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McMullan B, Kim HY, Alastruey-Izquierdo A, Tacconelli E, Dao A, Oladele R, Tanti D, Govender NP, Shin JH, Heim J, Ford NP, Huttner B, Galas M, Nahrgang SA, Gigante V, Sati H, Alffenaar JW, Morrissey CO, Beardsley J. Features and global impact of invasive fungal infections caused by Pneumocystis jirovecii: A systematic review to inform the World Health Organization fungal priority pathogens list. Med Mycol 2024; 62:myae038. [PMID: 38935910 PMCID: PMC11210620 DOI: 10.1093/mmy/myae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 02/15/2024] [Accepted: 04/27/2024] [Indexed: 06/29/2024] Open
Abstract
This systematic review evaluates the current global impact of invasive infections caused by Pneumocystis jirovecii (principally pneumonia: PJP), and was carried out to inform the World Health Organization Fungal Priority Pathogens List. PubMed and Web of Science were used to find studies reporting mortality, inpatient care, complications/sequelae, antifungal susceptibility/resistance, preventability, annual incidence, global distribution, and emergence in the past 10 years, published from January 2011 to February 2021. Reported mortality is highly variable, depending on the patient population: In studies of persons with HIV, mortality was reported at 5%-30%, while in studies of persons without HIV, mortality ranged from 4% to 76%. Risk factors for disease principally include immunosuppression from HIV, but other types of immunosuppression are increasingly recognised, including solid organ and haematopoietic stem cell transplantation, autoimmune and inflammatory disease, and chemotherapy for cancer. Although prophylaxis is available and generally effective, burdensome side effects may lead to discontinuation. After a period of decline associated with improvement in access to HIV treatment, new risk groups of immunosuppressed patients with PJP are increasingly identified, including solid organ transplant patients.
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Affiliation(s)
- Brendan McMullan
- Faculty of Medicine and Health, UNSW, Sydney, New South Wales, Australia
- Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, Sydney, New South Wales, Australia
| | - Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
- Department of Pharmacy, Westmead Hospital, Western Sydney LHD, North Parramatta, New South Wales, Australia
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Evelina Tacconelli
- Department of Diagnostics and Public Health, Verona University, Verona, Italy
| | - Aiken Dao
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, New South Wales, Australia
- Westmead Hospital, Western Sydney LHD, North Parramatta, New South Wales, Australia
| | - Rita Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Daniel Tanti
- Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, Sydney, New South Wales, Australia
- Discipline of Paediatrics, Faculty of Medicine and Health, University of NSW, Sydney, Australia
| | - Nelesh P Govender
- Division of the National Health Laboratory Service, National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Infection and Immunity, St George’s University of London, London, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Jong-Hee Shin
- Department of Laboratory Medicine, Chonnam National University School of Medicine, Gwangju, South Korea
| | - Jutta Heim
- Scientific Advisory Committee, Helmholtz Centre for Infection Research, Germany
| | - Nathan Paul Ford
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Marcelo Galas
- Antimicrobial Resistance Special Program, Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization, Washingdom, District of Columbia, USA
| | - Saskia Andrea Nahrgang
- Antimicrobial Resistance Programme, World Health Organization European Office, Copenhagen, Denmark
| | | | | | - Jan Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
- Department of Pharmacy, Westmead Hospital, Western Sydney LHD, North Parramatta, New South Wales, Australia
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - C Orla Morrissey
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Monash University, Clayton, Victoria, Australia
| | - Justin Beardsley
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, New South Wales, Australia
- Westmead Hospital, Western Sydney LHD, North Parramatta, New South Wales, Australia
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Cheng B, Qi C, Zhang S, Wang X. Risk factors for Pneumocystis jirovecii pneumonia after kidney transplantation: A systematic review and meta-analysis. Clin Transplant 2024; 38:e15320. [PMID: 38690617 DOI: 10.1111/ctr.15320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND AND OBJECTIVE Pneumocystis jirovecii pneumonia (PJP), an opportunistic infection, often leads to an increase in hospitalization time and mortality rates in kidney transplant (KT) recipients. However, the risk factors associated with PJP in KT recipients remain debatable. Therefore, we conducted this meta-analysis to identify risk factors for PJP, which could potentially help to reduce PJP incidence and improve outcome of KT recipients. METHODS We systematically retrieved relevant studies in PubMed, EMBASE, and the Cochrane Library up to November 2023. Pooled odds ratios (ORs) or mean differences (MDs) and the corresponding 95% confidence intervals (CIs) were calculated to assess the impact of potential risk factors on the occurrence of PJP. RESULTS 27 studies including 42383 KT recipients were included. In this meta-analysis, age at transplantation (MD = 3.48; 95% CI = .56-6.41; p = .02), cytomegalovirus (CMV) infection (OR = 4.00; 95% CI = 2.53-6.32; p = .001), BK viremia (OR = 3.38; 95% CI = 1.70-6.71; p = .001), acute rejection (OR = 3.66; 95% CI = 2.44-5.49; p = .001), ABO-incompatibility (OR = 2.51; 95% CI = 1.57-4.01; p = .001), estimated glomerular filtration rate (eGFR) (MD = -14.52; 95% CI = -25.37- (-3.67); p = .009), lymphocyte count (MD = -.54; 95% CI = -.92- (-.16); p = .006) and anti-PJP prophylaxis (OR = .53; 95% CI = .28-.98; p = .04) were significantly associated with PJP occurrence. CONCLUSION Our findings suggest that transplantation age greater than 50 years old, CMV infection, BK viremia, acute rejection, ABO-incompatibility, decreased eGFR and lymphopenia were risk factors for PJP.
