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Vernooij RW, Michael M, Ladhani M, Webster AC, Strippoli GF, Craig JC, Hodson EM. Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2024; 5:CD003774. [PMID: 38700045 PMCID: PMC11066972 DOI: 10.1002/14651858.cd003774.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND The risk of cytomegalovirus (CMV) infection in solid organ transplant recipients has resulted in the frequent use of prophylaxis to prevent the clinical syndrome associated with CMV infection. This is an update of a review first published in 2005 and updated in 2008 and 2013. OBJECTIVES To determine the benefits and harms of antiviral medications to prevent CMV disease and all-cause death in solid organ transplant recipients. SEARCH METHODS We contacted the information specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 5 February 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing antiviral medications with placebo or no treatment, comparing different antiviral medications or different regimens of the same antiviral medications for CMV prophylaxis in recipients of any solid organ transplant. Studies examining pre-emptive therapy for CMV infection are studied in a separate review and were excluded from this review. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility, risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS This 2024 update found four new studies, bringing the total number of included studies to 41 (5054 participants). The risk of bias was high or unclear across most studies, with a low risk of bias for sequence generation (12), allocation concealment (12), blinding (11) and selective outcome reporting (9) in fewer studies. There is high-certainty evidence that prophylaxis with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment is more effective in preventing CMV disease (19 studies: RR 0.42, 95% CI 0.34 to 0.52), all-cause death (17 studies: RR 0.63, 95% CI 0.43 to 0.92), and CMV infection (17 studies: RR 0.61, 95% CI 0.48 to 0.77). There is moderate-certainty evidence that prophylaxis probably reduces death from CMV disease (7 studies: RR 0.26, 95% CI 0.08 to 0.78). Prophylaxis reduces the risk of herpes simplex and herpes zoster disease, bacterial and protozoal infections but probably makes little to no difference to fungal infection, acute rejection or graft loss. No apparent differences in adverse events with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment were found. There is high certainty evidence that ganciclovir, when compared with aciclovir, is more effective in preventing CMV disease (7 studies: RR 0.37, 95% CI 0.23 to 0.60). There may be little to no difference in any outcome between valganciclovir and IV ganciclovir compared with oral ganciclovir (low certainty evidence). The efficacy and adverse effects of valganciclovir or ganciclovir were probably no different to valaciclovir in three studies (moderate certainty evidence). There is moderate certainty evidence that extended duration prophylaxis probably reduces the risk of CMV disease compared with three months of therapy (2 studies: RR 0.20, 95% CI 0.12 to 0.35), with probably little to no difference in rates of adverse events. Low certainty evidence suggests that 450 mg/day valganciclovir compared with 900 mg/day valganciclovir results in little to no difference in all-cause death, CMV infection, acute rejection, and graft loss (no information on adverse events). Maribavir may increase CMV infection compared with ganciclovir (1 study: RR 1.34, 95% CI: 1.10 to 1.65; moderate certainty evidence); however, little to no difference between the two treatments were found for CMV disease, all-cause death, acute rejection, and adverse events at six months (low certainty evidence). AUTHORS' CONCLUSIONS Prophylaxis with antiviral medications reduces CMV disease and CMV-associated death, compared with placebo or no treatment, in solid organ transplant recipients. These data support the continued routine use of antiviral prophylaxis in CMV-positive recipients and CMV-negative recipients of CMV-positive organ transplants.
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Affiliation(s)
- Robin Wm Vernooij
- Department of Nephrology and Hypertension and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Mini Michael
- Division of Pediatric Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Maleeka Ladhani
- Nephrology, Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - Angela C Webster
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Westmead Applied Research Centre, The University of Sydney at Westmead, Westmead, Australia
- Centre for Transplant and Renal Medicine, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Elisabeth M Hodson
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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2
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Mansour MK, King JD, Chen ST, Fishman JA, Nazarian RM. Case 7-2023: A 70-Year-Old Man with Covid-19, Respiratory Failure, and Rashes. N Engl J Med 2023; 388:926-937. [PMID: 36884326 PMCID: PMC10029363 DOI: 10.1056/nejmcpc2211369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Affiliation(s)
- Michael K Mansour
- From the Departments of Medicine (M.K.M., S.T.C., J.A.F.), Radiology (J.D.K.), Dermatology (S.T.C.), and Pathology (R.M.N.), Massachusetts General Hospital, and the Departments of Medicine (M.K.M., J.A.F.), Radiology (J.D.K.), Dermatology (S.T.C.), and Pathology (R.M.N.), Harvard Medical School - both in Boston
| | - Joseph D King
- From the Departments of Medicine (M.K.M., S.T.C., J.A.F.), Radiology (J.D.K.), Dermatology (S.T.C.), and Pathology (R.M.N.), Massachusetts General Hospital, and the Departments of Medicine (M.K.M., J.A.F.), Radiology (J.D.K.), Dermatology (S.T.C.), and Pathology (R.M.N.), Harvard Medical School - both in Boston
| | - Steven T Chen
- From the Departments of Medicine (M.K.M., S.T.C., J.A.F.), Radiology (J.D.K.), Dermatology (S.T.C.), and Pathology (R.M.N.), Massachusetts General Hospital, and the Departments of Medicine (M.K.M., J.A.F.), Radiology (J.D.K.), Dermatology (S.T.C.), and Pathology (R.M.N.), Harvard Medical School - both in Boston
| | - Jay A Fishman
- From the Departments of Medicine (M.K.M., S.T.C., J.A.F.), Radiology (J.D.K.), Dermatology (S.T.C.), and Pathology (R.M.N.), Massachusetts General Hospital, and the Departments of Medicine (M.K.M., J.A.F.), Radiology (J.D.K.), Dermatology (S.T.C.), and Pathology (R.M.N.), Harvard Medical School - both in Boston
| | - Rosalynn M Nazarian
- From the Departments of Medicine (M.K.M., S.T.C., J.A.F.), Radiology (J.D.K.), Dermatology (S.T.C.), and Pathology (R.M.N.), Massachusetts General Hospital, and the Departments of Medicine (M.K.M., J.A.F.), Radiology (J.D.K.), Dermatology (S.T.C.), and Pathology (R.M.N.), Harvard Medical School - both in Boston
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3
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Rinaldi M, Bartoletti M, Ferrarese A, Franceschini E, Campoli C, Coladonato S, Pascale R, Tedeschi S, Gatti M, Cricca M, Ambretti S, Siniscalchi A, Morelli MC, Cescon M, Cillo U, Di Benedetto F, Burra P, Mussini C, Cristini F, Lewis R, Viale P, Giannella M. Breakthrough invasive fungal infection after liver transplantation in patients on targeted antifungal prophylaxis: A prospective multicentre study. Transpl Infect Dis 2021; 23:e13608. [PMID: 33768656 PMCID: PMC8519035 DOI: 10.1111/tid.13608] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/08/2021] [Accepted: 03/14/2021] [Indexed: 01/21/2023]
Abstract
Objective To investigate the rate of and the risk factors for breakthrough‐IFI (b‐IFI) after orthotopic liver transplantation (OLT) according to the new definition proposed by Mycoses‐Study‐Group‐Education‐and‐Research‐Consortium (MSG‐ERC) and the European‐Confederation‐of‐Medical‐Mycology (ECMM). Methods Multicenter prospective study of adult patients who underwent OLT at three Italian hospitals, from January 2015 to December 2018. Targeted antifungal prophylaxis (TAP) protocol was developed and shared among participating centers. Follow‐up was 1‐year after OLT. B‐IFI was defined as infection occurring during exposure to antifungal prophylaxis. Risk factors for b‐IFI were analyzed among patients exposed to prophylaxis by univariable analysis. Results We enrolled 485 OLT patients. Overall compliance to TAP protocol was 64.3%, 220 patients received antifungal prophylaxis, 172 according to TAP protocol. Twenty‐nine patients were diagnosed of IFI within 1 year after OLT. Of them, 11 presented with b‐IFI within 17 (IQR 11‐33) and 16 (IQR 4‐30) days from OLT and from antifungal onset, respectively. Then out of 11 patients with b‐IFI were classified as having high risk of IFI and were receiving anti‐mould prophylaxis, nine with echinocandins and one with polyenes. Comparison of patients with and without b‐IFI showed significant differences for prior Candida colonization, need of renal replacement therapy after OLT, re‐operation, and CMV infection (whole blood CMV‐DNA >100 000 copies/mL). Although non‐significant, a higher rate of b‐IFI in patients on echinocandins was observed (8.2% vs 1.8%, P = .06). Conclusions We observed 5% of b‐IFI among OLT patients exposed to antifungal prophylaxis. The impact of echinocandins on b‐IFI risk in this setting should be further explored.
