Strategies for safe living following solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

The pre-transplant evaluation: Considerations for trainees and early career transplant infectious diseases clinician

Transplant infectious disease (TID) clinicians are integral to the pre-transplantation evaluation. Pre-transplant evaluations allow clinicians to assess risk factors for latent infections and relevant exposures to potential pathogens, address immunizations, and optimize patients' health and understanding of life after transplant. However, there is not a standardized approach to the pre-transplant evaluation. This article reviews the details of performing successful pre-transplant evaluations, including updated recommendations on available vaccines and contemporary opinions on marijuana use. This resource can be used for teaching with trainees or for early career TID clinicians.

The role of veterinarians in zoonosis prevention: Advising families of immunocompromised children with pets

Background

Pet ownership is widespread, offering numerous benefits to individuals and families. However, the risk of zoonotic diseases must be carefully considered, especially for immunosuppressed patients. Knowledge gaps in preventive measures for zoonoses have been identified, underscoring the vital role of veterinarians in addressing this issue.

Objectives

This study aimed to assess the knowledge and recommendations of veterinarians regarding pet ownership by immunocompromised individuals. Additionally, we compared these insights with responses from European healthcare professionals specializing in pediatric transplant recipients.

Methods

We conducted an observational, cross-sectional study involving small animal veterinarians in Spain. An online survey was administered to gather information on veterinarians' knowledge of zoonoses and their recommendations for immunocompromised pet owners.

Results

A survey of 514 individuals was collected from experienced veterinarians mainly working in primary care clinics. Surprisingly, 63% of respondents did not routinely inquire about the presence of immunocompromised individuals among pet owners, although 54% offered specific recommendations for this group. Most respondents adhered to deworming guidelines for pets owned by immunocompromised individuals and demonstrated sound practices in Leishmania and Leptospira prevention, as well as the avoidance of raw food. However, gaps were noted concerning Bordetella bronchiseptica vaccination. Notably, veterinarians outperformed medical professionals in their knowledge of zoonotic cases and identification of zoonotic microorganisms. The presence of specific recommendations in veterinary clinics was viewed positively by nearly all respondents.

Conclusions

Our findings indicate that veterinarians possess a superior understanding of zoonotic pathogens and exhibit greater proficiency in diagnosing zoonoses compared with physicians. They stay well-informed about recommendations outlined in established guidelines and are more likely to provide written recommendations in their clinics than physicians. Nevertheless, knowledge gaps among veterinarians emphasize the need for enhanced communication between medical and veterinary professionals. Reinforcing the "One Health" concept is imperative, with veterinarians playing a pivotal role in this collaborative effort.

Flexible bronchoscopy in pediatric lung transplantation

Pediatric lung transplantation represents a treatment option for children with advanced lung disease or pulmonary vascular disorders who are deemed an appropriate candidate. Pediatric flexible bronchoscopy is an important and evolving field that is highly relevant in the pediatric lung transplant population. It is thus important to advance our knowledge to better understand how care for children after lung transplant can be maximally optimized using pediatric bronchoscopy. Our goals are to continually improve procedural skills when performing bronchoscopy and to decrease the complication rate while acquiring adequate samples for diagnostic evaluation. Attainment of these goals is critical since allograft assessment by bronchoscopic biopsy is required for histological diagnosis of acute cellular rejection and is an important contributor to establishing chronic lung allograft dysfunction, a common complication after lung transplant. Flexible bronchoscopy with bronchoalveolar lavage and transbronchial lung biopsy plays a key role in lung transplant graft assessment. In this article, we discuss the application of bronchoscopy in pediatric lung transplant evaluation including historical approaches, our experience, and future directions not only in bronchoscopy but also in the evolving pediatric lung transplantation field. Pediatric flexible bronchoscopy has become a vital modality for diagnosing lung transplant complications in children as well as assessing therapeutic responses. Herein, we review the value of flexible bronchoscopy in the management of children after lung transplant and discuss the application of novel techniques to improve care for this complex pediatric patient population and we provide a brief update about new diagnostic techniques applied in the growing lung transplantation field.

Rapid Progression of Invasive Listeria monocytogenes Infection in a Patient With Cirrhosis and Primary Sclerosing Cholangitis on Ustekinumab

We present the case of a 62-year-old immunocompromised man with ulcerative colitis, primary sclerosing cholangitis, and cirrhosis treated with azathioprine and ustekinumab who quickly developed invasive Listeria monocytogenes infection after incidental identification on routine paracentesis. The infection rapidly progressed from bacterial peritonitis to bacteremia and meningitis within three days. Treatment with ampicillin and trimethoprim/sulfamethoxazole was successful. We highlight the increased risk of invasive listeriosis in immunocompromised individuals, including those on biologic therapies, and the importance of considering Listeria as a pathogen from sterile sites even in asymptomatic patients.