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Affiliation(s)
- Bingjie Cheng
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chang Qi
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Senlin Zhang
- Department of Hematology and Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Xiaowen Wang
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Van Den Daele C, Martiny D, Etienne I, Kemlin D, Roussoulières A, Sokolow Y, Germanova D, Gustot T, Nobile L, Hites M. Monocentric, Retrospective Study on Infectious Complications within One Year after Solid-Organ Transplantation at a Belgian University Hospital. Microorganisms 2024; 12:755. [PMID: 38674699 PMCID: PMC11052249 DOI: 10.3390/microorganisms12040755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
The epidemiology, diagnostic methods and management of infectious complications after solid-organ transplantation (SOT) are evolving. The aim of our study is to describe current infectious complications in the year following SOT and risk factors for their development and outcome. We conducted a retrospective study in adult SOT recipients in a Belgian university hospital between 2018 and 2019. We gathered demographic characteristics, comorbidities leading to transplantation, clinical, microbiological, surgery-specific and therapeutic data concerning infectious episodes, and survival status up to one year post-transplantation. Two-hundred-and-thirty-one SOT recipients were included (90 kidneys, 79 livers, 35 lungs, 19 hearts and 8 multiple organs). We observed 381 infections in 143 (62%) patients, due to bacteria (235 (62%)), viruses (67 (18%)), and fungi (32 (8%)). Patients presented a median of two (1-5) infections, and the first infection occurred during the first six months. Nineteen (8%) patients died, eleven (58%) due to infectious causes. Protective factors identified against developing infection were obesity [OR [IC]: 0.41 [0.19-0.89]; p = 0.025] and liver transplantation [OR [IC]: 0.21 [0.07-0.66]; p = 0.007]. Risk factors identified for developing an infection were lung transplantation [OR [IC]: 6.80 [1.17-39.36]; p = 0.032], CMV mismatch [OR [IC]: 3.53 [1.45-8.64]; p = 0.006] and neutropenia [OR [IC]: 2.87 [1.27-6.47]; p = 0.011]. Risk factors identified for death were inadequate cytomegalovirus prophylaxis, infection severity and absence of pneumococcal vaccination. Post-transplant infections were common. Addressing modifiable risk factors is crucial, such as pneumococcal vaccination.
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Affiliation(s)
- Céline Van Den Daele
- Clinic of Infectious Diseases, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium;
| | - Delphine Martiny
- Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), Department of Microbiologie, Faculté de Médecine et Pharmacie, Université de Mons (UMONS), 7000 Mons, Belgium;
| | - Isabelle Etienne
- Department of Pneumology, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium;
| | - Delphine Kemlin
- Department of Nephrology, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium;
| | - Ana Roussoulières
- Department of Cardiology, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium;
| | - Youri Sokolow
- Department of Thoracic Surgery, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium;
| | - Desislava Germanova
- Department of Digestive Surgery, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium;
| | - Thierry Gustot
- Department of Transplantation, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium;
| | - Leda Nobile
- Department of Intensive Care Unit, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium;
| | - Maya Hites
- Clinic of Infectious Diseases, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium;
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Esnault V, Hoisnard L, Peiffer B, Fihman V, Fourati S, Angebault C, Champy C, Gallien S, Attias P, Morel A, Grimbert P, Melica G, Matignon M. Beyond the First Year: Epidemiology and Management of Late-Onset Opportunistic Infections After Kidney Transplantation. Transpl Int 2024; 37:12065. [PMID: 38468638 PMCID: PMC10926380 DOI: 10.3389/ti.2024.12065] [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: 09/18/2023] [Accepted: 02/13/2024] [Indexed: 03/13/2024]
Abstract
Late opportunistic infections (OI) occurring beyond the first year after kidney transplantation (KT) are poorly described and not targeted by prophylactic strategies. We performed a ten-year retrospective monocentric cohort study describing epidemiology, risk factors and impact of late OI occurring 1 year after KT. We included clinically symptomatic OI requiring treatment besides BK virus nephropathy. Control groups included early OI occurring in the first year after KT, and KT recipients without OI since KT and alive with a functional allograft at 1 year. Among 1066 KT recipients, 185 (19.4%) presented a first episode of OI 21.0 (8.0-45.0) months after KT: 120 late OI (64.9%) and 65 early OI (35.1%). Late OI were mainly viral (N = 83, 69.2%), mostly herpes zoster (HZ) (N = 36, 43.4%). Pneumocystis represented most late fungal infections (N = 12/25, 48%). Compared to early OI, we reported more pneumocystis (p = 0.002) and less invasive aspergillosis (p = 0.01) among late OI. Patients with late OI were significatively younger at KT (54.0 ± 13.3 vs. 60.2 ± 14.3 years, p = 0.05). Patient and allograft survival rates between late OI and control groups were similar. Only age was independently associated with mortality. While late OI were not associated with higher mortality or graft loss, implementing prophylactic strategies might prevent such infections.