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Affiliation(s)
- Matteo Rinaldi
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Michele Bartoletti
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Alberto Ferrarese
- Multivisceral Transplant Unit (Gastroenterology), Department of Surgery Oncology and Gastroenterology, Surgical and Gastroenterological Sciences, Padua University Hospital, Padua, Italy
| | - Erica Franceschini
- Infectious Diseases Unit, Department of Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Caterina Campoli
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simona Coladonato
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Renato Pascale
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sara Tedeschi
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Monica Cricca
- Operative Unit of Clinical Microbiology, PoliclinicoSant' Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Simone Ambretti
- Infectious Diseases Unit, Department of Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Antonio Siniscalchi
- Division of Anesthesia, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria Cristina Morelli
- Division of Internal Medicine for the Treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,Division of Liver and Multiorgan Transplant, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Umberto Cillo
- Department of Surgical, Oncological, and Gastroenterological Sciences, Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, Padova, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit (Gastroenterology), Department of Surgery Oncology and Gastroenterology, Surgical and Gastroenterological Sciences, Padua University Hospital, Padua, Italy
| | - Cristina Mussini
- Infectious Diseases Unit, Department of Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Francesco Cristini
- Infectious Diseases Unit, AUSL Romagna Infermi Hospital Rimini, Rimini, Italy
| | - Russell Lewis
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Pierluigi Viale
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Maddalena Giannella
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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4
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Long B, Brady WJ, Gragossian A, Koyfman A, Gottlieb M. A primer for managing cardiac transplant patients in the emergency department setting. Am J Emerg Med 2021; 41:130-138. [PMID: 33440325 DOI: 10.1016/j.ajem.2020.12.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/26/2020] [Accepted: 12/27/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Cardiac transplant is an effective long-term management option for several severe cardiac diseases. These cardiac transplant patients may present to the emergency department with a range of issues involving the cardiac transplantation, including complications due to their transplant as well as altered presentations of disease resulting from their transplant. OBJECTIVE This narrative review provides a focused guide to the evaluation and management of patients with cardiac transplantation and its complications. DISCUSSION Cardiac transplant is an effective therapy for end-stage heart failure. A transplanted heart varies both anatomically and physiologically from a native heart. Several significant complications may occur. Graft failure, rejection, and infection are common causes of morbidity and mortality within the first year of transplant. As these patients are on significant immunosuppressive medication regimens, they are at risk of infection, but inadequate immunosuppression increases the risk of acute rejection. A variety of dysrhythmias such as atrial fibrillation and ventricular dysrhythmias may occur. These patients are also at risk of acute coronary syndrome, cardiac allograft vasculopathy, and medication adverse events. Importantly, patients with acute coronary syndrome can have an altered presentation with the so-called "painless" myocardial infarction. Consultation with the transplant physician is recommended, if available, for these patients to assist in evaluation and management. CONCLUSIONS An understanding of the presentations and various complications that may affect patients with cardiac transplant will assist emergency clinicians in the care of these patients.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States of America.
| | - Alin Gragossian
- The Mt Sinai Hospital, Institute for Critical Care Medicine, New York, NY, United States of America
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
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5
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Kaplan B, Bonagura VR. Secondary Hypogammaglobulinemia: An Increasingly Recognized Complication of Treatment with Immunomodulators and After Solid Organ Transplantation. Immunol Allergy Clin North Am 2019; 39:31-47. [PMID: 30466771 DOI: 10.1016/j.iac.2018.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Secondary hypogammaglobulinemia is a common development in patients treated with immunomodulatory agents for autoimmune, connective tissue, and malignant diseases. It has been observed in the medical management of patients undergoing hematopoietic stem cell and solid organ transplantation. Some patients have preexisting immunodeficiency associated with these illnesses; immunosuppressive treatment magnifies their immune defect. This article reviews immunosuppressive medications, including biological treatments that cause secondary hypogammaglobulinemia. It summarizes risk factors for rituximab-induced hypogammaglobulinemia, such as preexisting low immunoglobulin G levels, CD19 levels, host factors, and additive effect of all immunomodulatory drugs used. The evaluation and management of secondary hypogammaglobulinemia are discussed.
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Affiliation(s)
- Blanka Kaplan
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Steven and Alexandra Cohen Medical Center of New York, 865 Northern Boulevard, Suite 101, Great Neck, NY 11021, USA.
| | - Vincent R Bonagura
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Steven and Alexandra Cohen Medical Center of New York, 865 Northern Boulevard, Suite 101, Great Neck, NY 11021, USA
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6
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Thomas S, Pawar B, Fernandes D, Nayar S, George P, Cherian S. An Unusual Case of Pulmonary Mucormycosis. Transplant Proc 2018; 50:3943-3945. [PMID: 30503525 DOI: 10.1016/j.transproceed.2018.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 06/01/2018] [Indexed: 01/15/2023]
Abstract
Invasive fungal infections in solid organ transplant recipients are associated with significant morbidity and mortality. Of these fungal infections, mucormycosis presents as an aggressive, frequently fatal angioinvasive infection. Immunocompromised hosts and diabetes are important risk factors. These infections are frequently difficult to diagnose. A high index of suspicion in the appropriate setting and early, aggressive treatment with the newer antifungal agents have altered the previously grave prognosis. We present the first reported case of cavitating pulmonary mucormycosis in a renal transplant recipient caused by an unusual species of Mucorales. The patient was treated with a combination of lobectomy and antifungal treatment comprising of amphotericin B and posaconazole. He remains free of disease recurrence on monotherapy with posaconazole.
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Affiliation(s)
- S Thomas
- Alice Springs Hospital, Northern Territory, Australia.
| | - B Pawar
- Alice Springs Hospital, Northern Territory, Australia
| | - D Fernandes
- Alice Springs Hospital, Northern Territory, Australia
| | - S Nayar
- Alice Springs Hospital, Northern Territory, Australia
| | - P George
- Alice Springs Hospital, Northern Territory, Australia
| | - S Cherian
- Alice Springs Hospital, Northern Territory, Australia
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Tang M, Xu X, Shen B, Zhang J, Li P, Pan Q, Mei M, Xie P, Liu H. Fifty-one cases of fungal arteritis after kidney transplantation: A case report and review of the literature. Transpl Infect Dis 2017; 19. [PMID: 28940730 DOI: 10.1111/tid.12781] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 04/02/2017] [Accepted: 06/14/2017] [Indexed: 12/27/2022]
Abstract
Fungal arteritis affecting graft arteries is a rare but life-threatening complication in kidney transplantation (KT). Here, we report the case of a patient with Aspergillus arteritis who experienced renal artery rupture 8 days after KT. We also reviewed 50 other reported cases of fungal arteritis after KT. We found that fungal contamination can occur during kidney graft harvest, preservation, and/or transplantation. Typically, early diagnosis, timely antifungal treatment, and emergency surgery seem crucial for avoiding life-threatening vascular complications.
