1
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Kim HD, Chung BH, Yang CW, Kim SC, Kim KH, Kim SY, Kim KY, Lee J. Management of Immunosuppressive Therapy in Kidney Transplant Recipients with Sepsis: A Multicenter Retrospective Study. J Intensive Care Med 2024; 39:758-767. [PMID: 38321761 DOI: 10.1177/08850666241231495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Up to 6% of kidney transplant recipients (KTRs) experience life-threatening complications requiring intensive care unit (ICU) admission, and one of the most common medical complications requiring ICU admission is infection. This study aimed to evaluate the effect of immunosuppressive therapy (IST) modification on prognosis of KTRs with sepsis. METHODS We conducted a multicenter retrospective study in 4 university-affiliated hospitals to evaluate the effect of adjusting the IST in KTRs with sepsis. Only patients who either maintained IST after ICU admission or those who underwent immediate (within 24 h of ICU admission) reduction or withdrawal of IST following ICU admission were included in this study. "Any reduction" was defined as a dosage reduction of any IST or discontinuation of at least 1 IST. "Complete withdrawal of IST" was defined as concomitant discontinuation of all ISTs, except steroids. RESULTS During the study period, 1596 of the KTRs were admitted to the ICU, and 112 episodes of sepsis or septic shock were identified. The overall in-hospital mortality rate was 35.7%. In-hospital mortality was associated with higher sequential organ failure assessment score, simplified acute physiology score 3, non-identical human leukocyte antigen relation, presence of septic shock, and complete withdrawal of IST. After adjusting for potential confounding factors, complete withdrawal of IST remained significantly associated with in-hospital mortality (adjusted coefficient, 1.029; 95% confidence interval, 0.024-2.035) and graft failure (adjusted coefficient, 2.001; 95% confidence interval, 0.961-3.058). CONCLUSIONS Complete IST withdrawal was common and associated with worse outcomes in critically ill KTRs with sepsis.
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Affiliation(s)
- Hyung Duk Kim
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Ha Chung
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok Chan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kyung Hoon Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Shin Young Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, South Korea
| | - Kyu Yean Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, South Korea
| | - Jongmin Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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2
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Freire MP, Pouch S, Manesh A, Giannella M. Burden and Management of Multi-Drug Resistant Organism Infections in Solid Organ Transplant Recipients Across the World: A Narrative Review. Transpl Int 2024; 37:12469. [PMID: 38952482 PMCID: PMC11215024 DOI: 10.3389/ti.2024.12469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/07/2024] [Indexed: 07/03/2024]
Abstract
Solid organ transplant (SOT) recipients are particularly susceptible to infections caused by multidrug-resistant organisms (MDRO) and are often the first to be affected by an emerging resistant pathogen. Unfortunately, their prevalence and impact on morbidity and mortality according to the type of graft is not systematically reported from high-as well as from low and middle-income countries (HIC and LMIC). Thus, epidemiology on MDRO in SOT recipients could be subjected to reporting bias. In addition, screening practices and diagnostic resources may vary between countries, as well as the availability of new drugs. In this review, we aimed to depict the burden of main Gram-negative MDRO in SOT patients across HIC and LMIC and to provide an overview of current diagnostic and therapeutic resources.
