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Surgical site infection prevention and management in immunocompromised patients: a systematic review of the literature. World J Emerg Surg 2021; 16:33. [PMID: 34112231 PMCID: PMC8194010 DOI: 10.1186/s13017-021-00375-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/26/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Immunocompromised patients are at higher risk of surgical site infection and wound complications. However, optimal management in the perioperative period is not well established. Present systematic review aims to analyse existing strategies and interventions to prevent and manage surgical site infections and other wound complications in immunocompromised patients. METHODS A systematic review of the literature was conducted. RESULTS Literature review shows that partial skin closure is effective to reduce SSI in this population. There is not sufficient evidence to definitively suggest in favour of prophylactic negative pressure wound therapy. The use of mammalian target of rapamycin (mTOR) and calcineurin inhibitors (CNI) in transplanted patient needing ad emergent or undeferrable abdominal surgical procedure must be carefully and multidisciplinary evaluated. The role of antibiotic prophylaxis in transplanted patients needs to be assessed. CONCLUSION Strict adherence to SSI infection preventing bundles must be implemented worldwide especially in immunocompromised patients. Lastly, it is necessary to elaborate a more widely approved definition of immunocompromised state. Without such shared definition, it will be hard to elaborate the needed methodologically correct studies for this fragile population.
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Talayero P, Ramos Boluda E, Gómez Massa E, Castro Panete MJ, Prieto Bozano G, Hernández Oliveros F, López Santamaría M, Calvo Pulido J, Paz-Artal E, Mancebo E. Donor-Specific Antibodies in Pediatric Intestinal and Multivisceral Transplantation: The Role of Liver and Human Leukocyte Antigen Mismatching. Liver Transpl 2018; 24:1726-1735. [PMID: 30112820 DOI: 10.1002/lt.25323] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/07/2018] [Indexed: 01/13/2023]
Abstract
Rejection is one of the most important drawbacks for graft and patient survival in intestinal and multivisceral transplantation. However, there is no consensus on the diagnostic criteria for humoral rejection, and the literature about the role of donor-specific antibodies (DSA) on allograft outcome and the risk factors that contribute to their development is scant with contradictory results. The present study analyzes the role of DSA exclusively in a pediatric cohort of 43 transplants. Among our patients, 11.6% showed preformed DSA, but they did not correlate with more rejection or less allograft survival. Having previous transplants was the main sensitization factor with an odds ratio (OR) = 44.85 (P = 0.001). In total, 16.3% of recipients developed de novo donor-specific antibodies (dnDSA), mostly directed against human leukocyte antigen (HLA) class II, polyspecific and complement fixing. Additionally, the presence of dnDSA had a deleterious effect on graft rejection (hazard ratio [HR] = 11.00; P = 0.01) and survival (HR = 66.52; P < 0.001) in an observational period of 5 years after transplantation. The inclusion of the liver emerged as the main protective factor against dnDSA development with an OR = 0.07 (P = 0.007). The analysis of HLA compatibility at the serological and epitope level with the computational tools HLAMatchmaker and PIRCHE revealed no association between HLA mismatching and dnDSA. In conclusion, this study performed in pediatric recipients shows the deleterious effect of dnDSA on intestinal transplantation supported by the complement-fixing activity observed. Additionally, the liver inclusion in the allografts showed to be a protective factor against dnDSA generation.
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Affiliation(s)
- Paloma Talayero
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain
| | - Esther Ramos Boluda
- Pediatric Gastroenterology Intestinal Rehabilitation Unit, University Hospital La Paz, Madrid, Spain
| | - Elena Gómez Massa
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain
| | | | - Gerardo Prieto Bozano
- Pediatric Gastroenterology Intestinal Rehabilitation Unit, University Hospital La Paz, Madrid, Spain
| | - Francisco Hernández Oliveros
- Department of Pediatric Surgery, University Hospital La Paz, Madrid, Spain.,EOC of ERN-Transplantchild, University Hospital La Paz, Madrid, Spain
| | | | - Jorge Calvo Pulido
- General and Digestive Surgery and Abdominal Organ Transplantation, University Hospital 12 de Octubre, Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain
| | - Estela Paz-Artal
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain.,Section of Immunology, San Pablo CEU University, Madrid, Spain
| | - Esther Mancebo
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain
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Abstract
PURPOSE OF REVIEW This article reviews the role of biologicals in intestinal transplantation. RECENT FINDINGS Several biologicals have been used in intestinal and multivisceral transplantation for various indications, such as induction therapy, prevention and treatment of antibody-mediated rejection, desensitization, anti-inflammatory treatment, as well as treatment of Epstein-Barr virus-associated posttransplant lymphoproliferative disease. Particularly, the administration of biologicals in induction therapy such as T-cell depleting antibodies and interleukin-2 receptor antagonists have significantly contributed to the great improvement of patient and allograft outcome. Novel biologicals, such as B-cell, plasma-cell, and complement-directed agents have been successfully applied to treat antibody and complement-driven alloimmune processes to stabilize long-term outcome. Several other inflammatory allotransplant conditions have been addressed with anti-TNF-α antibodies, such as infliximab. SUMMARY Biologicals have contributed significantly to the recent success of intestinal transplantation. Novel developments in this field are supposed to aid in addressing various urgent needs in intestinal transplantation, such as preimmunization, antibody and complement-induced graft injury, as well as pathologies originating from innate immune responses.