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Affiliation(s)
- Maozhi Tang
- Department of Nephrology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Xiaosong Xu
- Department of Nephrology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Bingbing Shen
- Department of Nephrology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Jun Zhang
- Department of Nephrology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Peng Li
- Department of Nephrology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Qianguang Pan
- Department of Nephrology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Mei Mei
- Department of Nephrology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Pan Xie
- Department of Nephrology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Hong Liu
- Department of Nephrology, Southwest Hospital, Third Military Medical University, Chongqing, China
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8
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Cutaneous fungal infections in solid organ transplant recipients. Transplant Rev (Orlando) 2017; 31:158-165. [DOI: 10.1016/j.trre.2017.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/05/2017] [Accepted: 03/06/2017] [Indexed: 12/29/2022]
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9
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Al Hammadi A, Ostrosky-Zeichner L. Epidemiology and Management of Candidiasis in Solid Organ Transplant Recipients. CURRENT FUNGAL INFECTION REPORTS 2016. [DOI: 10.1007/s12281-016-0269-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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10
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Long B, Koyfman A. The emergency medicine approach to transplant complications. Am J Emerg Med 2016; 34:2200-2208. [DOI: 10.1016/j.ajem.2016.08.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/18/2016] [Accepted: 08/20/2016] [Indexed: 02/07/2023] Open
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11
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Jacobs RE. Isolated cryptococcuria in a patient with impaired immunity. HIV & AIDS REVIEW 2016. [DOI: 10.1016/j.hivar.2016.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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12
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Invasive Fungal Infections in Pediatric Solid Organ Transplant Patients: Epidemiology and Management. CURRENT FUNGAL INFECTION REPORTS 2015. [DOI: 10.1007/s12281-015-0217-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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13
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Evans JDW, Morris PJ, Knight SR. Antifungal prophylaxis in liver transplantation: a systematic review and network meta-analysis. Am J Transplant 2014; 14:2765-76. [PMID: 25395336 DOI: 10.1111/ajt.12925] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/09/2014] [Accepted: 07/04/2014] [Indexed: 01/25/2023]
Abstract
Invasive fungal infections (IFIs) cause significant morbidity and mortality in liver transplant recipients, but the need and best agent for prophylaxis is uncertain. A comprehensive literature search was performed to identify randomized controlled trials comparing regimens for antifungal prophylaxis in liver transplant recipients. Direct comparisons were made between treatments using random-effects meta-analysis and a Bayesian network meta-analysis was performed for the primary end point of proven IFI. Fourteen studies met inclusion criteria, reporting comparisons of fluconazole, liposomal amphotericin B (L-AmB), itraconazole, micafungin and placebo. Overall, antifungal prophylaxis reduced the rate of proven IFI (odds ratio [OR] 0.37, confidence interval [CI] 0.19-0.72, p = 0.003), suspected or proven IFI (OR 0.40, CI 0.25-0.66, p = 0.0003) and mortality due to IFI (OR 0.32, CI 0.10-0.83, p = 0.02) when compared to placebo. All-cause mortality was not significantly affected. There was no difference in risk of adverse events requiring cessation of prophylaxis (OR 1.11, 95% CI 0.48-2.55, p = 0.81). In the network meta-analysis an equivalent reduction in the rate of IFI was seen with fluconazole (OR 0.21, CI 0.06-0.57) and L-AmB (OR 0.21, CI 0.05-0.71) compared with placebo. Routine prophylaxis with fluconazole or L-AmB reduces the incidence of IFI following liver transplantation, and the available evidence suggests that the two are equivalent in efficacy.
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Affiliation(s)
- J D W Evans
- Department of Medicine, Cambridge University, Cambridge, UK; Centre for Evidence in Transplantation, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, London, UK
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14
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Candida species contamination of preservation fluid-outcome of renal transplantation in 6 patients. Transplant Proc 2014; 45:2215-9. [PMID: 23953531 DOI: 10.1016/j.transproceed.2013.03.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/06/2013] [Accepted: 03/21/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Fungal infections are a rare but important cause of morbidity and mortality in kidney transplantation. Fungal contamination of the kidney preservation fluid may, sometimes, be the cause of these infections. However, the clinical consequences of fungal contamination of this fluid are not completely understood and literature on this topic is controversial. The purpose of this study was to determine the incidence of preservation fluid contamination by fungi and its clinical consequences. METHODS From June 2010 to September 2011, a prospective cohort analysis was conducted at our center, enrolling all patients who received a renal allograft and whose perfusion fluid was analyzed for microbiology sterility. Patients with perfusion fluids positive for fungi were further studied: the patients' status was assessed during regular visits and data were recorded, including clinical characteristics, infections, graft function, immunosuppressive regimen and outcomes. RESULTS Microbiologic, cultures of 70 kidney perfusion fluids using specific mycologic media, obtained from 74 cadaveric renal transplants (4 fluids were unsuitable for analysis), were evaluated. Six samples were positive for yeasts (8.6%), with 4 isolates of Candida albicans and 2 isolates of Candida glabrata. Four patients had no evidence of fungal infection during the follow-up period (median 321 days); conversely, 2 patients developed severe mycotic vascular complications leading to transplantectomy. CONCLUSIONS Perfusion fluid contamination by fungi is an elusive situation that can lead either to an unremarkable clinical course or to graft loss life-threatening situations. Routine culture of kidney perfusion fluid is critical for prompt diagnosis and early implementation of appropriate treatment.
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EXP CLIN TRANSPLANTExp Clin Transplant 2014; 12. [DOI: 10.6002/ect.25liver.p19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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16
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Brizendine KD, Vishin S, Baddley JW. Antifungal prophylaxis in solid organ transplant recipients. Expert Rev Anti Infect Ther 2014; 9:571-81. [DOI: 10.1586/eri.11.29] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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17
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Dou YH, Du JK, Liu HL, Shong XD. The role of procalcitonin in the identification of invasive fungal infection-a systemic review and meta-analysis. Diagn Microbiol Infect Dis 2013; 76:464-9. [PMID: 23711529 DOI: 10.1016/j.diagmicrobio.2013.04.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 04/19/2013] [Indexed: 11/24/2022]
Abstract
We aimed to summarize evidence on the accuracy of procalcitonin (PCT) test in differentiating fungal infection from other causes of infection. We searched electronic database for original researches that reported diagnostic performance of PCT alone or compare with other biomarkers to diagnose invasive fungal infection (IFI). We included 8 qualifying studies studying 474 episodes of suspected fungal infection with 155 (32.7%) probable or proven IFIs. Four studies compared IFI to bacterial sepsis, in which the pooled positive likelihood ratios and negative likelihood ratios were 4.65 (95% confidence interval [CI], 2.46-8.79) and 0.15 (95% CI, 0.05-0.41), respectively. Another 4 studies compared IFI to uninfected individuals, in which the pooled positive likelihood ratios and negative likelihood ratios were 4.01 (95% CI, 2.04-7.88) and 0.23 (0.07-0.77), respectively. The existing literature suggests good diagnostic accuracy for the PCT test for discrimination between IFIs and bacterial infection or noninfectious conditions. Given the high heterogeneity, medical decisions should be based on both PCT test results and clinical findings.
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Affiliation(s)
- Yu-Hong Dou
- Clinical Laboratory, Shenzhen Shajing Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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18
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Hodson EM, Ladhani M, Webster AC, Strippoli GFM, Craig JC. Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2013:CD003774. [PMID: 23450543 DOI: 10.1002/14651858.cd003774.pub4] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The risk of cytomegalovirus (CMV) infection in solid organ transplant recipients has resulted in the frequent use of prophylaxis with the aim of preventing the clinical syndrome associated with CMV infection. This is an update of a review first published in 2005 and updated in 2008. OBJECTIVES To determine the benefits and harms of antiviral medications to prevent CMV disease and all-cause mortality in solid organ transplant recipients. SEARCH METHODS We searched MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials (CENTRAL) in The Cochrane Library to February 2004 for the first version of this review. The Cochrane Renal Group's specialised register was searched to February 2007 and to July 2011 for the first and current updates of the review without language restriction. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing antiviral medications with placebo or no treatment, comparing different antiviral medications and comparing different regimens of the same antiviral medications in recipients of any solid organ transplant. Studies examining pre-emptive therapy were excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility, risk of bias and extracted data. Results were reported as risk ratios (RR) or risk differences (RD) with 95% confidence intervals (CI) for dichotomous outcomes and by mean difference (MD) with 95% CI for continuous outcomes. Statistical analyses were performed using the random-effects model. Subgroup analysis and univariate meta-regression were performed using restricted maximum-likelihood to estimate the between study variance. Multivariate meta-regression was performed to investigate whether the results were altered after allowing for differences in drugs used, organ transplanted, and recipient CMV serostatus at the time of transplantation. MAIN RESULTS We identified 37 studies (4342 participants). Risk of bias attributes were poorly performed or reported with low risk of bias reported for sequence generation, allocation concealment, blinding and selective outcome reporting in 25% or fewer studies.Prophylaxis with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment significantly reduced the risk for CMV disease (19 studies; RR 0.42, 95% CI 0.34 to 0.52), CMV infection (17 studies; RR 0.61, 95% CI 0.48 to 0.77), and all-cause mortality (17 studies; RR 0.63, 95% CI 0.43 to 0.92) primarily due to reduced mortality from CMV disease (7 studies; RR 0.26, 95% CI 0.08 to 0.78). Prophylaxis reduced the risk of herpes simplex and herpes zoster disease, bacterial and protozoal infections but not fungal infection, acute rejection or graft loss.Meta-regression showed no significant difference in the relative benefit of treatment (risk of CMV disease or all-cause mortality) by organ transplanted or CMV serostatus; no conclusions were possible for CMV negative recipients of negative organs.Neurological dysfunction was more common with ganciclovir and valaciclovir compared with placebo/no treatment. In direct comparison studies, ganciclovir was more effective than aciclovir in preventing CMV disease (7 studies; RR 0.37, 95% CI 0.23 to 0.60) and leucopenia was more common with aciclovir. Valganciclovir and IV ganciclovir were as effective as oral ganciclovir. The efficacy and adverse effects of valganciclovir/ganciclovir did not differ from valaciclovir in three small studies. Extended duration prophylaxis significantly reduced the risk of CMV disease compared with three months therapy (2 studies; RR 0.20, 95% CI 0.12 to 0.35). Leucopenia was more common with extended duration prophylaxis but severe treatment associated adverse effects did not differ between extended and three month durations of treatment. AUTHORS' CONCLUSIONS Prophylaxis with antiviral medications reduces CMV disease and CMV-associated mortality in solid organ transplant recipients. These data suggest that antiviral prophylaxis should be used routinely in CMV positive recipients and in CMV negative recipients of CMV positive organ transplants.
