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Husain S, Wagener MM, Singh N. Cryptococcus neoformans infection in organ transplant recipients: variables influencing clinical characteristics and outcome. Emerg Infect Dis 2001; 7:375-81. [PMID: 11384512 PMCID: PMC2631789 DOI: 10.3201/eid0703.010302] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Unique clinical characteristics and other variables influencing the outcome of Cryptococcus neoformans infection in organ transplant recipients have not been well defined. From a review of published reports, we found that C. neoformans infection was documented in 2.8% of organ transplant recipients (overall death rate 42%). The type of primary immunosuppressive agent used in transplantation influenced the predominant clinical manifestation of cryptococcosis. Patients receiving tacrolimus were significantly less likely to have central nervous system involvement (78% versus 11%, p =0.001) and more likely to have skin, soft-tissue, and osteoarticular involvement (66% versus 21%, p = 0.006) than patients receiving nontacrolimus- based immunosuppression. Renal failure at admission was the only independently significant predictor of death in these patients (odds ratio 16.4, 95% CI 1.9-143, p = 0.004). Hypotheses based on these data may elucidate the pathogenesis and may ultimately guide the management of C. neoformans infection in organ transplant recipients.
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Affiliation(s)
- S Husain
- Veterans Affairs Medical Center and University of Pittsburgh, Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania 15240, USA
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253
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Mehrad B, Paciocco G, Martinez FJ, Ojo TC, Iannettoni MD, Lynch JP. Spectrum of Aspergillus infection in lung transplant recipients: case series and review of the literature. Chest 2001; 119:169-75. [PMID: 11157600 DOI: 10.1378/chest.119.1.169] [Citation(s) in RCA: 156] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES (1) To define the incidence and natural history of Aspergillus colonization and infection in lung transplant recipients, and (2) to assess the impact of prophylaxis, surveillance, and therapy on the incidence and outcome of the disease. DESIGN Retrospective review of 133 consecutive single or bilateral lung transplantations performed at a single institution, and review of the published literature. RESULTS Airway colonization, isolated tracheobronchitis, and invasive pneumonia due to Aspergillus species occurred in 29%, 5%, and 8% of our series, and in 26%, 4%, and 5% of the pooled published data (all series, including ours), respectively. Greater than 50% of all diagnoses were made in the first 6 months after transplantation in both our series and the published literature. Incidence of progression from airway colonization to invasive disease was 1 in 38 in our series and 3 of 97 (3%) in the pooled published data. In patients with isolated tracheobronchitis, all 6 patients in our series and 41 of 50 patients (82%) in all published series, including ours, responded to antifungal therapy and/or surgical debridement. Among patients with invasive pneumonia or disseminated disease, however, 5 of 10 patients in our series and 26 of 64 patients (41%) in the pooled series survived their infection. CONCLUSIONS The role of antifungal therapy in Aspergillus airway colonization in lung transplant recipients is unclear. Data support a strategy of scheduled screening bronchoscopy followed by aggressive treatment for isolated Aspergillus tracheobronchitis in lung transplant recipients.
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Affiliation(s)
- B Mehrad
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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254
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Richardson M, Ellis M. Fungi, mycological disease and pathogenic determinants. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2000; 61:600-4. [PMID: 11048598 DOI: 10.12968/hosp.2000.61.9.1414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The rapid evolution of human fungal infections is providing a strong impetus for understanding pathogenesis and host-fungus interactions and hence new diagnostics.
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Affiliation(s)
- M Richardson
- Haartman Institute, University of Helsinki, Finland
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255
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Singh N. Antifungal prophylaxis for solid organ transplant recipients: seeking clarity amidst controversy. Clin Infect Dis 2000; 31:545-53. [PMID: 10987719 DOI: 10.1086/313943] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2000] [Revised: 04/14/2000] [Indexed: 11/03/2022] Open
Affiliation(s)
- N Singh
- Veterans Affairs Medical Center and the University of Pittsburgh, Thomas E. Starzl Transplantation Institute, Pittsburgh, PA 15240, USA. nis5+@pitt.edu
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256
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Abstract
The spectrum of major infections after transplantation has undergone a striking evolution. The epidemiologic trends in infectious diseases through the last decade have been most notable for a dramatic decrease in the incidence of several opportunistic infections, largely because of advances in prophylaxis against these pathogens. Paralleling these trends has been an exponential rise in the proportion of infections caused by antimicrobial-resistant bacteria. These multiresistant organisms have now emerged as leading pathogens at many transplant centers, and their management is a daunting challenge.