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Lauro A, Zanfi C, Bagni A, Cescon M, Siniscalchi A, Pellegrini S, Pironi L, Pinna AD. Induction therapy in adult intestinal transplantation: reduced incidence of rejection with "2-dose" alemtuzumab protocol. Clin Transplant 2013; 27:567-70. [PMID: 23815302 DOI: 10.1111/ctr.12166] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2013] [Indexed: 12/01/2022]
Abstract
The incidence of early rejection after intestinal transplantation correlates with heightened risk of graft loss and mortality. Many different induction or pre-conditioning protocols have been reported in the last 10 yr to improve outcomes; however, sepsis remains prevalent and diminishes long-term results. We recently began a "2-dose" alemtuzumab trial protocol - 15 mg at day 0 and 15 mg repeated on day 7 - with the hope of reducing our infection rate. We compared three different protocols used at our institution (daclizumab, conventional "4-dose" alemtuzumab, and "2-dose" alemtuzumab). There was a significantly lower rate of early rejection with the "2-dose" alemtuzumab protocol in our study group of mainly (88%) intestinal grafts without accompanying liver engraftment with its protective immunologic effect. Sepsis remained low. Longer follow-up will be required to evaluate the effects of this new protocol on longer-term outcomes.
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Affiliation(s)
- A Lauro
- Liver and Multiorgan Transplant Center, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Trevizol AP, David AI, Dias ER, Mantovani D, Pécora R, D'Albuquerque LAC. Intestinal and multivisceral transplantation immunosuppression protocols--literature review. Transplant Proc 2013; 44:2445-8. [PMID: 23026616 DOI: 10.1016/j.transproceed.2012.07.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Currently the most used techniques for small bowel transplant are isolated intestinal transplantation, multivisceral transplantation (MVT), and modified multivisceral transplantation. One important factor is early diagnosis of acute cellular rejection (ACR). In addition, improvements in immunosuppression have recently reduced the number and enhanced treatment of ACR episodes, enabling graft recovery. OBJECTIVE We analyzed immunosuppression protocols of leading transplantation centers in the last 5 years. METHOD We reviewed papers published in PubMed from major multivisceral and intestinal transplantation centers from 2006 to 2010 in adult recipients. The 211 adults transplanted in seven centers were divided into three groups according to the immunosuppression protocol used: protocol 1: daclizumab induction with tacrolimus and steroid maintenance; protocol 2: alemtuzumab and tacrolimus; and protocol 3: thymoglobulin and rituximab and tacrolimus. RESULTS Protocol 2 showed the lowest rate of ACR (34%). Protocols 1 and 3 displayed 54% and 48% ACR rates; respectively. However, protocol 1 patients developed only mild ACR, whereas those in protocols 2 and 3 developed moderate ACR in 26.3% and 11.7%, and severe ACR in 7.9% and 47% of cases, respectively. The infection rate was considerably lower in protocol 3 (7.4%). Protocols 1 and 2 showed infection rates of 62.5% and 52%, respectively. One-year patient survival rates were 70%, 79% and 81%, respectively. Three-year patient survival rates were 62%, 56%, and 78% for protocols 1, 2 and 3, respectively. CONCLUSION Protocol 2 was the strongest immunosuppressive regimen capable of reducing ACR rates when compared with the other protocols, but the strong effect resulted in high infection rate that impacts 1-year patient survival. Protocol 3 seems to be the best available one balancing ACR and infection rates.
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Affiliation(s)
- A P Trevizol
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil
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