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Affiliation(s)
- Elisabeth M Hodson
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia.
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19
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Ramírez E, García-Rodríguez J, Borobia AM, Ortega JM, Lei S, Barrios-Fernández A, Sánchez M, Carcas AJ, Herrero A, Puente JM, Frías J. Use of antifungal agents in pediatric and adult high-risk areas. Eur J Clin Microbiol Infect Dis 2011; 31:337-47. [DOI: 10.1007/s10096-011-1315-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Accepted: 06/01/2011] [Indexed: 11/25/2022]
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20
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Jaiswal S, Vij M, Prasad N, Kaul A, Marak RSK, Pandey R. Diagnostic pitfalls in cytological diagnosis of subcutaneous fungal infection in renal transplant recipients. Diagn Cytopathol 2011; 40:255-61. [PMID: 21381226 DOI: 10.1002/dc.21626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 11/18/2010] [Indexed: 11/09/2022]
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21
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Avoiding pitfalls: what an endoscopist should know in liver transplantation--part II. Dig Dis Sci 2009; 54:1386-402. [PMID: 19085103 DOI: 10.1007/s10620-008-0520-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Accepted: 08/27/2008] [Indexed: 02/07/2023]
Abstract
Over the last decade the number of patients undergoing transplantation has increased. At the same time, effective peri- and postoperative care and better surgical techniques have resulted in greater numbers of recipients achieving long-term survival. Identification and effective management in the form of adequate treatment is essential, since any delay in diagnosis or treatment may result in graft loss or serious threat to patient's life. Various aspects of endoscopic findings that can be commonly encountered among liver transplant recipients are discussed herein. Topics include: persistent and/or recurrent esophageal varices, reflux, Candida or cytomegalovirus (CMV) esophagitis, esophageal neoplasms, posttransplant peptic ulcer, biliary complications, posttransplant lymphoproliferative disorder (PTLD), Kaposi's sarcoma, CMV colitis and inflammatory bowel disease, colonic neoplasms, Clostridium difficile infection, and graft versus host disease (GVHD).
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22
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Stie J, Bruni G, Fox D. Surface-associated plasminogen binding of Cryptococcus neoformans promotes extracellular matrix invasion. PLoS One 2009; 4:e5780. [PMID: 19492051 PMCID: PMC2685986 DOI: 10.1371/journal.pone.0005780] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Accepted: 05/06/2009] [Indexed: 01/17/2023] Open
Abstract
Background The fungal pathogen Cryptococcus neoformans is a leading cause of illness and death in persons with predisposing factors, including: malignancies, solid organ transplants, and corticosteroid use. C. neoformans is ubiquitous in the environment and enters into the lungs via inhalation, where it can disseminate through the bloodstream and penetrate the central nervous system (CNS), resulting in a difficult to treat and often-fatal infection of the brain, called meningoencephalitis. Plasminogen is a highly abundant protein found in the plasma component of blood and is necessary for the degradation of fibrin, collagen, and other structural components of tissues. This fibrinolytic system is utilized by cancer cells during metastasis and several pathogenic species of bacteria have been found to manipulate the host plasminogen system to facilitate invasion of tissues during infection by modifying the activation of this process through the binding of plasminogen at their surface. Methodology The invasion of the brain and the central nervous system by penetration of the protective blood-brain barrier is a prerequisite to the establishment of meningoencephalitis by the opportunistic fungal pathogen C. neoformans. In this study, we examined the ability of C. neoformans to subvert the host plasminogen system to facilitate tissue barrier invasion. Through a combination of biochemical, cell biology, and proteomic approaches, we have shown that C. neoformans utilizes the host plasminogen system to cross tissue barriers, providing support for the hypothesis that plasminogen-binding may contribute to the invasion of the blood-brain barrier by penetration of the brain endothelial cells and underlying matrix. In addition, we have identified the cell wall-associated proteins that serve as plasminogen receptors and characterized both the plasminogen-binding and plasmin-activation potential for this significant human pathogen. Conclusions The results of this study provide evidence for the cooperative role of multiple virulence determinants in C. neoformans pathogenesis and suggest new avenues for the development of anti-infective agents in the prevention of fungal tissue invasion.
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Affiliation(s)
- Jamal Stie
- Research Institute for Children, Louisiana State University Health Science Center, Children's Hospital, New Orleans, Louisiana, United States of America
| | - Gillian Bruni
- Institute for Microbiology, ETH Zurich, Zurich, Switzerland
| | - Deborah Fox
- Research Institute for Children, Louisiana State University Health Science Center, Children's Hospital, New Orleans, Louisiana, United States of America
- Department of Pediatrics, Louisiana State University Health Science Center, Children's Hospital, New Orleans, Louisiana, United States of America
- * E-mail:
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23
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Safadi AR, Soubani AO. Diagnostic approach of pulmonary disease in the HIV negative immunocompromised host. Eur J Intern Med 2009; 20:268-79. [PMID: 19393494 DOI: 10.1016/j.ejim.2008.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 05/26/2008] [Accepted: 07/07/2008] [Indexed: 02/04/2023]
Abstract
The advances in medicine have resulted in increasing number of immunocompromised patients with complications related to their underlying disease or the treatment of these conditions. Pulmonary infectious and non-infectious conditions are a major cause of morbidity and mortality in these patients, and represent a diagnostic challenge. This article reviews the major conditions causing pulmonary symptoms in the HIV negative immunocompromised host. It also discusses the role of the different diagnostic methods, including the recent advances in non-invasive studies, in reaching a diagnosis of pulmonary disease in this patient population.
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Affiliation(s)
- Abdul Rahman Safadi
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Karmanos Cancer Center and Wayne State University School of Medicine, Detroit, MI 48201, United States.
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24
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van Hal SJ, Marriott DJE, Chen SCA, Nguyen Q, Sorrell TC, Ellis DH, Slavin MA. Candidemia following solid organ transplantation in the era of antifungal prophylaxis: the Australian experience. Transpl Infect Dis 2009; 11:122-7. [PMID: 19220822 PMCID: PMC7190180 DOI: 10.1111/j.1399-3062.2009.00371.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Solid organ transplant (SOT) recipients have high rates of invasive fungal infections, with Candida species the most commonly isolated fungi. The aim of this study was to identify differences between incidence rates, risk factors, clinical presentations, and outcomes of candidemia in SOT recipients and non-SOT patients. Data from the multicenter prospective Australian Candidaemia Study were examined. From August 2001 to July 2004, 24 episodes (2.2%; 24/1068) of candidemia were identified in SOT recipients. During this period, the numbers of transplanted organs included liver (n=455), kidney (n=1605), single lung (n=57), bilateral lung (n=183), heart and lung (n=18), heart (n=157), and pancreas (n=62). The overall annual estimated incidence of candidemia in SOT recipients was higher (3 per 1000 transplant admissions) than in non-SOT patients (incidence 0.21 per 1000 admissions; P<0.001). The incidence and timing of candidemia post transplant was influenced by the transplanted organ type, with the majority of episodes (n=14, 54%) occurring >6 months after renal transplantation. Risk factors for candidemia in the month preceding diagnosis were similar to non-SOT recipients except for corticosteroid therapy (P<0.001). Antifungal prophylaxis did not select for more resistant or non-albicans Candida species in the SOT group. The 30-day all-cause mortality was similar to non-SOT patients with candidemia and remains high at 21%. All deaths in SOT recipients occurred early (within 5 days of diagnosis), underlining a need for better diagnostic tests, targeted prevention, and early treatment strategies.
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Affiliation(s)
- S J van Hal
- Department of Microbiology and Infectious Diseases, St Vincent's Hospital, Sydney, Australia.