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Affiliation(s)
- N Singh
- Infectious Disease Section, Veterans Affairs Medical Center, Pittsburgh, Pennsylvania, USA
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257
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Donnelly JP. Infection in the neutropenic and haematopoietic stem cell transplant recipient. Curr Opin Infect Dis 2000; 13:337-342. [PMID: 11964799 DOI: 10.1097/00001432-200008000-00002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patterns of bacterial infection have remained fairly static with Gram-positive bacteria predominating, although this varies between institutions and between patient populations. Similarly, antimicrobial resistance rates differ widely and reflect antibiotic use and exposure. Hence, each institution should devote microbiological resources to maintain surveillance and employ vigilance so that antimicrobial treatment protocols can be adapted to meet any new challenges. Most changes are being seen in the diagnosis of fungal infections, particularly aspergillosis, and the way in which it is being incorporated into treatment strategies.
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Affiliation(s)
- J. Peter Donnelly
- Department of Haematology, University Medical Center, St Radboud, Nijmegen, The Netherlands
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258
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Patterson TF, Kirkpatrick WR, White M, Hiemenz JW, Wingard JR, Dupont B, Rinaldi MG, Stevens DA, Graybill JR. Invasive aspergillosis. Disease spectrum, treatment practices, and outcomes. I3 Aspergillus Study Group. Medicine (Baltimore) 2000; 79:250-60. [PMID: 10941354 DOI: 10.1097/00005792-200007000-00006] [Citation(s) in RCA: 500] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A review of representative cases of invasive aspergillosis was conducted to describe current treatment practices and outcomes. Eighty-nine physicians experienced with aspergillosis completed case forms on 595 patients with proven or probable invasive aspergillosis diagnosed using modifications of the Mycoses Study Group criteria. Pulmonary disease was present in 56%, with disseminated infection in 19%. The major risk factors for aspergillosis were bone marrow transplantation (32%) and hematologic malignancy (29%), but patients had a variety of underlying conditions including solid organ transplants (9%), AIDS (8%), and pulmonary diseases (9%). Overall, high antifungal failure rates occurred (36%), and complete antifungal responses were noted in only 27%. Treatment practices revealed that amphotericin B alone (187 patients) was used in most severely immunosuppressed patients while itraconazole alone (58 patients) or sequential amphotericin B followed by itraconazole (93 patients) was used in patients who were less immunosuppressed than patients receiving amphotericin B alone. Response rate for patients receiving amphotericin B alone was poor, with complete responses noted in only 25% and death due to or with aspergillosis in 65%. In contrast, patients receiving itraconazole alone or following amphotericin B had death due to or with Aspergillus in 26% and 36%, respectively. These results confirm that mortality from invasive aspergillosis in severely immunosuppressed patients remains high even with standard amphotericin B. Improved responses were seen in the less immunosuppressed patients receiving sequential amphotericin B followed by itraconazole and those receiving itraconazole alone. New approaches and new therapies are needed to improve the outcome of invasive aspergillosis in high-risk patients.
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Affiliation(s)
- T F Patterson
- Division of Infectious Diseases, University of Texas Health Science Center, San Antonio 78284-7881, USA.
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259
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Abstract
Invasive fungal infections remain an important cause of morbidity and mortality in transplant recipients. Since conventional diagnostic tools such as culture lack sensitivity and specificity, alternative diagnostic assays have been developed. Among the most promising techniques are the detection of fungal DNA and serology. Fungal DNA can be detected with high sensitivity and specificity when performed with specimens from sterile sites such as blood. Polymerase chain reaction (PCR) assays can be used to detect a broad range of fungal pathogens and combined with species identification. Multicenter diagnostic studies are needed to establish the diagnostic value of PCR but lack of standardization hampers such studies. The serodiagnosis of invasive fungal infections has become an important tool in the management of invasive fungal infections. Especially the detection of circulating galactomannan has been shown to be a sensitive marker for invasive aspergillosis. Both serology and PCR can be used to monitor the response to antifungal therapy. The optimal use of non-culture-based methods is in prospective screening of patients at high risk. Since the incidence of disease greatly influences the positive predictive value, screening should take place only in those patients at very high risk for invasive fungal disease.