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Affiliation(s)
- V. Esnault
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Maladies Infectieuses et d’Immunologie Clinique, Centre Hospitalo-Universitaire (CHU) Henri Mondor, Créteil, France
| | - L. Hoisnard
- Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, AP-HP, Henri Mondor Hospital, Créteil, France
- INSERM, Centre d’Investigation Clinique 1430, Créteil, France
- EpiDermE Epidemiology in Dermatology and Evaluation of Therapeutics, EA7379, Paris Est Créteil University UPEC, Créteil, France
| | - B. Peiffer
- AP-HP, Département Médico-Universitaire Médecine, CHU Henri Mondor, Créteil, France
| | - V. Fihman
- AP-HP, Service de Microbiologie, Département de Prévention, Diagnostic et Traitement des Infections, CHU Henri Mondor, Créteil, France
| | - S. Fourati
- AP-HP, Service de Microbiologie, Département de Prévention, Diagnostic et Traitement des Infections, CHU Henri Mondor, Créteil, France
| | - C. Angebault
- AP-HP, Service de Microbiologie, Département de Prévention, Diagnostic et Traitement des Infections, CHU Henri Mondor, Créteil, France
- EA DYNAMiC 7380, Faculté de Santé, University Paris-Est Créteil (UPEC), Ecole Nationale Vétérinaire d’Alfort (ENVA), USC Anses, Créteil, France
| | - C. Champy
- AP-HP, Service d’Urologie, CHU Henri Mondor, Créteil, France
| | - S. Gallien
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Maladies Infectieuses et d’Immunologie Clinique, Centre Hospitalo-Universitaire (CHU) Henri Mondor, Créteil, France
- EA DYNAMiC 7380, Faculté de Santé, University Paris-Est Créteil (UPEC), Ecole Nationale Vétérinaire d’Alfort (ENVA), USC Anses, Créteil, France
| | - P. Attias
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
| | - A. Morel
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
| | - P. Grimbert
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
- University of Paris-Est-Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Team 21, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - G. Melica
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Maladies Infectieuses et d’Immunologie Clinique, Centre Hospitalo-Universitaire (CHU) Henri Mondor, Créteil, France
| | - M. Matignon
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
- University of Paris-Est-Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Team 21, Institut Mondor de Recherche Biomédicale, Créteil, France
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Miyake K, Senoo S, Shiiba R, Itano J, Kimura G, Kawahara T, Tamura T, Kudo K, Kawamura T, Nakahara Y, Higo H, Himeji D, Takigawa N, Miyahara N. Pneumocystis jirovecii pneumonia mortality risk associated with preceding long-term steroid use for the underlying disease: A multicenter, retrospective cohort study. PLoS One 2024; 19:e0292507. [PMID: 38330061 PMCID: PMC10852346 DOI: 10.1371/journal.pone.0292507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/10/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVE Long-term steroid use increases the risk of developing Pneumocystis pneumonia (PcP), but there are limited reports on the relation of long-term steroid and PcP mortality. METHODS Retrospective multicenter study to identify risk factors for PcP mortality, including average steroid dose before the first visit for PcP in non-human immunodeficiency virus (HIV)-PcP patients. We generated receiver operating characteristic (ROC) curves for 90-day all-cause mortality and the mean daily steroid dose per unit body weight in the preceding 10 to 90 days in 10-day increments. Patients were dichotomized by 90-day mortality and propensity score-based stabilized inverse probability of treatment weighting (IPTW) adjusted covariates of age, sex, and underlying disease. Multivariate analysis with logistic regression assessed whether long-term corticosteroid use affected outcome. RESULTS Of 133 patients with non-HIV-PcP, 37 died within 90 days of initial diagnosis. The area under the ROC curve for 1-40 days was highest, and the optimal cutoff point of median adjunctive corticosteroid dosage was 0.34 mg/kg/day. Past steroid dose, underlying interstitial lung disease and emphysema, lower serum albumin and lower lymphocyte count, higher lactate dehydrogenase, use of therapeutic pentamidine and therapeutic high-dose steroids were all significantly associated with mortality. Underlying autoimmune disease, past immunosuppressant use, and a longer time from onset to start of treatment, were associated lower mortality. Logistic regression analysis after adjusting for age, sex, and underlying disease with IPTW revealed that steroid dose 1-40 days before the first visit for PcP (per 0.1 mg/kg/day increment, odds ratio 1.36 [95% confidence interval = 1.16-1.66], P<0.001), low lymphocyte counts, and high lactate dehydrogenase revel were independent mortality risk factor, while respiratory failure, early steroid, and sulfamethoxazole/trimethoprim for PcP treatment did not. CONCLUSION A steroid dose before PcP onset was strongly associated with 90-day mortality in non-HIV-PcP patients, emphasizing the importance of appropriate prophylaxis especially in this population.
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Affiliation(s)
- Kohei Miyake
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Satoru Senoo
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Ritsuya Shiiba
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Junko Itano
- Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Okayama, Japan
| | - Goro Kimura
- Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Okayama, Japan
| | - Tatsuyuki Kawahara
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Tomoki Tamura
- Department of Respiratory Medicine, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan
| | - Kenichiro Kudo
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Tetsuji Kawamura
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Yasuharu Nakahara
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Hisao Higo
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Daisuke Himeji
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Nagio Takigawa
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Nobuaki Miyahara
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Burzio C, Balzani E, Corcione S, Montrucchio G, Trompeo AC, Brazzi L. Pneumocystis jirovecii Pneumonia after Heart Transplantation: Two Case Reports and a Review of the Literature. Pathogens 2023; 12:1265. [PMID: 37887781 PMCID: PMC10610317 DOI: 10.3390/pathogens12101265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 10/28/2023] Open
Abstract
Post-transplant Pneumocystis jirovecii pneumonia (PcP) is an uncommon but increasingly reported disease among solid organ transplantation (SOT) recipients, associated with significant morbidity and mortality. Although the introduction of PcP prophylaxis has reduced its overall incidence, its prevalence continues to be high, especially during the second year after transplant, the period following prophylaxis discontinuation. We recently described two cases of PcP occurring more than one year after heart transplantation (HT) in patients who were no longer receiving PcP prophylaxis according to the local protocol. In both cases, the disease was diagnosed following the diagnosis of a viral illness, resulting in a significantly increased risk for PcP. While current heart transplantation guidelines recommend Pneumocystis jirovecii prophylaxis for up to 6-12 months after transplantation, after that period they only suggest an extended prophylaxis regimen in high-risk patients. Recent studies have identified several new risk factors that may be linked to an increased risk of PcP infection, including medication regimens and patient characteristics. Similarly, the indication for PcP prophylaxis in non-HIV patients has been expanded in relation to the introduction of new medications and therapeutic regimens for immune-mediated diseases. In our experience, the first patient was successfully treated with non-invasive ventilation, while the second required tracheal intubation, invasive ventilation, and extracorporeal CO2 removal due to severe respiratory failure. The aim of this double case report is to review the current timing of PcP prophylaxis after HT, the specific potential risk factors for PcP after HT, and the determinants of a prompt diagnosis and therapeutic approach in critically ill patients. We will also present a possible proposal for future investigations on indications for long-term prophylaxis.