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Affiliation(s)
- Maristela Pinheiro Freire
- Department of Infectious Diseases, Hospital das Clínicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Stephanie Pouch
- Transplant Infectious Diseases, Emory University School of Medicine, Atlanta, GA, United States
| | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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3
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Poudel S, Gupta S, Saigal S. Basics and Art of Immunosuppression in Liver Transplantation. J Clin Exp Hepatol 2024; 14:101345. [PMID: 38450290 PMCID: PMC10912712 DOI: 10.1016/j.jceh.2024.101345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 01/09/2024] [Indexed: 03/08/2024] Open
Abstract
Liver transplantation is one of the most challenging areas in the medical field. Despite that, it has already been established as a standard treatment option, especially in decompensated cirrhosis and selected cases of hepatocellular carcinoma and acute liver failure. Complications due to graft rejection, including mortality and morbidity, have greatly improved over time due to better immunosuppressive agents and management protocols. Currently, immunosuppression in liver transplant patients makes use of the best possible combinations of effective agents to achieve optimal immunosuppression for long-term graft survival. Induction agents are no longer used routinely, and the aim is to provide minimal immunosuppression in the maintenance phase. Currently available immunosuppressive agents are mainly classified as biological and pharmacological agents. Though the protocols may vary among the centers and over time, the basics of effective use usually remain similar. Most protocols use the combination of multiple agents with different mechanisms of action to reduce the dose and minimize the side effects. Along with the improvement in operative and perioperative techniques, this art of immunosuppression has contributed to the recent progress made in the outcomes of liver transplants. In this review, we will discuss the various types of immunosuppressive agents currently in use, the different protocols of immunosuppression used, and the art of optimal use for achieving maximum immunosuppression without increasing toxicity. We will also discuss the practical aspects of various immunosuppression regimens, including drug monitoring, and briefly discuss the concepts of immunosuppression minimization and withdrawal.
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Affiliation(s)
- Shekhar Poudel
- Fellow Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Principal Director and Head, Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
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4
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Mallick S, K.N. A, Sivaprasadan S, S. S. Immunosuppression in Liver Transplant Recipients in the Setting of Sepsis. J Clin Exp Hepatol 2023; 13:682-690. [PMID: 37440935 PMCID: PMC10333943 DOI: 10.1016/j.jceh.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
Management of immunosuppression (IS) in liver transplant recipients in the setting of sepsis is an open stage for debate. The age-long practice of reduction or complete cessation of IS during sepsis has been followed by most centres across the world, although, their exact strategies are highly heterogeneous. On the other hand, the emergence of striking new evidence suggesting that there is, in fact, decreased mortality with the continuation of IS in sepsis, has raised doubts about our previously conceived intuitive notion that IS portends increased risk in sepsis. The theory postulated is that IS agents, perhaps reverse the state of dysregulated immune response in sepsis to that of an iatrogenically modulated immune response, thus dimming the inflammatory cascade and preventing its deleterious effects. Of note, none of these studies reported exaggerated rejection-related complications. These contrasting outlooks have made it rather onerous to formulate an evidence-based recommendation for liver transplant recipients afflicted with sepsis. Inclusion of transplanted patients in randomised controlled trials of sepsis-related interventions seems to be the need of the hour.
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Affiliation(s)
- Shweta Mallick
- Department of Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Anila K.N.
- Department of Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Saraswathy Sivaprasadan
- Department of Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Sudhindran S.
- Department of Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, India
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Dolci G, Burastero GJ, Paglia F, Cervo A, Meschiari M, Guaraldi G, Chester J, Mussini C, Franceschini E. Epidemiology and Prevention of Early Infections by Multi-Drug-Resistant Organisms in Adults Undergoing Liver Transplant: A Narrative Review. Microorganisms 2023; 11:1606. [PMID: 37375108 DOI: 10.3390/microorganisms11061606] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Invasive bacterial infections are a leading cause of morbidity and mortality after liver transplant (LT), especially during the first months after LT, and infections due to multi-drug-resistant organisms (MDRO) are increasing in this setting. Most of the infections in patients in intensive care unit arise from the endogenous microflora and, for this reason, pre-LT MDRO rectal colonization is a risk factor for developing MDRO infections in the post-LT. Moreover, the transplanted liver may carry an increased risk of MDRO infections due to organ transportation and preservation, to donor intensive care unit stay and previous antibiotic exposure. To date, little evidence is available about how MDRO pre-LT colonization in donors and recipients should address LT preventive and antibiotic prophylactic strategies, in order to reduce MDRO infections in the post-LT period. The present review provided an extensive overview of the recent literature on these topics, with the aim to offer a comprehensive insight about the epidemiology of MDRO colonization and infections in adult LT recipients, donor-derived MDRO infections, possible surveillance, and prophylactic strategies to reduce post-LT MDRO infections.