Uncovering the diversity of pathogenic invaders: insights into protozoa, fungi, and worm infections

Post COVID-19, there has been renewed interest in understanding the pathogens challenging the human health and evaluate our preparedness towards dealing with health challenges in future. In this endeavour, it is not only the bacteria and the viruses, but a greater community of pathogens. Such pathogenic microorganisms, include protozoa, fungi and worms, which establish a distinct variety of disease-causing agents with the capability to impact the host's well-being as well as the equity of ecosystem. This review summarises the peculiar characteristics and pathogenic mechanisms utilized by these disease-causing organisms. It features their role in causing infection in the concerned host and emphasizes the need for further research. Understanding the layers of pathogenesis encompassing the concerned infectious microbes will help expand targeted inferences with relation to the cause of the infection. This would strengthen and augment benefit to the host's health along with the maintenance of ecosystem network, exhibiting host-pathogen interaction cycle. This would be key to discover the layers underlying differential disease severities in response to similar/same pathogen infection.

Pre-Transplantation Strategies for Infectious Disease Mitigation and Prevention

Pediatric Infectious Disease (ID) clinicians play a critical role in helping prevent and mitigate infectious risks in children peri- and post-transplantation. Prevention starts during the pre-transplant evaluation and persists throughout the solid organ transplant and hematopoietic cell transplant continuum. The pre-transplant evaluation is an opportunity to screen for latent infections, plan preventative strategies, optimize immunizations, and discuss risk mitigation practices. An ideal pre-transplant evaluation establishes a relationship with the family that further promotes post-transplant infectious risk reduction. This manuscript builds on shared pediatric ID prevention strategies, introduces updated ID testing recommendations for transplant donors/candidates, highlights emerging data, and identifies ongoing knowledge gaps that are potential areas of research.

Pet safety guidelines for pediatric transplant recipients

Approximately 70% (90.5 million) of United States (US) households own at least one pet. Dogs are the most common, making up about 38% of all household pets, followed by cats, which make up 25%. Other pets such as fish, birds, reptiles, and small animals such as hamsters, gerbils, and rabbits are less common household members. Pets are often considered a part of the family and there are significant medical and psychosocial benefits to pet ownership; however, the possibility of disease transmission exists related to the type of animal and infectious organism, and specific human risk factors. Immunocompromised individuals may be at increased risk of serious illness from zoonotic infections. During the transplant evaluation and routinely posttransplant, the multidisciplinary team should inquire about pet ownership and animal exposures to guide on potential risks. This review discusses the most common diseases seen in various household pets including dogs, cats, birds, fish, and some farm animals. We will also present guidelines for pet safety and include strategies to decrease the risk of infection while supporting the benefits of pet ownership after transplant.

Serratia marcescens causing recurrent superficial skin infections in an immunosuppressed patient

Serratia marcescens is a gram-negative bacterium found commonly in water and soil. Initially thought to be non-pathogenic, it is now recognised as an important cause of nosocomial and opportunistic infections. Skin infections are rare, but cases of S. marcescens causing ulcers, abscesses and necrotizing fasciitis have been reported. We report an unusual cutaneous presentation of S. marcescens in an immunosuppressed patient. A 77-year-old man under review for non-melanoma skin cancer in the context of a previous cardiac transplant, presented with an asymptomatic scalp eruption. Immunosuppressive medications included ciclosporin 90 mg twice daily (2.5 mg/kg/day) and mycophenolate mofetil 1 g twice daily. Physical examination revealed well-defined annular and polycyclic patches with brownish crusting across his scalp. Bacterial culture demonstrated a heavy growth of Staphylococcus aureus sensitive to flucloxacillin. The patient was treated with 7 days of flucloxacillin 500 mg four times daily. Despite this, the eruption extended. Skin biopsy demonstrated epidermal spongiosis, florid dermal inflammatory cell infiltrate and abundant bacteria and neutrophils in the parakeratotic crust. Fungal stains were negative as was direct immunofluorescence. Repeat culture demonstrated heavy growth of S. marcescens sensitive to ciprofloxacin. The patient was treated with 10 days of oral ciprofloxacin 500 mg twice daily along with 1% hydrogen peroxide cream topically with significant clinical improvement. Microbiological review indicated that a gram-negative organism was present in the initial scalp swab. In addition, S. marcescens had been detected previously on a skin swab from a recent transient eruption on the torso. Further, a heavy growth of a coliform bacillus was demonstrated in a similar eruption on the chest in 2013. It was concluded that the patient was likely colonised with S. marcescens which appeared to have caused recurrent superficial skin infections over several years. We report this case to highlight an unusual clinical presentation of cutaneous S. marcescens infection. This should be considered in the differential diagnosis of skin eruptions in immunocompromised patients. Clinical information detailing a patient's immunosuppressed state must be supplied on microbiology requests to allow accurate interpretation of results, and consideration of organisms which may otherwise be overlooked or considered contaminants.