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Affiliation(s)
- Carlo Burzio
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza di Torino Hospital, 10126 Torino, Italy; (C.B.); (G.M.); (A.C.T.); (L.B.)
| | - Eleonora Balzani
- Department of Surgical Science, University of Turin, 10124 Torino, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10124 Turin, Italy;
- School of Medicine, Tufts University, Boston, MA 02111, USA
| | - Giorgia Montrucchio
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza di Torino Hospital, 10126 Torino, Italy; (C.B.); (G.M.); (A.C.T.); (L.B.)
- Department of Surgical Science, University of Turin, 10124 Torino, Italy
| | - Anna Chiara Trompeo
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza di Torino Hospital, 10126 Torino, Italy; (C.B.); (G.M.); (A.C.T.); (L.B.)
| | - Luca Brazzi
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza di Torino Hospital, 10126 Torino, Italy; (C.B.); (G.M.); (A.C.T.); (L.B.)
- Department of Surgical Science, University of Turin, 10124 Torino, Italy
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7
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Sprute R, Nacov JA, Neofytos D, Oliverio M, Prattes J, Reinhold I, Cornely OA, Stemler J. Antifungal prophylaxis and pre-emptive therapy: When and how? Mol Aspects Med 2023; 92:101190. [PMID: 37207579 DOI: 10.1016/j.mam.2023.101190] [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] [Received: 01/07/2023] [Revised: 04/22/2023] [Accepted: 05/05/2023] [Indexed: 05/21/2023]
Abstract
The growing pool of critically ill or immunocompromised patients leads to a constant increase of life-threatening invasive infections by fungi such as Aspergillus spp., Candida spp. and Pneumocystis jirovecii. In response to this, prophylactic and pre-emptive antifungal treatment strategies have been developed and implemented for high-risk patient populations. The benefit by risk reduction needs to be carefully weighed against potential harm caused by prolonged exposure against antifungal agents. This includes adverse effects and development of resistance as well as costs for the healthcare system. In this review, we summarise evidence and discuss advantages and downsides of antifungal prophylaxis and pre-emptive treatment in the setting of malignancies such as acute leukaemia, haematopoietic stem cell transplantation, CAR-T cell therapy, and solid organ transplant. We also address preventive strategies in patients after abdominal surgery and with viral pneumonia as well as individuals with inherited immunodeficiencies. Notable progress has been made in haematology research, where strong recommendations regarding antifungal prophylaxis and pre-emptive treatment are backed by data from randomized controlled trials, whereas other critical areas still lack high-quality evidence. In these areas, paucity of definitive data translates into centre-specific strategies that are based on interpretation of available data, local expertise, and epidemiology. The development of novel immunomodulating anticancer drugs, high-end intensive care treatment and the development of new antifungals with new modes of action, adverse effects and routes of administration will have implications on future prophylactic and pre-emptive approaches.
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Affiliation(s)
- Rosanne Sprute
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Julia A Nacov
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Dionysios Neofytos
- Division of Infectious Diseases, Transplant Infectious Disease Service, University Hospital of Geneva, Geneva, Switzerland
| | - Matteo Oliverio
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Juergen Prattes
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Medical University of Graz, Department of Internal Medicine, Division of Infectious Disease, Excellence Center for Medical Mycology (ECMM), Graz, Austria
| | - Ilana Reinhold
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Zurich, Switzerland
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Jannik Stemler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.
