from the medical progress. Preserving the effectiveness of antimicrobials remains crucial, as otherwise transplant surgeries would be unsafe due to surgical site infections, and the risk of sepsis with neutropenia would preclude stem cell transplant. In this review, we provide updates on three previously discussed stewardship challenges: febrile neutropenia, Clostridioides difficile infection, and asymptomatic bacteriuria. We also offer insight into four new stewardship challenges: the applicability of the "shorter is better" paradigm shift to antimicrobial duration; antibiotic allergy delabeling and desensitization; colonization with multidrug-resistant gram-negative organisms; and management of cytomegalovirus infections. Specifically, data are accumulating for "shorter is better" and antibiotic allergy delabeling in transplant patients, following successes in the general population. Unique to transplant patients are the impact of multidrug-resistant organism colonization on clinical decision-making of antibiotic prophylaxis in transplant procedure and the need for antiviral stewardship in cytomegalovirus. We highlighted the expansion of antimicrobial stewardship interventions as potential solutions for these challenges, as well as gaps in knowledge and opportunities for further research.
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Affiliation(s)
- Helen Tsai
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rachel Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel Burack
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Neeraja Swaminathan
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Miranda So
- Sinai Health-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
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Serrano-Arias B, Araya-Zúñiga A, Waterhouse-Garbanzo J, Rojas-Barrantes Z, Arguedas-Chacón S, Zavaleta-Monestel E. A Comprehensive Review of Sulfonamide Hypersensitivity: Implications for Clinical Practice. Clin Rev Allergy Immunol 2023; 65:433-442. [PMID: 38175321 DOI: 10.1007/s12016-023-08978-w] [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] [Accepted: 12/12/2023] [Indexed: 01/05/2024]
Abstract
Sulfonamides, which are drugs commonly prescribed in hospital and outpatient settings, have historically been associated with a high incidence of hypersensitivity reactions. It is believed that there is an increased risk of cross-reactions with other drugs that contain this functional group in their structure. However, it has not been conclusively established that the sulfonamide group is the sole cause of hypersensitivity reactions, as non-antibiotic sulfonamides do not share the same accessory groups with antibiotic sulfonamides. Therefore, cross-reactivity between different types of sulfonamides and sulfonamide-type antibiotics is not clearly demonstrated, and allergic reactions may involve other mechanisms. Misinformation about this topic can lead to inappropriate use of alternative antibiotics with lower efficacy or higher adverse effects, contributing to antibiotic resistance. It is crucial to individualize and monitor patients with a history of allergies to sulfonamide-type antibiotics when introducing a new drug containing sulfa and manage any adverse reactions promptly. Desensitization protocols may be a viable option for patients who specifically benefit from these antibiotics, particularly those who are immunosuppressed. This article provides a descriptive bibliographic review to update information on sulfa allergy, its prevalence, management, and recommendations to prevent such reactions and optimize pharmacotherapy, without underusing these drugs.
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Affiliation(s)
- Bruno Serrano-Arias
- Pharmacy Department, Centro de Investigación y Manejo de Càncer, San José, Costa Rica
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Raglow Z, Advani SD, Aitken SL, Patel PK. Antimicrobial stewardship in solid organ transplant recipients: Current challenges and proposed metrics. Transpl Infect Dis 2022; 24:e13883. [PMID: 36254525 DOI: 10.1111/tid.13883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/03/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Solid organ transplant (SOT) recipients are challenging populations for antimicrobial stewardship interventions due to a variety of reasons, including immunosuppression, consequent risk of opportunistic and donor-derived infections, high rates of infection with multi-drug resistant organisms (MDROs), Clostridioides difficile, and need for prolonged antimicrobial prophylaxis. Despite this, data on stewardship interventions and metrics that address the distinct needs of these patients are limited. METHODS We performed a narrative review of the current state of antimicrobial stewardship in SOT recipients, existing interventions and metrics in this population, and considerations for implementation of transplant-specific stewardship programs. RESULTS Antimicrobial stewardship metrics are evolving even in the general patient population. Data on metrics applicable to the SOT population are even more limited. Standard process, outcomes, and balancing metrics may not always apply to the SOT population. A successful stewardship program for SOT recipients requires reviewing existing data, applying general stewardship principles, and understanding the nuances of SOT patients. CONCLUSION As antimicrobial stewardship interventions are being implemented in SOT recipients; new metrics are needed to assess their impact. In conclusion, SOT patients present a challenging but important opportunity for antimicrobial stewards. ABBREVIATIONS SOT, antimicrobial stewardship program, MDRO, Clostridioides difficile infection, Centers for Disease Control and Prevention, Infectious Diseases Society of America, prospective audit and feedback, hematopoietic cell transplant, cytomegalovirus, trimethoprim-sulfamethoxazole, surgical site infections, nucleic acid amplification testing, days of therapy, defined daily dose, and length of stay.