Approach to vaccinating the pediatric solid organ transplant candidate and recipient

Solid organ transplantation (SOT) candidates and recipients are at increased risk for morbidity and mortality from vaccine-preventable infections. Children are at particular risk given that they may not have completed their primary immunization series at time of transplant or have acquired natural immunity to pathogens from community exposures. Multiple society guidelines exist for vaccination of SOT candidate and recipients, although challenges remain given limited safety and efficacy data available for pediatric SOT recipients, particularly for live-vaccines. After transplant, individual patient nuances regarding exposure risks and net state of immunosuppression will impact timing of immunizations. The purpose of this review is to provide readers with a concise, practical, expert-opinion on the approach to vaccinating the SOT candidate and recipient and to supplement existing guidelines. In addition, pediatric-specific knowledge gaps in the field and future research priorities will be highlighted.

Outcomes of transplant recipients with pretransplant Nocardia colonization or infection

BACKGROUND

Specific pretransplant infections have been associated with poor posttransplant outcomes. However, the impact of pretransplant Nocardia isolation has not been studied.

METHODS

We performed a retrospective study from three centers in Arizona, Florida, and Minnesota of patients with Nocardia infection or colonization who subsequently underwent solid organ or hematopoietic stem cell transplantation from November 2011 through April 2022. Outcomes included posttransplant Nocardia infection and mortality.

RESULTS

Nine patients with pretransplant Nocardia were included. Two patients were deemed colonized with Nocardia, and the remaining seven had nocardiosis. These patients underwent bilateral lung (N = 5), heart (N = 1), heart-kidney (N = 1), liver-kidney (N = 1), and allogeneic stem cell transplantation (N = 1) at a median of 283 (interquartile range [IQR] 152-283) days after Nocardia isolation. Two (22.2%) patients had disseminated infection, and two were receiving active Nocardia treatment at the time of transplantation. One Nocardia isolate was resistant to trimethoprim-sulfamethoxazole (TMP-SMX) and all patients received TMP-SMX prophylaxis posttransplant, often for extended durations. No patients developed posttransplant nocardiosis during a median follow-up of 1.96 (IQR 0.90-6.33) years. Two patients died during follow-up, both without evidence of nocardiosis.

CONCLUSIONS

This study did not identify any episodes of posttransplant nocardiosis among nine patients with pretransplant Nocardia isolation. As patients with the most severe infections may have been denied transplantation, further studies with larger sample sizes are needed to better analyze any impact of pretransplant Nocardia on posttransplant outcomes. However, among patients who receive posttransplant TMP-SMX prophylaxis, these data suggest pretransplant Nocardia isolation may not impart a heightened risk of posttransplant nocardiosis.

Pet ownership during the first 5 years after breast cancer diagnosis in the NEON-BC cohort

BACKGROUND

Although human-animal interactions (HAI) have been associated with health benefits, they have not been extensively studied among cancer patients nor which factors may influence HAI during cancer survivorship. Therefore, this study aims to describe pet ownership in a breast cancer cohort within 5 years post-diagnosis and to identify associated factors.

METHODS

Four hundred sixty-six patients from the NEON-BC cohort were evaluated. Four groups of pet ownership over the 5 years were defined: 'never had', 'stopped having', 'started having' and 'always had'. Multinomial logistic regression was used to quantify the association between the patient characteristics and the groups defined (reference: 'never had').

RESULTS

51.7% of patients had pets at diagnosis, which increased to 58.4% at 5 years; dogs and cats were the most common. Women presenting depressive symptoms and poor quality of life were more likely to stop having pets. Older and unpartnered women were less likely to start having pets. Those retired, living outside Porto, having diabetes or having owned animals during adulthood were more likely to start having pets. Women with higher education and unpartnered were less likely to always have pets. Those living in larger households, with other adults or having animals throughout life, were more likely to always have pets. Obese women had lower odds of stopping having dogs/cats. Women submitted to neoadjuvant chemotherapy and longer chemotherapy treatments were more likely to stop having dogs/cats.

CONCLUSIONS

Pet ownership changed over the 5 years and is influenced by sociodemographic, clinical and treatment characteristics, patient-reported outcomes and past pet ownership, reflecting the importance of HAI during cancer survivorship.

Reduced Community-acquired Respiratory Virus Infection, but Not Non-virus Infection, in Lung Transplant Recipients During Government-mandated Public Health Measures to Reduce COVID-19 Transmission

Community-acquired respiratory viruses (CARVs) are an important cause of morbidity and mortality in lung transplant (LTx) recipients. Despite routine mask-wearing, LTx patients remain at a higher risk of CARV infection than the general population. In 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19 and a novel CARV, emerged leading federal and state officials to implement public health nonpharmaceutical interventions (NPIs) to curb its spread. We hypothesized that NPI would be associated with the reduced spread of traditional CARVs.