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Affiliation(s)
- Giovanni Dolci
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Giulia Jole Burastero
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Francesca Paglia
- Infectious Diseases Unit, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Adriana Cervo
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Marianna Meschiari
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Giovanni Guaraldi
- Infectious Diseases Unit, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Johanna Chester
- Department of Dermatology, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Cristina Mussini
- Infectious Diseases Unit, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Erica Franceschini
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
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Abstract
The term leishmaniasis includes multiple clinical syndromes: visceral, cutaneous, and mucosal leishmaniasis, resulting from an infection of macrophages throughout the reticuloendothelial system in the dermis and the naso-oropharyngeal mucosa, respectively. The clinical phenotype is mainly driven by the leishmania biologic characteristics and, ultimately, also by the host immune status. The disease is endemic in focal areas in the tropics, subtropics, and southern Europe, transmitted by the bite of female phlebotomine sandflies. Sandflies regurgitate the parasite’s flagellated promastigote stage into the host’s skin; promastigotes bind to receptors on macrophages are phagocytized and transformed within phagolysosomes into non-flagellated amastigotes which replicate and infect additional macrophages. Amastigotes ingested by sandflies transform back into infective promastigotes. Depending on the host’s innate and acquired immune status, systemic and visceral leishmaniasis can be characterized by irregular fever, weight loss, enlargement of the spleen and liver, and anaemia. We present a 42 year-old man with long-lasting type 1 autoimmune hepatitis under immunosuppressive treatment. In January 2017, the patient started to experience low-grade unresponsiveness to empiric antibiotic therapy. The patient developed severe anemia and progressive multilineage cytopenia accompanied by increased levels of inflammatory markers. FDG-PET revealed increased glucose uptake in the liver, spleen, and the whole bone marrow. The subsequently performed bone marrow biopsy evidenced Leishmania amastigotes inside macrophages, confirmed by serological positivity to anti-Leishmania antibody. Immunosuppressive therapy was suspended and replaced by treatment with amphotericin B at 4 mg/kg/day from day 1 to day 5, followed by a single infusion on days 10, 17, 24, 31, and 38. The bone marrow smear after treatment still evidenced few Leishmania amastigotes; in consideration of the patient’s immunosuppression status, two further doses of amphotericin B on days 45 and 52 were employed, leading to infection resolution. In real-life, as exemplified in this case, administering two additional doses of amphotericin B (concerning the guidelines) offered an additional therapeutic opportunity for a patient under long-term immunosuppressive treatment.
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7
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A Case Series of Extrapulmonary Mycobacterium in Liver Transplant Recipients. ACG Case Rep J 2021; 8:e00571. [PMID: 34549057 PMCID: PMC8443817 DOI: 10.14309/crj.0000000000000571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/02/2020] [Indexed: 11/17/2022] Open
Abstract
Liver transplant recipients are at increased risk of infection because of the immunosuppression required after transplantation. Infection by Mycobacterium species increases the morbidity and mortality of liver transplant recipients. The prompt recognition and diagnosis of opportunistic infection is necessary for good outcomes, particularly during periods of increased immunosuppression. The balance of immunosuppressive therapies during prolonged treatment with hepatotoxic medications has not been well studied and should be tailored for the unique clinical setting of each patient. The goal of treatment in these patients is to eradicate the disease and preserve allograft function.
