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Fayyaz A, Raja M, Natori Y. Prevention and Management of Infections in Lung Transplant Recipients. J Clin Med 2023; 13:11. [PMID: 38202018 PMCID: PMC10779253 DOI: 10.3390/jcm13010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/13/2023] [Accepted: 12/01/2023] [Indexed: 01/12/2024] Open
Abstract
Anti-rejection medications are essential in preventing organ rejection amongst solid organ transplant recipients; however, these agents also cause profound immunosuppression, predisposing lung transplant recipients (LTRs) to infectious complications. The timely management including prevention, diagnosis, and treatment of such infectious complications is vital to prevent significant morbidity and mortality in solid organ transplant recipients and allograft dysfunction. LTRs are inundated with microbes that may be recognized as commensals in hosts with intact immune systems. Bacterial infections are the most common ones, followed by viral pathogens. Indications of a brewing infectious process may be subtle. Hence, the importance of adapting vigilance around isolated hints through symptomatology and signs is pivotal. Signals to suggest an infectious process, such as fever and leukocytosis, may be dampened by immunosuppressive agents. One must also be vigilant about drug interactions of antibiotics and immunosuppressive agents. Treatment of infections can become challenging, as antimicrobials can interact with immunosuppressive agents, and antimicrobial resistance can surge under antimicrobial pressure. Transplant infectious disease physicians work in concert with transplant teams to obtain specimens for diagnostic testing and follow through with source control when possible. This heavily impacts medical decisions and fosters a multidisciplinary approach in management. Furthermore, the reduction of immunosuppression, although it augments the risk of allograft rejection, is as crucial as the initiation of appropriate antimicrobials when it comes to the management of infections.
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Affiliation(s)
| | | | - Yoichiro Natori
- Miami Transplant Institute, Jackson Health System, Division of Infectious Disease, Department of Clinical Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.F.); (M.R.)
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Lindstedt S, Silverborn M, Lannemyr L, Pierre L, Larsson H, Grins E, Hyllen S, Dellgren G, Magnusson J. Design and Rationale of Cytokine Filtration in Lung Transplantation (GLUSorb): Protocol for a Multicenter Clinical Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e52553. [PMID: 37855706 PMCID: PMC10753425 DOI: 10.2196/52553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Lung transplantation (LTx) is the only treatment option for end-stage lung disease. Despite improvements, primary graft dysfunction (PGD) remains the leading cause of early mortality and precipitates chronic lung allograft dysfunction, the main factor in late mortality after LTx. PGD develops within the first 72 hours and impairs the oxygenation capacity of the lung, measured as partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2). Increasing the PaO2/FiO2 ratio is thus critical and has an impact on survival. There is a general lack of effective treatments for PGD. When a transplanted lung is not accepted by the immune system in the recipient, a systemic inflammatory response starts where cytokines play a critical role in initiating, amplifying, and maintaining the inflammation leading to PGD. Cytokine filtration can remove these cytokines from the circulation, thus reducing inflammation. In a proof-of-concept preclinical porcine model of LTx, cytokine filtration improved oxygenation and decreased PGD. In a feasibility study, we successfully treated patients undergoing LTx with cytokine filtration (ClinicalTrials.gov; NCT05242289). OBJECTIVE The purpose of this clinical trial is to demonstrate the superiority of cytokine filtration in improving LTx outcome, based on its effects on oxygenation ratio, plasma levels of inflammatory markers, PGD incidence and severity, lung function, kidney function, survival, and quality of life compared with standard treatment with no cytokine filtration. METHODS This study is a Swedish national interventional randomized controlled trial involving 116 patients. Its primary objective is to investigate the potential benefits of cytokine filtration when used in conjunction with LTx. Specifically, this study aims to determine whether the application of cytokine filtration, administered for a duration of 12 hours within the initial 24 hours following a LTx procedure, can lead to improved patient outcomes. This study seeks to assess various aspects of patient recovery and overall health to ascertain the potential positive impact of this intervention on the posttransplantation course. RESULTS The process of patient recruitment for this study is scheduled to commence subsequent to a site initiation visit, which was slated to take place on August 28, 2023. The primary outcome measure that will be assessed in this research endeavor is the oxygenation ratio, a metric denoted as the highest PaO2/FiO2 ratio achieved by patients within a 72-hour timeframe following their LTx procedure. CONCLUSIONS We propose that cytokine filtration could enhance the overall outcomes of LTx. Our hypothesis suggests potential improvements in LTx outcome and patient care. TRIAL REGISTRATION ClinicalTrials.gov NCT05526950; https://www.clinicaltrials.gov/study/NCT05526950. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/52553.