Methods

A single-center, retrospective cohort analysis comparing CARV infection before a statewide stay-at-home order, during the stay-at-home order and subsequent statewide mask mandate, and during 5 mo following the elimination of NPI was performed. All LTx recipients followed by and tested at our center were included. Data (multiplex respiratory viral panels; SARS-CoV-2 reverse transcription polymerase chain reaction; blood cytomegalovirus and Epstein Barr virus polymerase chain reaction; blood and bronchoalveolar lavage bacterial and fungal cultures) were collected from the medical record. Chi-square or Fisher exact tests were utilized for categorical variables. A mixed-effect model was used for continuous variables.

Results

Incidence of non-COVID CARV infection was significantly lower during the MASK period than during the PRE period. No difference was noted in airway or bloodstream bacterial or fungal infections, but cytomegalovirus bloodborne viral infections increased.

Conclusions

Reductions in respiratory viral infections, but not bloodborne viral infections nor nonviral respiratory, bloodborne, or urinary infections, were observed in the setting of public health COVID-19 mitigation strategies, suggesting the effectiveness of NPI in preventing general respiratory virus transmission.

Supporting Reproductive Care for Patients Requiring Solid Organ Transplant

After a solid organ transplant, individuals have the capability to maintain a successful pregnancy. However, many posttransplant pregnancies are unintended, thereby posing risks to health. There is a critical need to strengthen patient education regarding safe approaches to conception, general reproductive health, and childbearing capabilities. The complex needs of patients after transplant, including management of graft health and medication regimens, may distract from the usual reproductive care offered to other individuals of childbearing potential. Thorough education about immunosuppressant medications, contraceptive methods, and expected waiting periods before conceiving are essential. Nurses can work with each individual and direct the interprofessional health care team to provide effective, safe, comprehensive, and inclusive reproductive care to patients posttransplant.

Balancing the Risks and Benefits of Pet Ownership in Pediatric Transplant Recipients

In recent decades, the number of pediatric transplantations and their survival rates have increased. Psychological problems and poorer quality of life are notable among children undergoing transplantation and can have long-lasting consequences and affect immunosuppressive therapy adherence. Pet ownership and animal contact have been associated with physical, mental, and social health benefits. Despite these potential benefits, however, companion animals are known to be a source of infection, which is one of the main concerns for clinicians. Because of immunosuppression, these children are particularly vulnerable to infections. Zoonoses comprise a long list of infectious diseases and represent a major public health problem. Nevertheless, many families and most healthcare providers are unaware of these potential risks, and there is a worrisome lack of recommendations to manage the risk-benefit balance, which could pose a risk for acquiring a zoonosis. Furthermore, no data are available on the number of transplanted patients with pets, and this risk-benefit balance is difficult to adequately evaluate. In this document, we review the currently available evidence regarding the epidemiology of zoonotic infections in patients undergoing transplantation, focusing on pediatric patients from a risk-benefit perspective, to help inform decision-making for clinicians. Families and healthcare professionals should be aware of the risks, and clinicians should actively screen for pets and offer comprehensive information as part of routine clinical practice. A multidisciplinary approach will ensure proper care of patients and pets and will establish preventive measures to ensure patients are safe living with their pets.

American Society for Transplantation and Cellular Therapy Return to Work Guidance Committee Recommendations for Health Care Providers Who Take Care of Hematopoietic Cell Transplantation Patients

Hematopoietic cell transplantation (HCT) health care providers report a desire to improve long-term outcomes and quality of life for their patients. One of the items frequently cited by patients in terms of transitioning from being a patient back to pre-HCT life is return to work (RTW). However, these patients report little support from their health care providers in facilitating this process, and only 50% to 60% achieve RTW, at a median of 3 years post-HCT. Barriers are physical, psychological, and logistical, as well as poor communication between the patient and their employer. We convened a group of experts in survivorship, rehabilitation, social work, and psychology to draft an evidence-based document to assist health care providers in guiding their patients' RTW journey. Guidance is drawn from the existing literature for HCT and general cancer patients and is divided into pre-HCT, peri-HCT, and post-HCT categories. Collaboration among health care providers, patients, and their employers is key to this transition. Suggested referrals and evaluations also are provided. The goal is for this guidance to be continually updated as we advance the field with more HCT-specific literature.

Pets for pediatric transplant recipients: To have or not to have

Pets have many health, emotional and social benefits for children, but the risk of zoonotic infections cannot be underestimated, especially for immunosuppressed patients. We report the recommendations given by health professionals working with pediatric transplant recipients to their families regarding pet ownership. An online survey addressing zoonosis knowledge and recommendations provided by health care practitioners regarding pets was distributed to clinicians treating pediatric transplant recipients. The European Society of Pediatric Infectious Disease (ESPID) and the European Reference Network ERN-TransplantChild, which works to improve the quality of life of transplanted children, allowed the online distribution of the survey. A total of 151 practitioners from 28 countries participated in the survey. Up to 29% of the respondents had treated at least one case of zoonosis. Overall, 58% of the respondents considered that the current available evidence regarding zoonotic risk for transplanted children of having a pet is too scarce. In addition, up to 23% of the surveyed professionals recognized to be unaware or outdated. Still, 27% of the respondents would advise against buying a pet. Practitioners already owning a pet less frequently advised patients against pet ownership, whereas non-pet-owners were more keen to advise against pet ownership (p = 0.058). 61% of the participants stated that there were no institutional recommendations regarding pets in their centers/units. However, 43% of them reported therapeutic initiatives that involved animals in their centers. Infectious disease specialists were more likely to identify zoonotic agents among a list of pathogens compared to other specialists (p < 0.05). We have observed a huge heterogeneity among the recommendations that health care providers offer to families in terms of risk related to pet ownership for transplant recipients. The lack of evidence regarding these recommendations results in practitioners' recommendations based on personal experience.