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8
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Xue F, Gao W, Qin T, Wu C, Luo Y, Chen J, Zhou T, Feng M, Qiu B, Zhu J, He J, Xia Q. Immune cell function assays in the diagnosis of infection in pediatric liver transplantation: an open-labeled, two center prospective cohort study. Transl Pediatr 2021; 10:333-343. [PMID: 33708519 PMCID: PMC7944184 DOI: 10.21037/tp-20-256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Limited studies have been performed in assessment of immune status of pediatric liver transplants (PLTs). We conducted this study to evaluate Cylex immune cell function assay in diagnosis of infection and its potential clinical application in Chinese infant PLTs. METHODS In this prospective cohort study, 227 infant PLTs from two medical centers were enrolled, and 216 completed the study. Cylex ATP values were measured before and after liver transplantation (LT) at week 1, 2, 3, 4, 8, 12 and 24 respectively. Accordingly, patients' clinical records, including demographic data, liver function results, tacrolimus dosages and concentrations were collected and analyzed. RESULTS One hundred and sixty of 216 PLTs (74.1%) were diagnosed infection based on the parameters including abnormal vital signs, imaging changes, and pathogens detection, while 44 (20.4%) were clinically stable and 12 (5.6%) experienced acute rejection. The median Cylex ATP value in infant PLTs post-surgery reduced significantly in infection group compared to stable group (median, 137 vs. 269 ng/mL, P<0.001). Receiver operating characteristic (ROC) curve analysis determined that the cut-off value of Cylex ATP was 152 ng/mL in diagnosis of infection [area under the curve (AUC): 0.784, 95% CI: 0.720-0.848]. Meanwhile, Cylex ATP value showed no correlation to tacrolimus dosage, blood concentration, dose-normalized concentration/dose ratio or Kaup index. However, it tended to correlate weakly with the white blood cell (WBC) number (R =0.462, P<0.0001) and lymphocyte counts (R =0.363, P<0.0001). CONCLUSIONS In this study, we demonstrated that low Cylex ATP represented partly over-immunosuppression and had diagnostic value in infant PLTs with infections, which might assist individualized immunosuppression in PLT patients.
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Affiliation(s)
- Feng Xue
- Department of Liver Surgery and Liver Transplantation, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Gao
- Transplant Center, Tianjin First Central Hospital, Tianjin, China
| | - Tian Qin
- Department of Liver Surgery and Liver Transplantation, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Cheng Wu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yi Luo
- Department of Liver Surgery and Liver Transplantation, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Chen
- Transplant Center, Tianjin First Central Hospital, Tianjin, China
| | - Tao Zhou
- Department of Liver Surgery and Liver Transplantation, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mingxuan Feng
- Department of Liver Surgery and Liver Transplantation, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bijun Qiu
- Department of Liver Surgery and Liver Transplantation, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianjun Zhu
- Department of Liver Surgery and Liver Transplantation, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jia He
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery and Liver Transplantation, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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9
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Chen F, Pang XY, Shen C, Han LZ, Deng YX, Chen XS, Zhang JJ, Xia Q, Qian YB. High mortality associated with gram-negative bacterial bloodstream infection in liver transplant recipients undergoing immunosuppression reduction. World J Gastroenterol 2020; 26:7191-7203. [PMID: 33362376 PMCID: PMC7723669 DOI: 10.3748/wjg.v26.i45.7191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/30/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Immunosuppression is an important factor in the incidence of infections in transplant recipient. Few studies are available on the management of immunosuppression (IS) treatment in the liver transplant (LT) recipients complicated with infection. The aim of this study is to describe our experience in the management of IS treatment during bacterial bloodstream infection (BSI) in LT recipients and assess the effect of temporary IS withdrawal on 30 d mortality of recipients presenting with severe infection.
AIM To assess the effect of temporary IS withdrawal on 30 d mortality of LT recipients presenting with severe infection.
METHODS A retrospective study was conducted with patients diagnosed with BSI after LT in the Department of Liver Surgery, Renji Hospital from January 1, 2016 through December 31, 2017. All recipients diagnosed with BSI after LT were included. Univariate and multivariate Cox regression analysis of risk factors for 30 d mortality was conducted in the LT recipients with Gram-negative bacterial (GNB) infection.