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25
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Hodson EM, Craig JC, Strippoli GFM, Webster AC. Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2008:CD003774. [PMID: 18425894 DOI: 10.1002/14651858.cd003774.pub3] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The risk of cytomegalovirus (CMV) infection in solid organ transplant recipients has resulted in the frequent use of prophylaxis with the aim of preventing the clinical syndrome associated with CMV infection. OBJECTIVES To determine the benefits and harms of antiviral medications to prevent CMV disease and all-cause mortality in solid organ transplant recipients. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists and abstracts from conference proceedings without language restriction. Date of last search: February 2007 SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing antiviral medications with placebo or no treatment, comparing different antiviral medications and comparing different regimens of the same antiviral medications in recipients of any solid organ transplant. DATA COLLECTION AND ANALYSIS Statistical analyses were performed using the random effects model and results expressed as relative risk (RR) for dichotomous outcomes with 95% confidence intervals (CI). Subgroup analysis and univariate meta-regression were performed using restricted maximum-likelihood to estimate the between study variance. Multivariate meta-regression was performed to investigate whether the results were altered after allowing for differences in drugs used, organ transplanted and recipient CMV serostatus at the time of transplantation. MAIN RESULTS Thirty four studies (3850 participants) were identified. Prophylaxis with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment significantly reduced the risk for CMV disease (19 studies; RR 0.42, 95% CI 0.34 to 0.52), CMV infection (17 studies; RR 0.61, 95% CI 0.48 to 0.77), and all-cause mortality (17 studies; RR 0.63, 95% CI 0.43 to 0.92) primarily due to reduced mortality from CMV disease (7 studies; RR 0.26, 95% CI 0.08 to 0.78). Prophylaxis reduced the risk of herpes simplex and herpes zoster disease, bacterial and protozoal infections but not fungal infection, acute rejection or graft loss. Meta-regression showed no significant difference in the relative benefit of treatment (risk of CMV disease or all-cause mortality) by organ transplanted or CMV serostatus; no conclusions were possible for CMV negative recipients of negative organs. In direct comparison studies, ganciclovir was more effective than aciclovir in preventing CMV disease (7 studies; RR 0.37, 95% CI 0.23 to 0.60). Valganciclovir and IV ganciclovir were as effective as oral ganciclovir. AUTHORS' CONCLUSIONS Prophylaxis with antiviral medications reduces CMV disease and CMV-associated mortality in solid organ transplant recipients. They should be used routinely in CMV positive recipients and in CMV negative recipients of CMV positive organ transplants.
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Affiliation(s)
- E M Hodson
- Children's Hospital at Westmead, Centre for Kidney Research, Locked Bag 4001, Westmead, NSW, Australia, 2145.
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26
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Rekha A, Kindo AJ, Ravi A. Fusarium solani in the Post-transplant Patient: An Unusual Fungus. INT J LOW EXTR WOUND 2008; 7:38-40. [DOI: 10.1177/1534734607313879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The incidence of fungal infections in post-transplant patients ranges from 2% to 50%, and more uncommon pathogens are being isolated. Earlier, the fungi seen were candida, aspergillus, and cryptococcus; and of late, histoplasma, coccidiodomycoses, and dematiaceous fungi are seen. In this article, a patient with invasive fusariosis is presented, and literature of this uncommon fungus is reviewed.
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Affiliation(s)
- Arcot Rekha
- Department of Surgery, Sri Ramachandra University,
| | - Anupma J. Kindo
- Department of Microbiology Sri Ramachandra Medical College
and Research Institute, Sri Ramachandra University, Porur, Chennai-600116,
India
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27
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Gabardi S, Kubiak DW, Chandraker AK, Tullius SG. Invasive fungal infections and antifungal therapies in solid organ transplant recipients. Transpl Int 2007; 20:993-1015. [PMID: 17617181 DOI: 10.1111/j.1432-2277.2007.00511.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This manuscript will review the risk factors, prevalence, clinical presentation, and management of invasive fungal infections (IFIs) in solid organ transplant (SOT) recipients. Primary literature was obtained via MEDLINE (1966-April 2007) and EMBASE. Abstracts were obtained from scientific meetings or pharmaceutical manufacturers and included in the analysis. All studies and abstracts evaluating IFIs and/or antifungal therapies, with a primary focus on solid organ transplantation, were considered for inclusion. English-language literature was selected for inclusion, but was limited to those consisting of human subjects. Infectious complications following SOT are common. IFIs are associated with high morbidity and mortality rates in this patient population. Determining the best course of therapy is difficult due to the limited availability of data in SOT recipients. Well-designed clinical studies are infrequent and much of the available information is often based on case-reports or retrospective analyses. Transplant practitioners must remain aware of their therapeutic options and the advantages and disadvantages associated with the available treatment alternatives.
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Affiliation(s)
- Steven Gabardi
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA.
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28
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Hodson EM, Jones CA, Strippoli GFM, Webster AC, Craig JC. Immunoglobulins, vaccines or interferon for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2007:CD005129. [PMID: 17443573 DOI: 10.1002/14651858.cd005129.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) is the most common virus causing disease and death in solid organ transplant recipients during the first six months post-transplant. Previous systematic reviews have demonstrated the efficacy of antiviral medications used prophylactically or pre-emptively in preventing CMV disease. In this review the efficacy of older agents (immunoglobulins (IgG), anti CMV vaccines and interferon) are examined. OBJECTIVES To assess the benefits and harms of IgG, anti CMV vaccines or interferon for preventing symptomatic CMV disease in solid organ transplant recipients. SEARCH STRATEGY We searched the Cochrane Renal Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library), MEDLINE, EMBASE, reference lists and abstracts from conference proceedings without language restriction. Date of last search: December 2005 SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing IgG, anti CMV vaccine or interferon with placebo or no treatment, IgG alone or combined with antiviral medications with antiviral medications or IgG alone in recipients of any solid organ transplant. DATA COLLECTION AND ANALYSIS Two of four authors independently assessed trial quality and extracted data from each trial. Statistical analyses were performed using the random effects model and results expressed as relative risk (RR) for dichotomous outcomes with 95% confidence intervals (CI). MAIN RESULTS Thirty seven trials (2185 participants) were included in this review. There was no significant difference in the risk for CMV disease (16 trials, 770 patients: RR 0.80, 95% CI 0.61 to 1.05), CMV infection (14 trials, 775 patients: RR 0.94, 95% CI 0.80 to 1.10) or all-cause mortality (8 trials, 502 patients: RR 0.57, 95% CI 0.32 to 1.03) with IgG compared with placebo/no treatment. However IgG significantly reduced the risk of death from CMV disease (6 trials, 346 patients: RR 0.33, 95% CI 0.14 to 0.80). There was no difference in the risk for CMV disease (4 trials, 298 patients: RR 1.17, 95% CI 0.74 to 1.86), CMV infection (4 trials, 298 patients: RR 1.16, 95% CI 0.89 to 1.52) or all-cause mortality (2 trials, 217 patients: RR 0.92, 95% CI 0.37 to 2.29) between antiviral medication combined with IgG and antiviral medication alone. There was no significant difference in the risk of CMV disease with anti CMV vaccine or interferon compared with placebo or no treatment. AUTHORS' CONCLUSIONS Currently there are no indications for IgG in the prophylaxis of CMV disease in recipients of solid organ transplants.
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Affiliation(s)
- E M Hodson
- Children's Hospital at Westmead, Centre for Kidney Research, Locked Bag 4001, Westmead, NSW, Australia, 2145.
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29
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Geyer AS, Fox LP, Husain S, Della-Latta P, Grossman ME. Acremonium mycetoma in a heart transplant recipient. J Am Acad Dermatol 2006; 55:1095-100. [PMID: 17097407 DOI: 10.1016/j.jaad.2006.08.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Mycetomas are chronic, progressive infections caused either by fungi (eumycetoma) or filamentous bacteria (actinomycetoma) and are characterized by the triad of draining sinuses, tumefaction, and the presence of macroscopic grains. We describe a case of eumycetoma in a cardiac transplant recipient caused by the soil saprophyte Acremonium species. This represents only the fifth case of eumycetoma reported in a solid organ transplant recipient. With the population of immunosuppressed patients and the incidence of invasive fungal infections increasing, consideration should be given to unusual saprophytic fungal infections as emerging opportunistic pathogens.
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Affiliation(s)
- Adam S Geyer
- Department of Dermatology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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30
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Abstract
OBJECTIVE To review the epidemiology, risk factors, diagnosis, treatment, and prevention of Candida infections in surgical intensive care unit patients. DESIGN : Selected review of the literature. SETTING Critically ill patients either in an intensive care unit or having undergone a major surgical procedure. INTERVENTIONS None. MAIN RESULTS Candida infections are the third most common cause of bloodstream infection in the intensive care unit, with increasing numbers of infections due to nonalbicans species. The diagnosis of an invasive fungal infection is difficult, and the risk factors must be recognized and minimized. There is no general consensus about what signs, symptoms, and cultures define a fungal infection. A new 1,3 beta-glucan blood test may assist is the definition of invasive fungal infection. Treatment of fungal infections is now possible with a variety of antifungal agents, with different spectrums of activity, mechanisms of action, and adverse events. Prevention (prophylaxis) is a reasonable strategy in highly selected patients with a significant risk of fungal infection. CONCLUSION New antifungal agents and diagnostic tests may improve the outcome of surgical intensive care unit patients with invasive fungal infections. However, agreement about definitions of fungal infection makes study and conclusions of prevention and treatment trials difficult to interpret.