Notifiable Infectious Diseases Among Organ Transplant Recipients: A Data-Linked Cohort Study, 2000–2015

Background

Infections, including common communicable infections such as influenza, frequently cause disease after organ transplantation, although the quantitative extent of infection and disease remains uncertain.

Methods

A cohort study was conducted to define the burden of notifiable infectious diseases among all solid organ recipients transplanted in New South Wales, Australia, 2000–2015. Data linkage was used to connect transplant registers to hospital admissions, notifiable diseases, and the death register. Standardized incidence ratios (SIRs) were calculated relative to general population notification rates, accounting for age, sex, and calendar year. Infection-related hospitalizations and deaths were identified.

Results

Among 4858 solid organ recipients followed for 39 183 person-years (PY), there were 792 notifications. Influenza was the most common infection (532 cases; incidence, 1358 [95% CI, 1247–1478] per 100 000 PY), highest within 3 months posttransplant. Next most common was salmonellosis (46 cases; incidence, 117 [95% CI, 87–156] per 100 000 PY), then pertussis (38 cases; incidence, 97 [95% CI, 71–133] per 100 000 PY). Influenza and invasive pneumococcal disease (IPD) showed significant excess cases compared with the general population (influenza SIR, 8.5 [95% CI, 7.8–9.2]; IPD SIR, 9.8 [95% CI, 6.9–13.9]), with high hospitalization rates (47% influenza cases, 68% IPD cases) and some mortality (4 influenza and 1 IPD deaths). By 10 years posttransplant, cumulative incidence of any vaccine-preventable disease was 12%, generally similar by transplanted organ, except higher among lung recipients. Gastrointestinal diseases, tuberculosis, and legionellosis had excess cases among transplant recipients, although there were few sexually transmitted infections and vector-borne diseases.

Conclusions

There is potential to avoid preventable infections among transplant recipients with improved vaccination programs, health education, and pretransplant donor and recipient screening.

Cryptogenic hepatitis patients have a higher Bartonella sp.-DNA detection in blood and skin samples than patients with non-viral hepatitis of known cause

Background

This study aimed to assess the prevalence of Bartonella sp.-DNA detection in blood and skin samples from patients with non-viral end-stage liver disease awaiting liver transplantation.

Methodology/Principal findings

Blood samples and healthy skin fragments from 50 patients were tested using microbiological and molecular methods. Fifteen patients had cryptogenic hepatitis (CH) and 35 had alcoholic, drug-induced or autoimmune liver disease. DNA was extracted from whole blood and liquid culture samples, isolates, and skin fragments. Thirteen of the 50 patients (26%) had Bartonella henselae DNA detection in their blood (9/50) and/or skin (5/50) samples. Colonies were isolated in 3/50 (6%) and infection was detected in 7/50 (14%) of the 50 patients. B. henselae-DNA detection was more prevalent in patients with CH than in other patients (p = 0.040). Of 39 patients followed-up for at least two years, a higher mortality rate was observed among patients with CH infected with B. henselae (p = 0.039).

Conclusions/Significance

Further studies assessing the role of B. henselae infection in the pathogenesis of hepatitis patients must be urgently conducted.

One in four patients with end-stage liver disease awaiting liver transplantation for hepatitis of non-viral origin had documented B. henselae-DNA detection and cryptogenic hepatitis patients have a higher bacterium molecular detection than patients with non-viral hepatitis of known cause.

Severe Bartonella henselae bone infection in a kidney transplanted young man

We present a case of a young kidney transplanted man. He was admitted with lymphadenopathy, fluctuating fever and night sweats 2 months after a cat bite. After admission, he developed severe pain around his right hip. An 18F-fluorodeoxyglucose (FDG)-positron emission tomography/CT revealed intense FDG-uptake in lymph nodes, spleen and bone, suggestive of lymphoma. An extracted lymph node showed confluent granulomas, microabscesses with neutrophils and scattered multinucleated giant cells histologically. The patient had history of latent tuberculosis and proteinase 3 -anti-neutrophil cytoplasmic antibodies associated (PR3-ANCA) vasculitis, making differential diagnostic considerations complicated. Bartonella henselae antibodies was detected in blood and B. henselae DNA in a lymph node. He was started on doxycycline and rifampicin. Due to severe drug interactions with both tacrolimus and increasing morphine doses, rifampicin was changed to azithromycin. He received 12 days of relevant antibiotic treatment and responded well. He was discharged after 16 days with close follow-up and was still in habitual condition 12 months later.