RESULTS Seventy-four episodes of BSI were identified in 70 LT recipients, including 45 episodes of Gram-positive bacterial (GPB) infections in 42 patients and 29 episodes of GNB infections in 28 patients. Overall, IS reduction (at least 50% dose reduction or cessation of one or more immunosuppressive agent) was made in 28 (41.2%) cases, specifically, in 5 (11.9%) cases with GPB infections and 23 (82.1%) cases with GNB infections. The 180 d all-cause mortality rate was 18.5% (13/70). The mortality rate in GNB group (39.3%, 11/28) was significantly higher than that in GPB group (4.8%, 2/42) (P = 0.001). All the deaths in GNB group were attributed to worsening infection secondary to IS withdrawal, but the deaths in GPB group were all due to graft-versus-host disease. GNB group was associated with significantly higher incidence of intra-abdominal infection, IS reduction, and complete IS withdrawal than GPB group (P < 0.05). Cox regression showed that rejection (adjusted hazard ratio 7.021, P = 0.001) and complete IS withdrawal (adjusted hazard ratio 12.65, P = 0.019) were independent risk factors for 30 d mortality in patients with GNB infections after LT.
CONCLUSION IS reduction is more frequently associated with GNB infection than GPB infection in LT recipients. Complete IS withdrawal should be cautious due to increased risk of mortality in LT recipients complicated with BSI.
IS
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Affiliation(s)
- Fang Chen
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Xiao-Yun Pang
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Chuan Shen
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Long-Zhi Han
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Yu-Xiao Deng
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Xiao-Song Chen
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Jian-Jun Zhang
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Yong-Bing Qian
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
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Pérez-Nadales E, Gutiérrez-Gutiérrez B, Natera AM, Abdala E, Reina Magalhães M, Mularoni A, Monaco F, Camera Pierrotti L, Pinheiro Freire M, Iyer RN, Mehta Steinke S, Grazia Calvi E, Tumbarello M, Falcone M, Fernández-Ruiz M, María Costa-Mateo J, Rana MM, Mara Varejão Strabelli T, Paul M, Carmen Fariñas M, Clemente WT, Roilides E, Muñoz P, Dewispelaere L, Loeches B, Lowman W, Tan BH, Escudero-Sánchez R, Bodro M, Antonio Grossi P, Soldani F, Gunseren F, Nestorova N, Pascual Á, Martínez-Martínez L, Aguado JM, Rodríguez-Baño J, Torre-Cisneros J. Predictors of mortality in solid organ transplant recipients with bloodstream infections due to carbapenemase-producing Enterobacterales: The impact of cytomegalovirus disease and lymphopenia. Am J Transplant 2019; 20:S1600-6135(22)22362-4. [PMID: 31891235 DOI: 10.1111/ajt.15769] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 11/30/2019] [Accepted: 12/22/2019] [Indexed: 01/25/2023]
Abstract
Treatment of carbapenemase-producing Enterobacterales bloodstream infections in solid organ transplant recipients is challenging. The objective of this study was to develop a specific score to predict mortality in solid organ transplant recipients with carbapenemase-producing Enterobacterales bloodstream infections. A multinational, retrospective (2004-2016) cohort study (INCREMENT-SOT, ClinicalTrials.gov NCT02852902) was performed. The main outcome variable was 30-day all-cause mortality. The INCREMENT-SOT-CPE score was developed using logistic regression. The global cohort included 216 patients. The final logistic regression model included the following variables: INCREMENT-CPE mortality score ≥8 (8 points), no source control (3 points), inappropriate empirical therapy (2 points), cytomegalovirus disease (7 points), lymphopenia (4 points), and the interaction between INCREMENT-CPE score ≥8 and CMV disease (minus 7 points). This score showed an area under the receiver operating characteristic curve of 0.82 (95% confidence interval [CI] 0.76-0.88) and classified patients into 3 strata: 0-7 (low mortality), 8-11 (high mortality), and 12-17 (very-high mortality). We performed a stratified analysis of the effect of monotherapy vs combination therapy among 165 patients who received appropriate therapy. Monotherapy was associated with higher mortality only in the very-high (adjusted hazard ratio [HR] 2.82, 95% CI 1.13-7.06, P = .03) and high (HR 9.93, 95% CI 2.08-47.40, P = .004) mortality risk strata. A score-based algorithm is provided for therapy guidance.