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Affiliation(s)
- P E Verweij
- Department of Medical Microbiology, University Medical Center St Radboud, Nijmegen, The Netherlands.
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260
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Mayaud C, Cadranel J. A persistent challenge: the diagnosis of respiratory disease in the non-AIDS immunocompromised host. Thorax 2000; 55:511-7. [PMID: 10817801 PMCID: PMC1745772 DOI: 10.1136/thorax.55.6.511] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- C Mayaud
- Service de Pneumologie et de Réanimation Respiratoire, Hôpital Tenon, 4 rue de la Chine, 75020 Paris, France
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261
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Singh N. Invasive mycoses in organ transplant recipients: controversies in prophylaxis and management. J Antimicrob Chemother 2000; 45:749-55. [PMID: 10837425 DOI: 10.1093/jac/45.6.749] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- N Singh
- VA Medical Center and University of Pittsburgh Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania, USA. nis5+@pitt.edu
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262
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Catalla R, Leaf HL. Aspects of Pulmonary Infections After Solid Organ Transplantation. Curr Infect Dis Rep 2000; 2:201-206. [PMID: 11095857 DOI: 10.1007/s11908-000-0036-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The increasing number of solid organ transplant (SOT) recipients have high rates of pulmonary infections due to bacterial, fungal, and viral pathogens. These patients have unique sets of factors predisposing to infection. Lung and heart-lung transplants are associated with particularly high infection rates. The prominence of cytomegalovirus (CMV) as a pathogen in all subsets of SOT patients has led to new strategies for prophylaxis, detection, and treatment of CMV pneumonitis. Progress is similarly being made in managing fungal and bacterial infections. Advances in liver, kidney, heart, and lung transplantation are being discussed, with further attention to specific pathogens (ie, CMV, Aspergillus, Pneumocystis carinii, and Mycobacterium tuberculosis).
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Affiliation(s)
- R Catalla
- Infectious Diseases Section, VA-New York Harbor Healthcare Medical Center and the Department of Medicine, New York University School of Medicine, 423 East 23rd Street, New York, NY 10010, USA.
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263
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Montejo M, Valdivielso A, Suárez MJ, Testillano M, Bustamante J, Gastaca M, Campo M, Errazti G, Pérdigo K, Aguirrebengoa K, González de Zárate P, Ortiz de Urbina J. [Infection after orthotopic liver transplantation: analysis of the first 120 consecutive cases]. Rev Clin Esp 2000; 200:245-51. [PMID: 10901001 DOI: 10.1016/s0014-2565(00)70623-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To report the infectious complications and presentation time of the first 120 consecutive liver transplants performed at our institution. METHODS Prospective study of infectious complications among 120 consecutive adult patients who received orthotopic liver transplantation at Hospital de Cruces, from February 1996 to November 1998. Two patients received a renal transplant concomitantly. The same surveillance protocols were used for all patients and the criteria used to define infections were those reported by other authors. RESULTS The group consisted of 120 patients, 95 males and 25 females. The age ranged from 20 and 66 years (mean: 54 +/- 9 years). The indications for transplantation included alcoholic cirrhosis (47%), HCV cirrhosis (20%), hepatocellular carcinoma (17.5%), fulminant hepatitis (6%), primary biliary cirrhosis (2.5%) and miscellaneous conditions (7%). Three patients required retransplantation. Acute rejection was histologically diagnosed in 38 patients (31%). None of the patients had corticosteroid-resistant rejection. Fifty-one patients (42.5%) developed 76 episodes of severe infection, which included: 48 episodes of bacterial infection among 33 patients (27.5%), tuberculosis in 7 patients (6%), 9 episodes of fungal infection among 8 patients (7%) and cytomegalovirus (CMV) infection among 8.5% of patients. No patient developed Pneumocystis carinii pneumonia. Fifteen (12.5%) patients died: six (12.5%) with active infection, and in four of them the infection was considered the cause of death. CONCLUSIONS Infection rates due to bacteria and fungi were similar to those reported in the literature. A high rate of tuberculosis was found, which possible correlated with the high incidence of this disease in the general population. The low incidence of CMV infection was probably due to the preemptive therapy with gancyclovir. Trimethoprim-sulfamethoxazol prophylaxis against Pneumocystis carinii was highly effective.