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Patrucco F, Curtoni A, Sidoti F, Zanotto E, Bondi A, Albera C, Boffini M, Cavallo R, Costa C, Solidoro P. Herpes Virus Infection in Lung Transplantation: Diagnosis, Treatment and Prevention Strategies. Viruses 2023; 15:2326. [PMID: 38140567 PMCID: PMC10747259 DOI: 10.3390/v15122326] [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: 09/23/2023] [Revised: 11/12/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023] Open
Abstract
Lung transplantation is an ultimate treatment option for some end-stage lung diseases; due to the intense immunosuppression needed to reduce the risk of developing acute and chronic allograft failure, infectious complications are highly incident. Viral infections represent nearly 30% of all infectious complications, with herpes viruses playing an important role in the development of acute and chronic diseases. Among them, cytomegalovirus (CMV) is a major cause of morbidity and mortality, being associated with an increased risk of chronic lung allograft failure. Epstein-Barr virus (EBV) is associated with transformation of infected B cells with the development of post-transplantation lymphoproliferative disorders (PTLDs). Similarly, herpes simplex virus (HSV), varicella zoster virus and human herpesviruses 6 and 7 can also be responsible for acute manifestations in lung transplant patients. During these last years, new, highly sensitive and specific diagnostic tests have been developed, and preventive and prophylactic strategies have been studied aiming to reduce and prevent the incidence of these viral infections. In this narrative review, we explore epidemiology, diagnosis and treatment options for more frequent herpes virus infections in lung transplant patients.
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Affiliation(s)
- Filippo Patrucco
- Respiratory Diseases Unit, Medical Department, AOU Maggiore della Carità di Novara, Corso Mazzini 18, 28100 Novara, Italy
| | - Antonio Curtoni
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Francesca Sidoti
- Division of Virology, Department of Public Health and Pediatrics, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Elisa Zanotto
- Division of Virology, Department of Public Health and Pediatrics, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Alessandro Bondi
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Carlo Albera
- Division of Respiratory Medicine, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
- Medical Sciences Department, University of Turin, 10126 Turin, Italy
| | - Massimo Boffini
- Cardiac Surgery Division, Surgical Sciences Department, AOU Città della Salute e della Scienza di Torino, University of Turin, 10126 Turin, Italy
| | - Rossana Cavallo
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Cristina Costa
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Paolo Solidoro
- Division of Respiratory Medicine, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
- Medical Sciences Department, University of Turin, 10126 Turin, Italy
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Yasinskaya Y, Bala S, Waack U, Dixon C, Higgins K, Moore JN, Jjingo CJ, O'Shaughnessy E, Colangelo P, Botgros R, Nambiar S, Angulo D, Dane A, Chiller T, Hodges MR, Sandison T, Hope W, Walsh TJ, Pappas P, Katragkou A, Kovanda L, Rex JH, Marr KA, Ostrosky-Zeichner L, Sekine S, Deshpande M, Shukla SJ, Farley J. Food and Drug Administration Public Workshop Summary-Development Considerations of Antifungal Drugs to Address Unmet Medical Need. Clin Infect Dis 2023; 77:380-387. [PMID: 37021650 DOI: 10.1093/cid/ciad195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/20/2023] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
Pressing challenges in the treatment of invasive fungal infections (IFIs) include emerging and rare pathogens, resistant/refractory infections, and antifungal armamentarium limited by toxicity, drug-drug interactions, and lack of oral formulations. Development of new antifungal drugs is hampered by the limitations of the available diagnostics, clinical trial endpoints, prolonged trial duration, difficulties in patient recruitment, including subpopulations (eg, pediatrics), and heterogeneity of the IFIs. On 4 August 2020, the US Food and Drug Administration convened a workshop that included IFI experts from academia, industry, and other government agencies to discuss the IFI landscape, unmet need, and potential strategies to facilitate the development of antifungal drugs for treatment and prophylaxis. This article summarizes the key topics presented and discussed during the workshop, such as incentives and research support for drug developers, nonclinical development, clinical trial design challenges, lessons learned from industry, and potential collaborations to facilitate antifungal drug development.