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Affiliation(s)
- Zoe Raglow
- Department of Internal Medicine Division of Infectious Diseases University of Michigan Ann Arbor Michigan USA
| | - Sonali D. Advani
- Department of Medicine Division of Infectious Diseases Duke University School of Medicine Durham North Carolina USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention Durham North Carolina USA
| | - Samuel L. Aitken
- Department of Pharmacy University of Michigan Ann Arbor Michigan USA
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | - Payal K. Patel
- Department of Internal Medicine Division of Infectious Diseases, Ann Arbor VA Healthcare System Ann Arbor Michigan USA
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Negishi S, Miyao K, Ohara F, Motegi K, Wakabayashi H, Yokota H, Kuwano S, Takeuchi Y, Sawa H, Inagaki Y, Sawa M. Feasibility of trimethoprim/sulfamethoxazole desensitization therapy in hematological diseases. Clin Exp Med 2022:10.1007/s10238-022-00868-3. [PMID: 35976516 DOI: 10.1007/s10238-022-00868-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/22/2022] [Indexed: 11/29/2022]
Abstract
The effectiveness and safety of trimethoprim/sulfamethoxazole (TMP/SMX) desensitization therapy is insufficiently evaluated in hematological diseases. From 2002 to 2019, we retrospectively analyzed 112 patients with hematological diseases who underwent desensitization therapy after TMP/SMX prophylaxis withdrawal due to adverse events. They orally started TMP/SMX at 0.4 mg/2 mg, which was then increased daily to 80 mg/400 mg for 5 or 9 days. Eighty-eight patients (79%) had complete desensitization, and the major reason for failure was rash seen in 21 cases (19%). The cause of desensitization and reasons for failure matched in 22 cases (92%). Pneumocystis pneumonia was not observed throughout the study. In the failure group, the number of eosinophils and alanine aminotransferase (ALT) levels were significantly increased after desensitization. In particular in the failure group, the slight increase in eosinophils was seen through the beginning to halfway during desensitization (36/μL (0-900/μL) and 48/μL (0-2560/μL), respectively, p = 0.025). These data show that TMP/SMX desensitization therapy is effective and safe in hematological diseases. The recurrence of adverse events could help predict desensitization success.
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Affiliation(s)
- Shuto Negishi
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan.
| | - Kotaro Miyao
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Fumiya Ohara
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Kenta Motegi
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Hiroya Wakabayashi
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Hirofumi Yokota
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Shihomi Kuwano
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Yuki Takeuchi
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Hitomi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Yuichiro Inagaki
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Masashi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
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Abstract
Infection remains a common cause of death throughout the lifespan of a lung transplant recipient. The increased susceptibility of lung transplant recipients is multifactorial including exposure of the graft to the external environment, impaired mucociliary clearance, and high levels of immunosuppression. Long-term outcomes in lung transplant recipients remain poor compared with other solid organ transplants largely due to deaths from infections and chronic allograft dysfunction. Antibacterial, antifungal, and antiviral prophylaxis may be used after lung transplantation to target a number of different opportunistic infections for varying durations of time. The first-month posttransplant is most commonly characterized by nosocomial infections and donor-derived infections. Following the first month to the first 6 months after transplant-a period of intense immunosuppression-is associated with opportunistic infections. While immunosuppression is reduced after the first year posttransplant, infection remains a risk with community-acquired and rarer infectious agents. Clinicians should be vigilant for infection at all time points after transplant. The use of patient-tailored prophylaxis and treatments help ensure graft and patient survival.
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Lum J, Echenique I, Athans V, Koval CE. Alternative pneumocystis prophylaxis in solid organ transplant recipients at two large transplant centers. Transpl Infect Dis 2020; 23:e13461. [PMID: 32894607 DOI: 10.1111/tid.13461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/03/2020] [Accepted: 08/20/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice for Pneumocystis jirovecii pneumonia (PJP) prophylaxis and has activity against other opportunistic infections (OIs) after solid organ transplant (SOT). We aimed to describe the incidence, reasons for and outcomes of use of alternative prophylactic agents (APAs) across SOT programs in our high volume centers. METHODS Solid organ transplant recipients (SOTRs) at our centers from 1/2015-12/2016 were identified. Pharmacy records identified APA (pentamidine, atovaquone, or dapsone) use within 1 year. Records were reviewed for allergies, laboratory values at APA initiation, diagnostic tests for TMP-SMX-preventable OIs, and APA side effects. RESULTS An APA was initiated in 105/1173 (8.9%) SOTRs. Of these, 51 (48.6%) were because of sulfonamide allergy recorded pre-SOT, mostly rash/hives (58.8%). The remaining 54 (51.4%) had TMP-SMX discontinued post-SOT, mostly for neutropenia (48%) and renal effects (34%). Differences occurred across programs, with kidney transplant never stopping TMP-SMX for renal issues. Of those changed to APAs post-transplant, 19 (35%) were later successfully re-challenged with TMP-SMX. With thresholds in mind, 67 (64%) received an APA unnecessarily, accounting for up to $100 000/y excess cost. Potential TMP-SMX-preventable OIs occurred in 7 (5 Nocardia; 2 PJP). APA side effects occurred in 14/105 (13.3%). CONCLUSIONS Use of APAs for PJP prophylaxis after SOT is less than previously reported but often unwarranted. Such decisions require scrutiny to avoid TMP-SMX-preventable OIs, cost and important APA side effects. Use of reasonable thresholds for cessation of TMP-SMX and data-driven approaches to re-challenge would substantially reduce APA use.
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Affiliation(s)
- Jessica Lum
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Ignacio Echenique
- Department of Infectious Diseases, Cleveland Clinic Florida, Weston, FL, USA.,Teva Pharmaceuticals, Miramar, FL, USA
| | - Vasilios Athans
- Department of Pharmacy, University of Pennsylvania, Philadelphia, PA, USA
| | - Christine E Koval
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
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