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Affiliation(s)
- M Montejo
- Unidad de Enfermedades Infecciosas, Hospital de Cruces, Bilbao
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264
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Malani PN, Kauffman CA. Prevention and prophylaxis of invasive fungal sinusitis in the immunocompromised patient. Otolaryngol Clin North Am 2000; 33:301-12. [PMID: 10736405 DOI: 10.1016/s0030-6665(00)80006-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fungal infections are a leading cause of morbidity and mortality among immunocompromised patients. Invasive fungal sinusitis is a devastating complication of immunosuppression. Treatment options are limited and often ineffective, making prevention important. Measures to decrease environmental exposure, indications for antifungal prophylaxis, and limitations of current regimens are discussed.
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Affiliation(s)
- P N Malani
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
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265
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Chang FY, Singh N, Gayowski T, Wagener MM, Mietzner SM, Stout JE, Marino IR. Thrombocytopenia in liver transplant recipients: predictors, impact on fungal infections, and role of endogenous thrombopoietin. Transplantation 2000; 69:70-5. [PMID: 10653383 DOI: 10.1097/00007890-200001150-00014] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Thrombocytopenia is a frequent and potentially serious complication in liver transplant recipients. The role of endogenous thrombopoietin level in posttransplant thrombocytopenia, has not been fully defined in liver transplant recipients. Additionally, there is accumulating evidence to suggest that platelets play a important role in antimicrobial host defense. METHODS There were 50 consecutive liver transplant recipients studied. Variables predictive of thrombocytopenia, its impact on infectious morbidity and outcome, and serial thrombopoietin (TPO) serum concentration were assessed. RESULTS The median pretransplant platelet count was 67 x 10(3)/cmm. After the liver transplantation, the median nadir platelet count was 33 x 10(3)/cmm and was reached a mean of 6 days after the transplant. A lower pretransplant platelet count (r= +.068, P=.0001), lower serum albumin before the transplants (r=+0.39, P=.014), longer operation time (r=0.27, P=.05), higher intraoperative packed red cells (r=0.28, P=.049) and fresh frozen plasma transfusions (r=0.42, P=.004), higher bilirubin at Day 7 (r=-.386, P=.005), and higher serum creatinine at Day 7 after the transplants (r=-.031, P=.025) correlated significantly with a lower nadir in platelets after the transplant. Nadir in platelet count was significantly lower in nonsurvivors compared with survivors (16 vs. 36 x 10(3)/cmm, P=.0001). Forty-three percent (9 of 21) of the patients with nadir platelet counts of < or =30 x 10(3)/cmm had a major infection within 30 days of the transplant compared with 17% (5 of 29) with nadir platelet counts > 30 x 10(3)/cmm (P=.04). Fungal infections occurred in 14% of the patients with nadir platelet counts of < or =30 x 10(3)/cmm versus 0% in those with nadir platelet counts of > 30 x 10(3)/cmm (P=.06); all patients with fungal infections had nadir platelet counts of < or =30 x 10(3)/cmm before fungal infection. Nadir in platelet count preceded the first major infection by a median of 7 days. Pretransplant TPO level did not differ between survivors (mean 103 pg/ml) or nonsurvivors (mean 144 pg/ml). After the transplantation, TPO levels increased in both groups. TPO level peaked at Day 7 and subsequently declined in survivors. Nonsurvivors had persistent thrombocytopenia despite a progressive rise in TPO level; TPO level was significantly higher at Day 7 (P=.02), Day 9 (P=.0019), and Day 14 (P=.04) in nonsurvivors compared with survivors. CONCLUSION Persistent thrombocytopenia portended a poor outcome in liver transplant recipients and was not related to low TPO levels. Thrombocytopenia preceded infections and identified a subgroup of liver transplant patients susceptible to early major infections; its precise role in fungal infections warrants validation in larger studies.
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Affiliation(s)
- F Y Chang
- Veterans Affairs Medical Center and University of Pittsburgh, Thomas E. Starzl Transplantation Institute, Pennsylvania 15240, USA
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266
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Fungal Diseases. Dermatology 2000. [DOI: 10.1007/978-3-642-97931-6_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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267
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