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Affiliation(s)
- Pamela A Lipsett
- Department of Surgery, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, MD, USA
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Lengerke C, Ljubicic T, Meisner C, Loeffler J, Sinzger C, Einsele H, Hebart H. Evaluation of the COBAS Amplicor HCMV Monitor for early detection and monitoring of human cytomegalovirus infection after allogeneic stem cell transplantation. Bone Marrow Transplant 2006; 38:53-60. [PMID: 16788683 DOI: 10.1038/sj.bmt.1705408] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Early diagnosis of human cytomegalovirus (HCMV) infection and the introduction of preemptive antiviral therapy have reduced HCMV-related mortality after allogeneic stem cell transplantation. A critical goal remains stratifying risk profiles and minimizing potential harm owing to antiviral overtreatment. We compared the commercially available standardized COBAS Amplicor CMV Monitor (CACM) to an in-house PCR assay, for the monitoring of HCMV infection. Seventy-two patients were surveyed by an in-house PCR of whole blood, quantitative viral load assessment by CACM and virus culture assays in a prospective and a retrospective study. A high concordance between CACM and PCR was documented. The viral load at onset correlated with the peak viral load (Spearman rank correlation R=0.634, P=0.0004). In patients developing HCMV disease, both viral loads were in trend higher (P=0.823, respectively P=0.053), and the viremic episodes longer (P=0.015), as compared to asymptomatically HCMV-infected patients. The serological pre-transplant status was the major risk factor for the development of HCMV disease, showing highest risk for seropositive patients receiving a seronegative graft, whereas donor type (related or unrelated) and graft type (bone marrow or peripheral blood mobilized stem cells) did not have an influence. HCMV infection proved to be a risk factor for the development of non-viral opportunistic infections (P=0.002).
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Affiliation(s)
- C Lengerke
- Department of Hematology/Oncology, University of Tübingen Medical Center, Tübingen, Germany
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32
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Laouad I, Buchler M, Noel C, Sadek T, Maazouz H, Westeel PF, Lebranchu Y. Renal artery aneurysm secondary to Candida albicans in four kidney allograft recipients. Transplant Proc 2006; 37:2834-6. [PMID: 16182825 DOI: 10.1016/j.transproceed.2005.05.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Infection is a frequent cause of morbidity and mortality in solid organ transplant recipients. It may occur at different periods after transplantation. We report four cases of mycotic aneurysms due to Candida albicans (CA) in renal transplant recipients occurring early after kidney transplantation. CASE REPORTS Four patients (three men, one woman) aged from 24 to 55 years who underwent cadaveric renal transplantation from three different donors developed a mycotic aneurysm at 9 to 90 days after transplantation. In all cases aneurysms were located at the anastomosis between the renal graft artery and the iliac axis. The clinical presentations were fever in three cases, including endocarditis in one patient or deterioration of graft function in two cases and hemorrhagic shock secondary to a ruptured renal artery in the fourth case, which led to death. The arterial aneurysm was discovered at autopsy. The diagnosis of a mycotic aneurysm was based on morphological investigations: echotomography, spiral computed tomography, and arteriography. In all cases bacteriological studies (blood culture, culture of the aneurysmal wall and content) isolated CA. In three patients CA was isolated from the preservation solution; it was of the same phenotype as the one isolated from the aneurysm in one recipient. Antifungal therapy was started in patients who lived, but all kidney transplants had to be removed. Anatomical results of arterial reconstructions were satisfactory in all cases and remained so during the follow-up. CONCLUSION The insidious presentation and clinical course of mycotic aneurysms due to CA require a high degree of suspicion to make the correct diagnosis.
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Affiliation(s)
- I Laouad
- Department of Nephrology and Clinical Immunology, University Hospital, Tours, France.
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Hodson EM, Barclay PG, Craig JC, Jones C, Kable K, Strippoli GFM, Vimalachandra D, Webster AC. Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2005:CD003774. [PMID: 16235341 DOI: 10.1002/14651858.cd003774.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The risk of cytomegalovirus (CMV) infection in solid organ transplant recipients has resulted in the frequent use of prophylaxis with the aim of preventing the clinical syndrome associated with CMV infection. OBJECTIVES To determine the benefits and harms of antiviral medications to prevent CMV disease and all-cause mortality in solid organ transplant recipients. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists and abstracts from conference proceedings without language restriction. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing antiviral medications with placebo or no treatment, trials comparing different antiviral medications and trials comparing different regimens of the same antiviral medications in recipients of any solid organ transplant. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality and extracted data from each trial. Statistical analyses were performed using the random effects model and results expressed as relative risk (RR) for dichotomous outcomes with 95% confidence intervals (CI). Subgroup analysis and univariate meta-regression were performed using restricted maximum-likelihood to estimate the between study variance. Multivariate meta-regression was performed to investigate whether the results were altered after allowing for differences in drugs used, organ transplanted and recipient CMV serostatus at the time of transplantation. MAIN RESULTS Thirty two trials (3737 participants) were identified. Prophylaxis with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment significantly reduced the risk for CMV disease (19 trials; RR 0.42, 95% CI 0.34 to 0.52), CMV infection (17 trials; RR 0.61, 95% CI 0.48 to 0.77), and all-cause mortality (17 trials; RR 0.63, 95% CI 0.43 to 0.92) primarily due to reduced mortality from CMV disease (seven trials; RR 0.26, 95% CI 0.08 to 0.78). Prophylaxis reduced the risk of herpes simplex and herpes zoster disease, bacterial and protozoal infections but not fungal infection, acute rejection or graft loss. Meta-regression showed no significant difference in the risk of CMV disease or all-cause mortality by organ transplanted or CMV serostatus; no conclusions were possible for CMV negative recipients of negative organs. In direct comparison trials, ganciclovir was more effective than aciclovir in preventing CMV disease (seven trials; RR 0.37, 95% Cl 0.23 to 0.60). Valganciclovir and intravenous ganciclovir were as effective as oral ganciclovir. AUTHORS' CONCLUSIONS Prophylaxis with antiviral medications reduces CMV disease and CMV-associated mortality in solid organ transplant recipients. They should be used routinely in CMV positive recipients and in CMV negative recipients of CMV positive organ transplants.
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Affiliation(s)
- E M Hodson
- Children's Hospital at Westmead, Centre for Kidney Research, Locked Bag 4001, Westmead, NSW, Australia 2145.
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Abstract
Echinocandins are a novel class of antifungal drugs. They have good activity against Candida spp and Aspergillus spp. Their low selective toxicity allows their administration at high doses with few secondary side effects. We have reviewed the available data on the endpoints for these drugs in their in vitro susceptibility testing on yeasts and moulds. The microdilution broth method is the most commonly used technique and MIC-1 (80% of growth inhibition) seems to be the most reliable endpoint when yeasts are tested. This endpoint also seems to be the most appropriate for the different drugs when they are combined with echinocandins using the checkerboard method for testing yeasts. By contrast, in the case of moulds, the minimum effective concentration (MEC) correlates better with the in vivo activity than the MIC when echinocandins are tested, and when these drugs are combined with other antifungals, MIC-2 (50% of growth inhibition) seems the most appropriate endpoint. Criteria based on drug pharmacodynamics is the most useful to define the echinocandin endpoints that best correlate with their in vivo efficacy.
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Affiliation(s)
- Francisco Javier Pastor
- Unitat de Microbiologia, Facultat de Medicina i Ciencies de la Salut, Universitat Rovira i Virgili, Reus, Spain.