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Affiliation(s)
- Elena Pérez-Nadales
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, Spain
| | - Belén Gutiérrez-Gutiérrez
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla, Seville, Spain
| | - Alejandra M Natera
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, Spain
| | - Edson Abdala
- Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | | | | | | | | | | | | | | | - Mario Tumbarello
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Falcone
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), Universidad Complutense, Madrid, Spain
| | - José María Costa-Mateo
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | | | | | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus and Faculty of Medicine, Technion - Israel Faculty of Technology, Haifa, Israel
| | - María Carmen Fariñas
- Infectious Diseases Unit, Hospital Universitario Marqués de Valdecilla, University of Cantabria, Santander, Spain
| | - Wanessa Trindade Clemente
- Faculty of Medicine, Liver Transplantation Program, Hospital das Clínicas -Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Emmanuel Roilides
- Infectious Diseases Unit and 3rd, Department of Pediatrics, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - Patricia Muñoz
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Laurent Dewispelaere
- Department of Microbiology, CUB-Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Belén Loeches
- Infectious Diseases Unit, Hospital La Paz, Madrid, Spain
| | - Warren Lowman
- Wits Donald Gordon Medical Centre, Vermaak & Partners/Pathcare, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ban Hock Tan
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - Rosa Escudero-Sánchez
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Ramón y Cajal University Hospital, Madrid, Spain
| | - Marta Bodro
- Infectious Diseases Department, Hospital Clinic - IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Fabio Soldani
- Department of Medicine, Infectious Diseases Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Filiz Gunseren
- Department of Infectious Diseases, Akdeniz University Hospital, Antalya, Turkey
| | | | - Álvaro Pascual
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla, Seville, Spain
| | - Luis Martínez-Martínez
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unidad de Gestión Clínica de Microbiología, Hospital Universitario Reina Sofía, IMIBIC, Universidad de Cordoba, Cordoba, Spain
| | - José María Aguado
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), Universidad Complutense, Madrid, Spain
| | - Jesús Rodríguez-Baño
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla, Seville, Spain
| | - Julián Torre-Cisneros
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba, Córdoba, Spain
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11
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Yahav D, Sulimani O, Green H, Margalit I, Ben-Zvi H, Mor E, Rozen-Zvi B. Immunosuppression reduction in kidney transplant recipients during bacterial infection-A retrospective study. Clin Transplant 2019; 33:e13707. [PMID: 31494965 DOI: 10.1111/ctr.13707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/15/2019] [Accepted: 08/29/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Immunosuppression reduction is a common practice in the management of bacterial infection among kidney transplant recipients (KTRs). This practice, however, is based on limited evidence. METHODS Retrospective study comparing clinical outcomes of KTRs whose antimetabolite was discontinued vs continued during hospitalization due to bacterial infection, considering calcineurin inhibitors (CNI) levels. Primary outcome was a composite of clinical failure at day 5; all-cause mortality; and/or re-hospitalization at 90 days. Multivariable analysis of risk factors for the primary outcome was performed using a propensity-matched cohort. RESULTS We included 183 KTRs hospitalized with bacterial infection. Neither discontinuation of antimetabolites nor lower levels of CNI at infection onset were associated with a significant decrease the composite primary outcome. No significant difference in graft loss or rejection was demonstrated between patients with low vs high CNI levels or discontinuation vs continuation of antimetabolite. In multivariable analysis, CNI levels and management of antimetabolite were not significantly associated with adverse outcome. CONCLUSIONS Immunosuppression reduction in hospitalized KTRs with bacterial infection did not offer a clinical advantage in terms of mortality, re-hospitalization, or clinical success. An interventional study evaluating continuation of immunosuppression vs reduction should be considered.