Long-Term Infectious Complications of Kidney Transplantation

Infections remain a common complication of solid-organ transplantation. Most infections in the first month after transplant are typically health care-associated infections, whereas late infections, beyond 6-12 months, are community-acquired infections. Opportunistic infections most frequently present in the first 12 months post-transplant and can be modulated on prior exposures and use of prophylaxis. In this review, we summarize the current epidemiology of postkidney transplant infections with a focus on key viral (BK polyomavirus, cytomegalovirus, Epstein-Barr virus, and norovirus), bacterial (urinary tract infections and Clostridioides difficile colitis), and fungal infections. Current guidelines for safe living post-transplant are also summarized. Literature supporting prophylaxis and vaccination is also provided.

Epidemiology and outcomes of medically attended and microbiologically confirmed bacterial foodborne infections in solid organ transplant recipients

Food-safety measures are recommended to solid organ transplant (SOT) recipients. However, the burden of foodborne infections in SOT recipients has not been established. We describe the epidemiology and outcomes of bacterial foodborne infections in a nationwide cohort including 4405 SOT recipients in Switzerland between 2008 and 2018. Participants were prospectively followed for a median of 4.2 years with systematic collection of data on infections, and patient and graft-related outcomes. We identified 151 episodes of microbiologically confirmed bacterial foodborne infections occurring in median 1.6 years (IQR 0.58-3.40) after transplantation (131 [88%] Campylobacter spp. and 15 [10%] non-typhoidal Salmonella). The cumulative incidence of bacterial foodborne infections was 4% (95% CI 3.4-4.8). Standardized incidence rates were 7.4 (95% CI 6.2-8.7) and 4.6 (95% CI 2.6-7.5) for Campylobacter and Salmonella infections, respectively. Invasive infection was more common with Salmonella (33.3% [5/15]) compared to Campylobacter (3.2% [4/125]; p = .001). Hospital and ICU admission rates were 47.7% (69/145) and 4.1% (6/145), respectively. A composite endpoint of acute rejection, graft loss, or death occurred within 30 days in 3.3% (5/151) of cases. In conclusion, in our cohort bacterial foodborne infections were late post-transplant infections and were associated with significant morbidity, supporting the need for implementation of food-safety recommendations.

Consensus guidelines for improving patients' understanding of invasive fungal disease and related risk prevention in the haematology/oncology setting, 2021

Patients with invasive fungal disease (IFD) are at significant risk of morbidity and mortality. A productive partnership between patients, their carers/families, and the multidisciplinary team managing the infection and any underlying conditions, is essential. Sharing information and addressing knowledge gaps are required to ensure those at risk of IFD avoid infection, while those with suspected or confirmed infection optimise their therapy and avoid toxicities. This new addition to the Australian and New Zealand consensus guidelines for the management of IFD and antifungal use in the haematology/oncology setting outlines the key information needs of patients and their carers/families. It specifically addresses risk factor reduction, antifungal agents and adherence, and the risks and benefits of complementary and alternative therapies. Knowledge gaps are also identified to help inform the future research agenda.

Prevention of infection and optimizing vaccination in the solid organ transplant candidate and recipient

PURPOSE OF REVIEW

Infections can result in serious complications in solid organ transplant (SOT) patients. The need to remain up to date on recommendations on screening, vaccinations, and chemoprophylaxis is paramount in the management of SOT patients. The goal of this review is to provide an overview of current recommendations for the prevention of infections and optimization of vaccinations from the pretransplant through posttransplant periods.

RECENT FINDINGS

There is an emphasis on thorough pretransplant evaluation to guide clinicians and pretransplant testing based on epidemiological and endemic risk factors. Additionally, recent studies on vaccine safety and efficacy of newer vaccine formulations in SOT recipients are addressed.

SUMMARY

This review provides insight on updated recommendations for pretransplant screening, new data on vaccine optimization in SOT recipients and posttransplant prophylaxis. Further research is needed in order to improve preventive measures including screening tests, vaccines, and chemoprophylaxis.

Maintaining mask momentum in transplant recipients

The widespread use of facemasks has been a crucial element in the control of the SARS‐CoV‐2 pandemic.  With mounting evidence for mask efficacy against respiratory infectious diseases and greater acceptability of this intervention, it is proposed that masking should continue after the pandemic has abated to protect some of our most vulnerable patients, recipients of stem cell and solid organ transplants. This may involve not only masking these high‐risk patients, but possibly their close contacts and the healthcare workers involved in their care. We review the evidence for mask efficacy in prevention of respiratory viruses other than SARS‐CoV‐2 and address the burden of disease in transplant recipients.  Although we acknowledge that there are limited data on masking to prevent infection in transplant recipients, we propose a framework for the study and implementation of routine masking as a part of infection prevention interventions after transplantation.