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Hellinger WC, Bonatti H, Yao JD, Alvarez S, Brumble LM, Keating MR, Mendez JC, Kramer DJ, Dickson RC, Harnois DM, Spivey JR, Hughes CB, Nguyen JH, Steers JL. Risk stratification and targeted antifungal prophylaxis for prevention of aspergillosis and other invasive mold infections after liver transplantation. Liver Transpl 2005; 11:656-62. [PMID: 15915482 DOI: 10.1002/lt.20365] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Antifungal prophylaxis has been proposed for liver transplant recipients at increased risk for invasive mold infection. Risk factors for invasive mold infection after liver transplantation were selected to divide recipients into 3 groups: (1) high risk-transplantation on hemodialysis or delay of hospital discharge beyond day 7 after transplantation because of allograft or renal insufficiency; (2) intermediate risk-retransplantation or transplantation for fulminant hepatic failure; (3) low risk-absence of conditions in groups 1 and 2. During an intervention period (February 1999-April 2001), prophylactic administration of a lipid complex of amphotericin (Abelcet) at 5 mg/kg intravenously every 24 to 48 hours was recommended for high-risk recipients. The frequency of mold infection was compared to that of a preintervention period (February 1998-January 1999) when antifungal prophylaxis was not provided. During the intervention period, invasive mold infection developed in 2 (6%) of 35 high-risk recipients, 0 of 28 intermediate-risk recipients, and 1 (0.5%) of 187 low-risk recipients. Overall, of 58 liver transplant recipients, 3 (5%) developed an invasive mold infection during the preintervention period, compared with 3 (1%) of 250 during the intervention period (P = 0.08). The only death from invasive mold infection occurred during the preintervention period. Rates of pulse corticosteroid treatment of rejection and cytomegalovirus infection were lower during the intervention period. In conclusion, readily identifiable patient characteristics can be used to stratify liver transplant recipients for risk of invasive mold infection. Antifungal prophylaxis given to high-risk recipients may provide cost-effective prevention of these infections.
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Affiliation(s)
- Walter C Hellinger
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL 32224, USA
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Strippoli GFM, Craig JC, Hodson EM, Jones C. Pre-emptive treatment for cytomegalovirus viraemia to prevent cytomegalovirus disease in solid organ transplant recipients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2005. [DOI: 10.1002/14651858.cd005133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Purkins L, Wood N, Greenhalgh K, Allen MJ, Oliver SD. Voriconazole, a novel wide-spectrum triazole: oral pharmacokinetics and safety. Br J Clin Pharmacol 2004; 56 Suppl 1:10-6. [PMID: 14616408 PMCID: PMC1884314 DOI: 10.1046/j.1365-2125.2003.01993.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AIMS Voriconazole is a potent new triazole with broad-spectrum antifungal activity against clinically significant and emerging pathogens. The present study evaluated the safety, toleration, and pharmacokinetics of oral voriconazole after single and multiple dosing. METHODS Sixty-four healthy subjects were randomized to receive treatment and 56 completed the study. Groups of eight subjects each received voriconazole doses of 2 mg kg-1 twice daily, 4 mg kg-1 once daily, 2 mg kg-1 three times daily, or 3 mg kg-1 twice daily. Eleven subjects received 1.5 mg kg-1 three times daily, and 21 subjects were administered placebo. RESULTS Voriconazole exhibited nonlinear (dose- and time-dependent) pharmacokinetics. This deviation from linear pharmacokinetics was confirmed by linearity ratios of > 1 and decreasing kel values on multiple dosing, with a consequent increase in the terminal phase t1/2. There was also notable intersubject variability in Cmax and AUCtau. The absorption of voriconazole was rapid (mean tmax= 0.9-1.7 h) after single and multiple dosing and the decline in plasma concentration-time curves after tmax was generally biphasic. By day 12, the Cmax, AUCtau, tmax, and t1/2 values for the 3 mg kg-1 twice-daily group were 2356 ng ml-1, 11 170 ng.h ml-1, 1.1 h, and 6.4 h, respectively. The observed accumulation of voriconazole after multiple dosing was greater than predicted from single-dose data. Accumulation ratios for Cmax and AUCtau, which were 1.97 and 3.55, respectively, for the group given voriconazole 3 mg kg-1 twice daily, varied between treatment groups and appeared to be influenced by total daily dose and the frequency and duration of dosing. Visual inspection of Cmin values together with statistical analyses of Cmax and AUCtau values suggest that steady-state levels were achieved by the fifth to sixth day of multiple dosing. Plasma concentrations of voriconazole were well above the minimum inhibitory concentrations (MICs) for Aspergillus spp., Candida spp., and for most emerging fungal pathogens (Cmin > 0.8 micro g ml-1). Voriconazole was well tolerated: most treatment-related adverse events (abnormal vision, headache, dizziness) were mild and resolved within an hour of dosing. CONCLUSIONS The oral dosing regimen selected for subsequent Phase II/III clinical trials on the basis of these results was 200 mg twice daily, equivalent to 3 mg kg-1 twice daily.
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Affiliation(s)
- Lynn Purkins
- Pfizer Global Research and Development, Sandwich, Kent, CT13 9NJ, UK.
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Gavaldà J, Ruiz I. [Guidelines for the treatment of invasive fungal infection. Invasive fungal infection by Candida spp. Invasive Fungal Infection Study Group (MICOMED) and Infection in Transplantation Study Group (GESITRA) of the Spanish Society for Infectious Diseases and Clinical Microbiology (SEIMC)]. Enferm Infecc Microbiol Clin 2003; 21:498-508. [PMID: 14572383 DOI: 10.1016/s0213-005x(03)72995-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
These guidelines resume different issues related to the clinical management of invasive candidosis in the immunossuppressed patients. They are based on the recommendations of the different Drug's Agencies.
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Affiliation(s)
- Joan Gavaldà
- Grupos de Estudio de la Infección Fúngica Invasora (MICOMED) y de Estudio de la Infección en el Trasplante (GESITRA) de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), Spain.
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Abstract
The compromised patient who presents to the emergency department with pulmonary complaints is becoming a common occurrence. An immunocompromised state can result from a disease process such as HIV or from medications used to prevent graft rejection in solid organ recipients or to treat conditions such as collagen vascular disease. The emergency department physician should be familiar with the more common complications that can afflict this unique patient group. This article addresses the presentation, evaluation, and treatment of the more common pulmonary complications that can occur in solid organ transplant recipients, cancer patients, patients suffering from collagen vascular disease, and patients with HIV disease.
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Affiliation(s)
- Walter G Belleza
- Division of Emergency Medicine, University of Maryland Medical System, 419 West Redwood Street, Suite 208, Baltimore, MD 21201, USA
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Kontoyiannis DP, Mantadakis E, Samonis G. Systemic mycoses in the immunocompromised host: an update in antifungal therapy. J Hosp Infect 2003; 53:243-58. [PMID: 12660121 DOI: 10.1053/jhin.2002.1278] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite significant advances in the management of immunosuppressed patients, invasive fungal infections remain an important life-threatening complication. In the last decade several new antifungal agents, including compounds in pre-existing classes (new generation of triazoles, polyenes in lipid formulations) and novel classes of antifungals with a unique mechanism of action (echinocandins), have been introduced in clinical practice. Ongoing and future studies will determine their exact role in the management of different mycoses. The acceleration of antifungal drug discovery offers promise for the management of these difficult to treat opportunistic infections.
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Affiliation(s)
- D P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas, M. D. Anderson Cancer Center, Houston 77030, USA.
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Litmathe J, Feindt P, Boeken U, Mayer K, Althaus C, Gams E. Cryptococcus neoformans infection as scleral abscess in a cardiac allograft recipient 6 months after heart transplantation. Transplant Proc 2002; 34:3252-4. [PMID: 12493437 DOI: 10.1016/s0041-1345(02)03677-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- J Litmathe
- Department of Thoracic and Cardiovascular Surgery, Heinrich-Heine-University, Düsseldorf, Germany
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Montejo M, Muñiz ML, Zárraga S, Aguirrebengoa K, Amenabar JJ, López-Soria L, Gonzalez R. Case Reports. Infection due to Scedosporium apiospermum in renal transplant recipients: a report of two cases and literature review of central nervous system and cutaneous infections by Pseudallescheria boydii/Sc. apiospermum. Mycoses 2002; 45:418-27. [PMID: 12421295 DOI: 10.1046/j.1439-0507.2002.00790.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Two cases of infections due to Scedosporium apiospermum in renal transplant recipients, one localized in the central nervous system, the other in the skin, are presented, and a literature review of 21 cases of central nervous system and cutaneous infections due to Pseudallescheria boydii/Sc. apiospermum is given.