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8
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Neofytos D, Stampf S, Hoessly LD, D’Asaro M, Tang GN, Boggian K, Hirzel C, Khanna N, Manuel O, Mueller NJ, Van Delden C. Bacteremia During the First Year After Solid Organ Transplantation: An Epidemiological Update. Open Forum Infect Dis 2023; 10:ofad247. [PMID: 37323422 PMCID: PMC10267299 DOI: 10.1093/ofid/ofad247] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/04/2023] [Indexed: 06/17/2023] Open
Abstract
Background There are limited contemporary data on the epidemiology and outcomes of bacteremia in solid organ transplant recipients (SOTr). Methods Using the Swiss Transplant Cohort Study registry from 2008 to 2019, we performed a retrospective nested multicenter cohort study to describe the epidemiology of bacteremia in SOTr during the first year post-transplant. Results Of 4383 patients, 415 (9.5%) with 557 cases of bacteremia due to 627 pathogens were identified. One-year incidence was 9.5%, 12.8%, 11.4%, 9.8%, 8.3%, and 5.9% for all, heart, liver, lung, kidney, and kidney-pancreas SOTr, respectively (P = .003). Incidence decreased during the study period (hazard ratio, 0.66; P < .001). One-year incidence due to gram-negative bacilli (GNB), gram-positive cocci (GPC), and gram-positive bacilli (GPB) was 5.62%, 2.81%, and 0.23%, respectively. Seven (of 28, 25%) Staphylococcus aureus isolates were methicillin-resistant, 2/67 (3%) enterococci were vancomycin-resistant, and 32/250 (12.8%) GNB produced extended-spectrum beta-lactamases. Risk factors for bacteremia within 1 year post-transplant included age, diabetes, cardiopulmonary diseases, surgical/medical post-transplant complications, rejection, and fungal infections. Predictors for bacteremia during the first 30 days post-transplant included surgical post-transplant complications, rejection, deceased donor, and liver and lung transplantation. Transplantation in 2014-2019, CMV donor-negative/recipient-negative serology, and cotrimoxazole Pneumocystis prophylaxis were protective against bacteremia. Thirty-day mortality in SOTr with bacteremia was 3% and did not differ by SOT type. Conclusions Almost 1/10 SOTr may develop bacteremia during the first year post-transplant associated with low mortality. Lower bacteremia rates have been observed since 2014 and in patients receiving cotrimoxazole prophylaxis. Variabilities in incidence, timing, and pathogen of bacteremia across different SOT types may be used to tailor prophylactic and clinical approaches.
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Affiliation(s)
- Dionysios Neofytos
- Correspondence: Dionysios Neofytos, MD, MPH, Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève 14, Switzerland (); or Christian van Delden, MD, Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève 14, Switzerland ()
| | - Susanne Stampf
- Clinic for Transplantation Immunology and Nephrology (Swiss Transplant Cohort Study), University Hospital of Basel, Basel, Switzerland
| | - Linard D Hoessly
- Clinic for Transplantation Immunology and Nephrology (Swiss Transplant Cohort Study), University Hospital of Basel, Basel, Switzerland
| | - Matilde D’Asaro
- Transplant Infectious Diseases Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Gael Nguyen Tang
- Transplant Infectious Diseases Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Katia Boggian
- Division of Infectious Diseases, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Cedric Hirzel
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | - Oriol Manuel
- Division of Infectious Diseases, University Hospital of Vaud, Lausanne, Switzerland
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Switzerland
| | - Christian Van Delden
- Correspondence: Dionysios Neofytos, MD, MPH, Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève 14, Switzerland (); or Christian van Delden, MD, Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève 14, Switzerland ()
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9
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Trubin PA, Azar MM. Current Concepts in the Diagnosis and Management of Pneumocystis Pneumonia in Solid Organ Transplantation. Infect Dis Clin North Am 2023:S0891-5520(23)00026-0. [PMID: 37142510 DOI: 10.1016/j.idc.2023.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Pneumocystis infection manifests predominantly as an interstitial pneumonia in immunocompromised patients. Diagnostic testing in the appropriate clinical context can be highly sensitive and specific and involves radiographic imaging, fungal biomarkers, nucleic acid amplification, histopathology, and lung fluid or tissue sampling. Trimethoprim-sulfamethoxazole remains the first-choice agent for treatment and prophylaxis. Investigation continues to promote a deeper understanding of the pathogen's ecology, epidemiology, host susceptibility, and optimal treatment and prevention strategies in solid organ transplant recipients.
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Affiliation(s)
- Paul A Trubin
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, 135 College Street, New Haven, CT 06510, USA.
| | - Marwan M Azar
- Department of Medicine, Section of Infectious Diseases; Department of Laboratory Medicine; Yale School of Medicine, 135 College Street, New Haven, CT 06510, USA
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10
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Lee HJ, Kwon HW, Baek JK, Park CH, Seo HK, Hong SK. Risk factors for Pneumocystis pneumonia with acute respiratory failure among kidney transplant recipients. BMC Nephrol 2023; 24:31. [PMID: 36759777 PMCID: PMC9912528 DOI: 10.1186/s12882-023-03071-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
PURPOSE One of the rare life-threatening fungal infections is pneumocystis pneumonia (PCP). Immunocompromised patients are the main vulnerable population. We investigate the risk factors associated with the development of severe PCP infection with acute respiratory failure after kidney transplantation. MATERIALS AND METHODS This is a retrospective, single-center, case-control study. PCP patients who are kidney transplant recipients and required high-flow oxygen support or mechanical ventilation between March 2009 and February 2017 were included in the study. The comparison was conducted between the non-severe and severe PCP groups. To identify associated risk factors, we performed univariate and multivariate logistic regression. RESULTS Among the total 2,330 kidney transplant recipients, 50 patients (2.1%) were diagnosed with PCP. Of these, 27 patients (54.0%) had severe PCP and 7 patients (14.0%) died, all of them were severe PCP patients. In the severe PCP group, the time from transplantation to PCP diagnosis (23.4 ± 24.9 months vs. 13.7 ± 9.9 months, p = 0.090) was insignificantly faster than in the non-severe PCP group. According to multiple logistic regression analysis, the significant risk factors associated with severe PCP were as follows, age (odds ratios (OR) 1.07; 95% confidence intervals (CI): 1.01-1.13; p = 0.027), time from transplantation to PCP diagnosis (odds ratios (OR) 0.92; 95% confidence intervals (CI): 0.86-0.99; p = 0.024), lymphopenia (OR 6.48; 95% CI: 1.05-40.09; p = 0.044), and history of acute rejection within 1 year (OR 8.28; 95% CI: 1.29-53.20; p = 0.026). CONCLUSION Patients who have lymphopenia at the time of hospital admission or have been recently treated with acute rejection are more likely to progress to severe PCP, requiring intensive monitoring and aggressive treatment.