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Affiliation(s)
- Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Omri Sulimani
- Department of general surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Hefziba Green
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Nephrology and Hypertension, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,Medicine B, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Ili Margalit
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Medicine F, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Haim Ben-Zvi
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Microbiology Laboratory, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Eytan Mor
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Transplantation, Rabin Medical Center, Petah-Tikva, Israel
| | - Benaya Rozen-Zvi
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Nephrology and Hypertension, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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12
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Shepshelovich D, Tau N, Green H, Rozen-Zvi B, Issaschar A, Falcone M, Coussement J, Zusman O, Manuel O, Mor E, Torre-Cisneros J, Yahav D. Immunosuppression reduction in liver and kidney transplant recipients with suspected bacterial infection: A multinational survey. Transpl Infect Dis 2019; 21:e13134. [PMID: 31242341 DOI: 10.1111/tid.13134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/30/2019] [Accepted: 06/02/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is no consensus on the optimal management of immunosuppression during bacterial infections among solid organ transplant recipients. METHODS A multicenter, cross-sectional survey, of high-volume kidney and liver transplant centers across US and Europe. Structured questionnaires including six multiple-choice questions concerning the management of immunosuppression during infection were distributed among 381 centers. RESULTS A total of 124 (33%) centers fully completed the questionnaire: 67 liver, 57 kidney centers. Participating centers reported heterogenous approaches to immunosuppression management for all types of immunosuppressive drugs. Notably, kidney centers reported similar frequencies of either discontinuation (19%), continuation (19%), or dose reduction (17.5%) of antimetabolites; discontinuation only for life-threatening infection (17.5%) or case by case decisions (27%). Calcineurin inhibitors (CNI) management was heterogenous mostly among liver centers, with 8% discontinuing the CNI, 18% continuing, and 22% reducing dose. Heterogenous approaches to management of steroids and inhibitors of the mammalian target of rapamycin were also demonstrated. CONCLUSIONS Immunosuppression management during bacterial infection is heterogenous in US and European centers. Immunosupression reduction (ISR) during infection is a common practice, though supported by limited evidence. Demonstrating high heterogeneity in the approach to ISR, together with the equivocal results of clinical studies, support consideration of an interventional clinical trial.
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Affiliation(s)
- Daniel Shepshelovich
- Medicine A, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Noam Tau
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Diagnostic Imaging, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Hefziba Green
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Nephrology and Hypertension, Rabin Medical Center, Petah Tikva, Israel.,Medicine B, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Benaya Rozen-Zvi
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Nephrology and Hypertension, Rabin Medical Center, Petah Tikva, Israel
| | - Assaf Issaschar
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Rabin Medical Center, The Liver Institute, Petah-Tikva, Israel
| | - Marco Falcone
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Julien Coussement
- Department of Microbiology and Division of Infectious Diseases, CUB-Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Oren Zusman
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Oriol Manuel
- Transplantation Center and Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Eytan Mor
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Transplantation, Rabin Medical Center, Petah Tikva, Israel
| | - Julian Torre-Cisneros
- Clinical Unit of Infectious Diseases, University Hospital 'Reina Sofía', Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), School of Medicine, University of Córdoba, Córdoba, Spain
| | - Dafna Yahav
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
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13
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Bartoletti M, Lewis RE, Giannella M, Tedeschi S, Viale P. The role of extended infusion β-lactams in the treatment of bloodstream infections in patients with liver cirrhosis. Expert Rev Anti Infect Ther 2018; 16:771-779. [DOI: 10.1080/14787210.2018.1523716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Russell Edward Lewis
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, Alma Mater University of Bologna, Bologna, Italy
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