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Affiliation(s)
- Yuliya Yasinskaya
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shukal Bala
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ursula Waack
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Cheryl Dixon
- Division of Biometrics IV, Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration ; Silver Spring, Maryland, USA
| | - Karen Higgins
- Division of Biometrics IV, Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration ; Silver Spring, Maryland, USA
| | - Jason N Moore
- Division of Infectious Disease Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Food and Drug Administration ; Silver Spring, Maryland, USA
| | - Caroline J Jjingo
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Elizabeth O'Shaughnessy
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Philip Colangelo
- Division of Infectious Disease Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Food and Drug Administration ; Silver Spring, Maryland, USA
| | - Radu Botgros
- Health Threats and Vaccines Strategy, European Medicines Agency, Amsterdam, the Netherlands
| | - Sumathi Nambiar
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Aaron Dane
- DaneStat Consulting, Macclesfield, United Kingdom
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | - William Hope
- Centre for Excellence in Infectious Diseases Research, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York, USA
| | - Peter Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Aspasia Katragkou
- Transplantation-Oncology Infectious Disease Program, Weill Cornell Medicine, New York, New York, USA
| | - Laura Kovanda
- Astellas Pharma Global Development, Northbrook, Illinois, USA
| | | | - Kieren A Marr
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Luis Ostrosky-Zeichner
- Director of the Laboratory of Mycology Research, McGovern Medical School, Houston, Texas, USA
| | - Shohko Sekine
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | | | - Sunita J Shukla
- Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - John Farley
- Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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Chen J, Liang Q, Ding S, Xu Y, Hu Y, Chen J, Huang M. Ceftazidime/Avibactam for the Treatment of Carbapenem-Resistant Pseudomonas aeruginosa Infection in Lung Transplant Recipients. Infect Drug Resist 2023; 16:2237-2246. [PMID: 37090036 PMCID: PMC10115196 DOI: 10.2147/idr.s407515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/05/2023] [Indexed: 04/25/2023] Open
Abstract
Background Experience of ceftazidime-avibactam (CAZ/AVI) for carbapenem-resistant Pseudomonas aeruginosa (CRPA) infection in recipients after lung transplantation (LT) is relatively limited. Methods A retrospective observational study was conducted on lung transplant recipients receiving CAZ/AVI therapy for CRPA infection. The primary outcomes were the 14-day and 30-day mortality. The secondary outcomes were clinical cure and microbiological cure. Results Among 183 LT recipients, a total of 15 recipients with CRPA infection who received CAZ/AVI therapy were enrolled in this study. The mean age of recipients was 54 years and 73.3% of recipients were male. The median time from infection onset to initiation of CAZ/AVI treatment was 4 days (IQR, 3-7) and the mean duration of CAZ/AVI therapy was 10 days. CAZ/AVI was mainly administered as monotherapy in LT recipients (80%). Among these eligible recipients, 14-day and 30-day mortality were 6.7% and 13.3%, respectively. The clinical cure and microbiological cure rates of CAZ/AVI therapy were 53.3% and 60%, respectively. Three recipients (20%) experienced recurrent infection. In addition, the mean lengths of ICU stay and hospital stay were 24 days and 35 days, respectively, among LT recipients. Conclusion CAZ/AVI may be an alternative and promising regimen for CRPA eradiation in lung transplant recipients.
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Affiliation(s)
- Juan Chen
- Department of General Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - Qiqiang Liang
- Department of General Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - Shuo Ding
- Department of General Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - Yongshan Xu
- Department of General Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - Yanting Hu
- Department of General Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - Jingyu Chen
- Wuxi Lung Transplant Center, Wuxi People’s Hospital affiliated to Nanjing Medical University, Wuxi, Jiangsu, People’s Republic of China
- Department of Lung Transplantation, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
- Jingyu Chen, Wuxi Lung Transplant Center, Wuxi People’s Hospital affiliated to Nanjing Medical University, Wuxi, Jiangsu, People’s Republic of China, Email
| | - Man Huang
- Department of General Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
- Department of Lung Transplantation, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
- Correspondence: Man Huang, Department of General Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China, Tel/Fax +86 571 89713427, Email
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