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Affiliation(s)
- Hak-Jae Lee
- grid.413967.e0000 0001 0842 2126Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, 05505 Seoul, Korea
| | - Hyun-Wook Kwon
- grid.413967.e0000 0001 0842 2126Division of Kidney and Pancreas Transplantation, Department of Surgery, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
| | - Jong-Kwan Baek
- grid.413967.e0000 0001 0842 2126Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, 05505 Seoul, Korea
| | - Chan-Hee Park
- grid.413967.e0000 0001 0842 2126Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, 05505 Seoul, Korea
| | - Hye-Kyung Seo
- grid.413967.e0000 0001 0842 2126Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, 05505 Seoul, Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, 05505, Seoul, Korea.
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11
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Risk of Pneumocystis jirovecii Pneumonia among Solid Organ Transplant Recipients: A Population-Based Study. J Fungi (Basel) 2022; 9:jof9010023. [PMID: 36675844 PMCID: PMC9866281 DOI: 10.3390/jof9010023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022] Open
Abstract
Few studies have comprehensively investigated the occurrence of Pneumocystis jirovecii pneumonia (PJP) among solid organ transplant (SOT) recipients. This study investigated the risk of PJP after organ transplantation. Each patient who underwent SOT was propensity-score-matched with four non-SOT individuals in terms of sex, age, insured salary, urbanization of residence, comorbidities, and year of enrollment. When considering the 3-year follow-up, the patients who had undergone SOT were at higher risk of PJP, with the adjusted odds ratio (aOR) being 17.18 (95% confidence interval (CI): 8.80-33.53). Furthermore, SOT recipients were also at higher PJP risk than the patients without SOT at 6 months, 1 year, and 2 years, with the aOR being 22.64 (95% CI: 7.53-68.11), 26.19 (95% CI: 9.89-69.37), and 23.06 (95% CI: 10.23-51.97), respectively. Patients comorbid with HIV infection, hematological malignancies, or vasculitis were at higher risk (aOR = 59.08, 95% CI = 20.30-171.92), (aOR = 11.94, 95% CI = 5.36-26.61), and (aOR = 21.72, 95% CI = 2.41-195.81), respectively. The recipients of SOT were at higher risk of PJP, and PJP can develop at any stage after transplantation. SOT recipients comorbid with HIV, hematologic malignancies, or vasculitis were at higher PJP risk.
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12
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Apostolopoulou A, Fishman JA. The Pathogenesis and Diagnosis of Pneumocystis jiroveci Pneumonia. J Fungi (Basel) 2022; 8:1167. [PMID: 36354934 PMCID: PMC9696632 DOI: 10.3390/jof8111167] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 07/29/2023] Open
Abstract
Pneumocystis jiroveci remains an important fungal pathogen in immunocompromised hosts. The environmental reservoir remains unknown. Pneumonia (PJP) results from airborne transmission, including in nosocomial clusters, or with reactivation after an inadequately treated infection. Pneumocystis pneumonia most often occurs within 6 months of organ transplantation, with intensified or prolonged immunosuppression, notably with corticosteroids and following cytomegalovirus (CMV) infections. Infection may be recognized during recovery from neutropenia and lymphopenia. Invasive procedures may be required for early diagnosis and therapy. Despite being a well-established entity, aspects of the pathogenesis of PJP remain poorly understood. The goal of this review is to summarize the data on the pathogenesis of PJP, review the strengths and weaknesses of the pertinent diagnostic modalities, and discuss areas for future research.
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Affiliation(s)
- Anna Apostolopoulou
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Jay A. Fishman
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- MGH Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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13
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Bielicki JA, Manuel O. Antimicrobial stewardship programs in solid-organ transplant recipients in Switzerland. Transpl Infect Dis 2022; 24:e13902. [PMID: 36254517 PMCID: PMC9788035 DOI: 10.1111/tid.13902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 06/29/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Antimicrobial stewardship programs (ASPs) are essential for minimizing the emergence of antimicrobial resistance, while improving patient outcomes. The current status of ASP in the field of organ transplantation in Switzerland has not been well characterized. METHODS We describe in this article the current status of ASP and discuss challenges and opportunities of implementing ASP dedicated to solid-organ transplant (SOT) recipients in Switzerland. RESULTS ASP have been implemented in the Swiss healthcare system over the last years, although specific strategies for SOT recipients are mostly based on transplant infectious diseases (TID) consultations rather than structured institutional interventions. Even so, there is a unique opportunity for developing a successful ASP in Switzerland that also specifically addresses areas of practice relevant to SOT recipients. This is due to the existent network of TID specialists in close collaboration with transplant physicians, the small number of centers involved in the care of transplant recipients, and the development of the Swiss Transplant Cohort Study (STCS), a prospective nationwide cohort of SOT recipients in Switzerland. The STCS can identify actual challenges through the updated reports on the epidemiology on transplant infections, accurately monitor the impact of potential antimicrobial stewardship interventions, and represent an opportunity for nesting of pragmatic randomized controlled trials to address key questions about optimized antibiotic use for SOT recipients. CONCLUSIONS Although ASP in SOT recipients rely more on specific TID consultations than in general antimicrobial stewardship teams, we identified several opportunities for the implementation of a successful ASP in Switzerland.