Ambulatory Risk Models for the Long-Term Prevention of Sepsis: Retrospective Study

Background

Sepsis is a life-threatening condition that can rapidly lead to organ damage and death. Existing risk scores predict outcomes for patients who have already become acutely ill.

Objective

We aimed to develop a model for identifying patients at risk of getting sepsis within 2 years in order to support the reduction of sepsis morbidity and mortality.

Methods

Machine learning was applied to 2,683,049 electronic health records (EHRs) with over 64 million encounters across five states to develop models for predicting a patient’s risk of getting sepsis within 2 years. Features were selected to be easily obtainable from a patient’s chart in real time during ambulatory encounters.

Results

The models showed consistent prediction scores, with the highest area under the receiver operating characteristic curve of 0.82 and a positive likelihood ratio of 2.9 achieved with gradient boosting on all features combined. Predictive features included age, sex, ethnicity, average ambulatory heart rate, standard deviation of BMI, and the number of prior medical conditions and procedures. The findings identified both known and potential new risk factors for long-term sepsis. Model variations also illustrated trade-offs between incrementally higher accuracy, implementability, and interpretability.

Conclusions

Accurate implementable models were developed to predict the 2-year risk of sepsis, using EHR data that is easy to obtain from ambulatory encounters. These results help advance the understanding of sepsis and provide a foundation for future trials of risk-informed preventive care.

Promoting safe sexual practices and sexual health maintenance in pediatric and young adult solid organ transplant recipients

The majority of Americans make their sexual debut during their adolescent years. Preventing pregnancy and STI during this period is vital to ensuring health and safety. As survival has improved after pediatric SOT, chronically immunosuppressed adolescents seek guidance in their medical home on matters of sexual health. Transplant practitioners often do not feel equipped to fully address these needs. This review serves as an introductory sexual preventive care resource for adolescent and young adult (AYA) SOT recipients. First, we review data on safety, efficacy, and use of contraceptive options currently available for transplant recipients with child-bearing potential. Then, we suggest a personalized sexual health discussion focusing on the diagnosis and prevention of STIs in adolescent and young adult transplant recipients. Finally, we present recommendations for STI screening of asymptomatic patients, use of index of suspicion and diagnostic testing in symptomatic patients, and opportunities to optimize STI prevention strategies. Data compiled from studies of adult SOT recipients, general population studies, and published guidelines are often extrapolated for use, as limited data exist in AYA SOT recipients. This informational dearth underscores the need for future research to better characterize the unique needs of AYA SOT recipients.

School and sports participation post-transplant

Pediatric recipients of life-saving organ transplants are living longer, with improved graft and overall survivals. After successful transplant, children are encouraged to return to "normal life," with school attendance and participation in age-appropriate physical activities. This transition may cause stress to the recipients, parents, teachers, and other participating caregivers and staff. Planning for school reentry and assuring education for and open lines of communication with the school staff can help alleviate some of this discomfort and ease the process for the patient and the family. Cardiovascular disease has emerged as the leading cause of death in survivors of pediatric transplantation and is contributed to by modifiable risk factors such as obesity, hypertension, and the MS. Physical activity is a proven tool in decreasing surrogate markers of this risk. Sports participation is an important way to promote an enjoyment of physical activity that can ideally persist into adulthood, but conflicting advice and opinions exist regarding type and participation in physical activity. Moreover, specific recommendations are likely not applicable to all recipients, as certain degrees of rehabilitation may be needed depending on degree and length of illness. In general, a program of rehabilitation and increased physical activity has been shown to be safe and effective for most pediatric transplant recipients. Focusing on optimizing the "normal" childhood activities of going to school and participating in sports can improve the physical, social, cognitive, and mental health outcomes of this population after transplant and should be prioritized.

Approaches to safe living and diet after solid organ transplantation

SOT recipients are at high risk for developing severe infectious complications following discharge from the hospital. Comprehensive anticipatory guidance surrounding everyday lifestyle choices can potentially prevent exposure to infectious agents from the environment. This paper reviews the risks that pediatric and adolescent SOT recipients encounter through exposures such as household contacts, outdoor activities, travel, animal exposures, and dietary choices. Although strong evidence is lacking, this paper makes recommendations aimed at minimizing the risk of infectious complications and hospitalization in pediatric SOT recipients.

Care of Pediatric Solid Organ Transplant Recipients: An Overview for Primary Care Providers

As the number of living pediatric solid organ transplant (SOT) recipients continues to grow, there is an increased likelihood that primary care providers (PCPs) will encounter pediatric SOT recipients in their practices. In addition, as end-stage organ failure is replaced with chronic medical conditions in transplant recipients, there is a need for a comprehensive approach to their management. PCPs can significantly enhance the care of immunosuppressed hosts by advising parents of safety considerations and avoiding adverse drug interactions. Together with subspecialty providers, PCPs are responsible for ensuring that appropriate vaccinations are given and can play an important role in the diagnosis of infections. Through early recognition of rejection and posttransplant complications, PCPs can minimize morbidity. Growth and development can be optimized through frequent assessments and timely referrals. Adherence to immunosuppressive regimens can be greatly improved through reinforcement at every encounter, particularly among adolescents. PCPs can also improve long-term outcomes by easing the transition of pediatric SOT recipients to adult providers. Although guidelines exist for the primary care management of adult SOT recipients, comprehensive guidance is lacking for pediatric providers. In this evidence-based overview, we outline the main issues affecting pediatric SOT recipients and provide guidance for PCPs regarding their management from the first encounter after the transplant to the main challenges that arise in childhood and adolescence. Overall, PCPs can and should use their expertise and serve as an additional layer of support in conjunction with the transplant center for families that are caring for a pediatric SOT recipient.