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Losada I, Cuervas-Mons V, Millán I, Dámaso D. [Early infection in liver transplant recipients: incidence, severity, risk factors and antibiotic sensitivity of bacterial isolates]. Enferm Infecc Microbiol Clin 2002; 20:422-30. [PMID: 12425875 DOI: 10.1016/s0213-005x(02)72837-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To conduct a descriptive study with an analysis of risk factors for early infection in liver transplant patients, and to determine the resistance of the bacteria involved. PATIENTS AND METHODS The study included 149 liver transplant recipients. All cases of infection occurring 0-90 days after transplantation were considered early infection. Pre-, intra- and postoperative variables were analyzed, and isolated microorganisms were studied. Selective bowel decontamination with quinolones, and perioperative and antifungal prophylaxis were carried out in all patients. RESULTS The incidence of infection was 73.1%: bacterial (49.7%), viral (35.5%), fungal (10.1%) and mixed (4.5%). In the first postoperative month the most frequent infections were bacterial and in the second and third months, viral (p = 0.001). Multivariate analysis of risk factors identified the following: days of parenteral nutrition, duration of surgery > 5 hours, rejection and CMV seronegative status. Among 1278 cultures, the following microorganisms were isolated: 77.9% gram-positive cocci (GP) and 19% aerobic gram-negative bacilli (GNB). Sensitivity of Staphylococcus to vancomycin was 99.6-100% and to teicoplanin 97.9-100%. VAN resistance was observed in 1.2% of E. faecalis and 4.5% of E. faecium. Among S. aureus strains, 68.7% were MRSA. The resistance rate of GNB to quinolones was 38.8%. CONCLUSIONS Incidence of infection was higher the first 30 days after transplantation, with bacterial infection predominating. Duration of surgery > 5 hours was the most important risk factor for acquiring bacterial infection. GP were the most frequently isolated bacteria. Empirical treatment of early bacterial infection should include vancomycin or teicoplanin. Selective bowel decontamination resulted in a low incidence of GNB infections, among which there was 38.8% resistance to quinolones.
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Affiliation(s)
- Isabel Losada
- Servicio de Microbiología. Complexo Hospitalario Juan Canalejo de A Coruña. España.
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Abstract
The decision to perform a human hand transplant was justified perhaps on less than an ideal scientific basis-only approximately 60 rat limb transplants and 2 primate limb transplants have survived for longer than 200 days and only 8 of 19 pig limb osteomyocutaneous transplants showed no signs of rejection at 90 days. It seems unlikely that the survival of a human hand transplant will be any better than the survival of a kidney transplant, which has a half-life of approximately 7.5 to 9.5 years. Fourteen hand transplants, however, have now been performed in 11 humans with the skin component of 1 remaining viable up to 3 years after surgery. Intermittent episodes of acute rejection seem to have been relatively simple to reverse by temporarily increasing the dose of immunosuppressive agents and steroids. Chronic rejection has occurred in 1 patient, necessitating re-amputation of the transplanted hand. Active range of motion of the digits has been surprisingly better than would have been expected based on previous results of replantation, but return of sensibility has been less than optimal. The immunosuppression has been well tolerated without any major medical problems or life-threatening episodes, but some patients have developed chronic viral and fungal infections and several have developed posttransplant diabetes. Extrapolating from the previous experience of solid-organ transplants, chronic immunosuppression may predispose a hand transplant patient to an 80% chance of developing an infection, a 20% potential risk of developing posttransplant diabetes, and a 4% to 18% potential risk of developing a malignancy. Even though there is universal agreement that composite tissue allograft transplantation will become the ultimate reconstructive option, no one can predict the eventual role of hand transplantation in the future, but perhaps an international database of these hand transplant patients should be established so that independent reviewers can more objectively evaluate their functional outcome, the incidence of chronic rejection, and the risks of long-term immunosuppression.
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Affiliation(s)
- Neil F Jones
- UCLA Hand Center, Department of Orthopaedic Surgery and Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, CA 90095, USA
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Abstract
Transplantation is now currently and increasingly performed for the treatment of various acute and chronic diseases. Today the kidney, heart, lung, heart-lung, liver, pancreas, kidney-pancreas, small bowel and bone marrow are being transplanted. The immunological status of patients receiving such transplants exposes them to the risk of developing bacterial, viral and fungal infections. The etiological agents of mycotic diseases involving the skin of transplant recipients range from the common dermatophytes through yeasts such as Candida spp., Malassezia spp. and dimorphic fungi to the emerging molds Fusarium spp. and Pseudallescheria boydii. The very wide spectrum of fungi causing cutaneous disease produces equally varied clinical aspects. Lesions may be typical, but are very often aspecific or ambiguous. Cutaneous lesions may be the sign of a trivial mycotic disease or the marker of a disseminated, potentially lethal fungal illness, so great attention should be given to their early recognition. Cutaneous manifestations due to Candida spp., Aspergillus spp., dematiaceous fungi and Pityrosporum folliculitis are usually observed early after transplant, cryptococcosis more than 6 months later, while the frequency of dermatophytoses increases as time goes by. Coccidioides immitis, Histoplasma capsulatum and Blastomyces dermatitidis may appear any time after transplantation. The management of the more severe forms of cutaneous mycosis in transplant recipients is difficult. Besides the fact that early recognition is not easy, there are also problems regarding the effectiveness and the toxicity of the therapy and drug-drug interactions. Prophylactic measures to avoid fungal contamination must be performed during hospitalization; patients should be taught how to avoid contamination, not only during the first period after transplantation, when high dosage immunosuppressive drugs are given, but also later when a normal lifestyle is resumed.
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Affiliation(s)
- Annarosa Virgili
- Dipartimento di Medicina Clinica e Sperimentale - Sezione di Dermatologia, Università degli Studi di Ferrara, Ferrara, Italy.
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Nagy GS, Rubin RH. Disseminated Mycobacterium avium-intracellulare in a kidney transplant recipient. Transpl Infect Dis 2001; 3:220-30. [PMID: 11844154 DOI: 10.1034/j.1399-3062.2001.30406.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- G S Nagy
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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Gordon SM, Avery RK. Aspergillosis in lung transplantation: incidence, risk factors, and prophylactic strategies. Transpl Infect Dis 2001; 3:161-7. [PMID: 11493398 DOI: 10.1034/j.1399-3062.2001.003003161.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Invasive aspergillosis remains a significant cause of morbidity and mortality in transplantation, especially lung and allogeneic bone marrow transplant recipients. The epidemiology, classic and newly recognized risk factors, and incidence of aspergillosis are reviewed. Risk factors include environmental exposures, airway colonization, profound immunosuppression, neutropenia, prior cytomegalovirus infection, and renal dysfunction. Clinical and radiographic presentations of invasive aspergillosis are discussed, including some unusual manifestations in lung transplant recipients. Early and accurate diagnosis of aspergillosis remains a challenge, and diagnostic strategies are reviewed, with an emphasis on the chest computerized tomography scan and on transbronchial or open lung biopsy. Recent advances include prophylactic and pre-emptive antifungal strategies, newer therapeutic agents, and improved risk stratification.
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Affiliation(s)
- S M Gordon
- Department of Infectious Disease, Infection Control, and Transplant Center, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Pegues CF, Daar ES, Murthy AR. The epidemiology of invasive pulmonary aspergillosis at a large teaching hospital. Infect Control Hosp Epidemiol 2001; 22:370-4. [PMID: 11519915 DOI: 10.1086/501915] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To characterize the epidemiology of invasive pulmonary aspergillosis (IPA). DESIGN A retrospective case series. SETTING An 850-bed, academic, tertiary-care medical center. PARTICIPANTS Adult inpatients, between January 1, 1990, and December 31, 1998, with either a histopathology report consistent with IPA or a discharge diagnosis of aspergillosis. METHODS We reviewed medical records and categorized case-patients as definitive or probable and acquisition of IPA as nosocomial, indeterminate, or community using standard definitions. To determine the rate of aspergillus respiratory colonization, we identified all inpatients who had a respiratory culture positive for Aspergillus species without a histopathology report consistent with IPA or a discharge diagnosis of aspergillosis. Three study intervals were defined: interval 1, 1990 to 1992; interval 2, 1993 to 1995; and interval 3, 1996 to 1998. Carpeting in rooms for patients following heart-lung and liver transplant was removed and ceiling tiles were replaced during interval 1; a major earthquake occurred during interval 2. RESULTS 72 case-patients and 433 patients with respiratory colonization were identified. Acquisition was nosocomial for 18 (25.0%), indeterminate for 9 (12.5%), and community-acquired for 45 (62.5%) case-patients. Seventeen (23.6%) of the 72 case-patients had prior transplants, including 15 solid organ and 2 bone marrow. The IPA rate per 100 solid organ transplants (SOTs) decreased from 2.45 during interval 1 to 0.93 during interval 2 and to 0.52 during interval 3 (chi-square for trend, 5.44; P<.05). The hospitalwide IPA rate remained stable at 0.03 per 1,000 patient days. CONCLUSIONS The SOT IPA rate decreased after intervals 1 and 2, although the hospitalwide IPA rate remained stable during the study period. Post-earthquake hospital demolition and construction occurring after interval 2 was not associated with an increase in the rate of IPA at our institution.
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Affiliation(s)
- C F Pegues
- Department of Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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