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Affiliation(s)
- Julia A. Bielicki
- Department of Paediatric PharmacologyUniversity of Basel Children's Hospital (UKBB)BaselSwitzerland,Department of Infectious Diseases and VaccinologyUniversity of Basel Children's Hospital (UKBB)BaselSwitzerland
| | - Oriol Manuel
- Infectious Diseases Service and Transplantation CenterLausanne University Hospital (CHUV) and University of LausanneLausanneSwitzerland
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14
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Zou J, Wang T, Qiu T, Zhou J, Chen Z, Ma X, Jin Z, Xu Y, Zhang L. Single-center retrospective analysis of Pneumocystis jirovecii pneumonia in patients after deceased donor renal transplantation. Transpl Immunol 2022; 72:101593. [PMID: 35367619 DOI: 10.1016/j.trim.2022.101593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the clinical features, early diagnosis, and treatment methods of Pneumocystis jirovecii pneumonia (PJP) after renal transplantation (RT). METHODS We retrospectively analyzed the clinical data of 80 patients with confirmed PJP who underwent RT between 2018 and 2021 in our hospital. RESULTS In the present study, the incidence of PJP was 6.2% (80/1300). A 50% of cases (40 out of 80 patients) had developed a PJP infection during the first 6 months after RT and 81.3% (65 out of 80 patients) within 12 months. The median onset time of PJP was 6.5 months after RT. The most common symptom was fever (73.8%), followed by progressive dyspnea (51.3%) and dry cough (31.3%). In the initial phase of PJP, the most frequent CT finding was the presence of diffuse ground-grass shadows. In all, 27.5%, 37.5%, and 35% patients were diagnosed by induced sputum metagenomic next-generation sequencing (mNGS), peripheral blood mNGS, and characteristic clinical diagnostic features, respectively. The median 1,3-β-D-glucan level was 500 pg/mL, while the median C-reactive protein level was 63.4 mg/L. In most patients (83.8%), the procalcitonin levels were negative. The mean serum creatinine level was 171.9 ± 87.4 μmol/L. Of the 80 patients, 37 (46.2%) had coexisting cytomegalovirus (CMV) infection. All patients were treated with trimethoprim-sulfamethoxazole and third generation cephalosporin to prevent bacterial infection. The methylprednisolone dose (40-120 mg/d) varied according to illness. CONCLUSION PJP usually occurs within 1 year after RT, typically within 6 months. Fever, dry cough, and progressive dyspnea are the most common clinical symptoms. PJP should be highly suspected if the patient has clinical symptoms and diffuse, patchy, ground-glass opacities on CT in both lungs after RT within 1 year. Peripheral blood or induced sputum mNGS is helpful for early diagnosis of PJP. Trimethoprim-sulfamethoxazole is still the first choice for the treatment of PJP. Combined use of caspofungin can reduce the dose and adverse reactions of trimethoprim-sulfamethoxazole in theory.
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Affiliation(s)
- Jilin Zou
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Tianyu Wang
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Tao Qiu
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Jiangqiao Zhou
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Zhongbao Chen
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Xiaoxiong Ma
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Zeya Jin
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Yu Xu
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Long Zhang
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China.
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15
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Meyer AMJ, Sidler D, Hirzel C, Furrer H, Ebner L, Peters AA, Christe A, Huynh-Do U, Walti LN, Arampatzis S. Distinct Clinical and Laboratory Patterns of Pneumocystis jirovecii Pneumonia in Renal Transplant Recipients. J Fungi (Basel) 2021; 7:jof7121072. [PMID: 34947054 PMCID: PMC8707918 DOI: 10.3390/jof7121072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/30/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022] Open
Abstract
Late post-transplant Pneumocystis jirovecii pneumonia (PcP) has been reported in many renal transplant recipients (RTRs) centers using universal prophylaxis. Specific features of PcP compared to other respiratory infections in the same population are not well reported. We analyzed clinical, laboratory, administrative and radiological data of all confirmed PcP cases between January 2009 and December 2014. To identify factors specifically associated with PcP, we compared clinical and laboratory data of RTRs with non-PcP. Over the study period, 36 cases of PcP were identified. Respiratory distress was more frequent in PcP compared to non-PcP (tachypnea: 59%, 20/34 vs. 25%, 13/53, p = 0.0014; dyspnea: 70%, 23/33 vs. 44%, 24/55, p = 0.0181). In contrast, fever was less frequent in PcP compared to non-PcP pneumonia (35%, 11/31 vs. 76%, 42/55, p = 0.0002). In both cohorts, total lymphocyte count and serum sodium decreased, whereas lactate dehydrogenase (LDH) increased at diagnosis. Serum calcium increased in PcP and decreased in non-PcP. In most PcP cases (58%, 21/36), no formal indication for restart of PcP prophylaxis could be identified. Potential transmission encounters, suggestive of interhuman transmission, were found in 14/36, 39% of patients. Interhuman transmission seems to contribute importantly to PcP among RTRs. Hypercalcemia, but not elevated LDH, was associated with PcP when compared to non-PcP.
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Affiliation(s)
- Andreas M. J. Meyer
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.M.J.M.); (D.S.); (U.H.-D.); (S.A.)
| | - Daniel Sidler
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.M.J.M.); (D.S.); (U.H.-D.); (S.A.)
| | - Cédric Hirzel
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (C.H.); (H.F.)
| | - Hansjakob Furrer
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (C.H.); (H.F.)
| | - Lukas Ebner
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (L.E.); (A.A.P.); (A.C.)
| | - Alan A. Peters
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (L.E.); (A.A.P.); (A.C.)
| | - Andreas Christe
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (L.E.); (A.A.P.); (A.C.)
| | - Uyen Huynh-Do
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.M.J.M.); (D.S.); (U.H.-D.); (S.A.)
| | - Laura N. Walti
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (C.H.); (H.F.)