Medical care of liver transplant patients

INTRODUCTION

Liver transplantation is a life-changing event for patients and survival following transplantation has improved significantly since the first transplantation in 1967. Following liver transplantation, patients face a unique set of healthcare management decisions including transplantation-specific complications, recurrence of primary liver disease, as well as metabolic and malignancy concerns related to immunosuppression. As more patients with liver disease receive transplantation and live longer, understanding and managing these patients will require not only transplant specialist but also local subspecialist and primary care physicians.

AREAS COVERED

This review covers common issues related to the management of patients following liver transplantation including immunosuppression, liver allograft dysfunction, metabolic complications, as well as routine health maintenance such as immunizations and cancer screening.

EXPERT OPINION

Optimizing medical care for patients following liver transplant will benefit from ensuring all providers, not just transplant specialist, have a basic understanding of the common issues encountered in the post-transplant patient. This review provides an overview of common healthcare concerns and management options for patients following liver transplantation.

Cannabis Use and Fungal Infections in a Commercially Insured Population, United States, 2016

Case reports have identified invasive fungal diseases in persons who use cannabis, and fungal contamination of cannabis has been described. In a large health insurance claims database, persons who used cannabis were 3.5 (95% CI 2.6–4.8) times more likely than persons who did not use cannabis to have a fungal infection in 2016.

Real-life food-safety behavior and incidence of foodborne infections in solid organ transplant recipients

Food-safety measures are recommended in solid organ transplant (SOT) recipients. However, the actual adherence of patients in a real-life setting and the impact on the incidence of foodborne infections remain largely unexplored. We performed a survey among SOT recipients followed at our institution, aiming to evaluate their food-safety behavior. We assessed the incidence of microbiologically proven foodborne infections by chart review. One hundred ninety-seven SOT recipients (kidney = 117, lung = 35, liver = 29, and heart = 16) participated in the survey. Overall, 17.7% of the participants observed all food-safety recommendations (22.0% avoided food at risk of contamination while 67.9% applied hygiene recommendations). Patients within the first year after transplantation (odds ratio [OR] 5.42; P = .001) and females (OR 4.67; P = .001) followed food-safety recommendations more closely. Although the majority of SOT recipients felt concerned and actively sought information on food safety (68%-70%), only 27% were able to recognize all risks of foodborne infection in hypothetical scenarios. Incidence of proven foodborne infections was 17.9% (95% confidence interval 9.9%-30.9%) 5 years after transplantation. Importantly, foodborne infections occurred exclusively among patients not following food-safety recommendations. In summary, most SOT recipients eat foods that make them at risk of foodborne infections. Our results indicate that there is room for improvement in patient education, particularly later after transplantation, and reinforce current food-safety recommendations.

Management and prophylaxis of bacterial and mycobacterial infections among lung transplant recipients

Bacterial and mycobacterial infections are associated with morbidity and mortality in lung transplant recipients. Infectious complications are categorized by timing post-transplant: <1, 1–6, and >6 months. The first month post-transplant is associated with the highest risk of infection. During this period, infections are most commonly healthcare-associated, and include infections related to surgical complications. The lungs and bloodstream are common sites of infections. Common healthcare-associated organisms include methicillin-resistant Staphylococcus aureus (MRSA), Gram-negative bacilli such as Pseudomonas aeruginosa, and Clostridioides difficile. More than 1-month post-transplant, opportunistic infections can occur. Tuberculosis occurs in 0.8–10% of lung transplant recipients which reflects variation in background prevalence. The majority of post-transplant tuberculosis stems from reactivation of untreated or undiagnosed latent tuberculosis. Most post-transplant tuberculosis occurs in the lungs and develops within a year of transplant. Non-tuberculous mycobacteria commonly colonize the lungs of lung transplant candidates and are often hard to eradicate even with prolonged courses of antimycobacterial agents. Drug interactions between antimycobacterial agents and calcineurin and mTOR inhibitors also complicates treatment post-transplant. Given that infection adversely impacts outcomes after lung transplant, and that anti-infective therapy is often less effective after transplant, infection prevention is key to long-term success. A comprehensive approach that includes pre-transplant evaluation, perioperative prophylaxis, long-term antimicrobial prophylaxis, immunization, and safer living at home and in the community, should be employed to minimize the risk of infection.