- Correspondence:
| | - Spyridon Arampatzis
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.M.J.M.); (D.S.); (U.H.-D.); (S.A.)
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16
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Andreasen PB, Rezahosseini O, Møller DL, Wareham NE, Thomsen MT, Houmami R, Knudsen AD, Knudsen J, Kurtzhals JAL, Rostved AA, Pedersen CR, Rasmussen A, Nielsen SD. Pneumocystis jirovecii pneumonia in liver transplant recipients in an era of routine prophylaxis. IMMUNITY INFLAMMATION AND DISEASE 2021; 10:93-100. [PMID: 34713963 PMCID: PMC8669693 DOI: 10.1002/iid3.546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/22/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) is an opportunistic infection in organ transplant recipients that may be prevented by antibiotic prophylaxis. We aimed to investigate the incidence rate (IR) of PCP and the related hospitalization and mortality rates in liver transplant recipients in an era of routine prophylaxis. METHODS We included all adult liver transplant recipients transplanted at Rigshospitalet between January 1, 2011 and October 1, 2019. Microbiology data were obtained from the Danish Microbiology Database (MiBa), a national database containing all data from all Departments of Clinical Microbiology in Denmark receiving samples from both hospitals and general practices. According to local guidelines, PCP prophylaxis was initiated 1 week posttransplantation and discontinued after 6 months or sooner in patients experiencing side effects. RESULTS We included 343 liver transplant recipients with 1153 person-years of follow-up (PYFU), of which 269 (78%) received PCP prophylaxis during the first 6 months posttransplantation. Seven (2%) recipients were diagnosed with PCP during follow-up. In the first 6 months posttransplantation and in 269 transplant recipients who received prophylaxis there were zero PCP events while the IR was 32 (95% confidence interval [CI] 2.9-148) per 1000 PYFU in 74 recipient who did not receive prophylaxis. During 7th to 12th month posttransplantation the IR was 20 (95% CI: 5.5-53) per 1000 PYFU. All seven (100%) recipients diagnosed with PCP were hospitalized, however none died. CONCLUSIONS PCP was not detected in liver transplant recipients while on prophylaxis. Though, it worth mentioning that two out of the seven PCP patients received high-dose prednisolone before the PCP event. All liver transplant recipients with PCP were hospitalized, but none died. Randomized clinical trials to determine the optimal duration of prophylaxis are warranted.
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Affiliation(s)
- Philip B Andreasen
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Omid Rezahosseini
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dina L Møller
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Neval E Wareham
- Centre of Excellence for Personalized Medicine of Infectious Complications in Immune Deficiency, Rigshospitalet, Copenhagen, Denmark
| | - Magda T Thomsen
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ranya Houmami
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Andreas D Knudsen
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jenny Knudsen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jørgen A L Kurtzhals
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Andreas A Rostved
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christian R Pedersen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Susanne D Nielsen
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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17
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Wilmes D, Coche E, Rodriguez-Villalobos H, Kanaan N. Fungal pneumonia in kidney transplant recipients. Respir Med 2021; 185:106492. [PMID: 34139578 DOI: 10.1016/j.rmed.2021.106492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
Fungal pneumonia is a dreaded complication encountered after kidney transplantation, complicated by increased mortality and often associated with graft failure. Diagnosis can be challenging because the clinical presentation is non-specific and diagnostic tools have limited sensitivity and specificity in kidney transplant recipients and must be interpreted in the context of the clinical setting. Management is difficult due to the increased risk of dissemination and severity, multiple comorbidities, drug interactions and reduced immunosuppression which should be applied as an important adjunct to therapy. This review will focus on the main causes of fungal pneumonia in kidney transplant recipients including Pneumocystis, Aspergillus, Cryptococcus, mucormycetes and Histoplasma. Epidemiology, clinical presentation, laboratory and radiographic features, specific characteristics will be discussed with an update on diagnostic procedures and treatment.
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Affiliation(s)
- D Wilmes
- Division of Internal Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - E Coche
- Division of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - H Rodriguez-Villalobos
- Division of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - N Kanaan
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
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18
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Marinaki S, Vallianou K, Melexopoulou C, Lionaki S, Darema M, Lambrou P, Boletis I. The Changing Landscape of Pneumocystis Jiroveci Infection in Kidney Transplant Recipients: Single-Center Experience of Late-Onset Pneumocystis Pneumonia. Transplant Proc 2021; 53:1576-1582. [PMID: 33962778 DOI: 10.1016/j.transproceed.2021.03.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/10/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pneumocystis jiroveci pneumonia (PCP) is a life-threatening pulmonary infection after kidney transplantation (KTx). Its onset in the current era of modern immunosuppression and of routine use of universal PCP prophylaxis seems to differ from its onset in previous decades in terms of late onset with subtle clinical presentation, indicating a need for increased vigilance. METHODS We retrospectively studied all KTx recipients from our center who underwent bronchoscopy and bronchoalveolar lavage (BAL) between 2009 and 2018. Of these, all cases with confirmed PCP any time after the first post-KTx year were included in the analysis. RESULTS Among 60 patients with KTx who had undergone bronchoscopy and BAL, 12 cases with late-onset PCP were identified. PCP appeared late at a median of 10.8 (interquartile range, 2.4-15.8) years after transplantation. Patients' mean age was 59 years, and all were receiving stable low-dose immunosuppression. Most of the patients (67%) had received PCP prophylaxis after KTx. Five out of 12 patients (42%) had concomitant cytomegalovirus (CMV) reactivation at the time of PCP. In almost all cases, clinical presentation was mild. Treatment consisted of trimethoprim-sulfamethoxazole (TMP-SMX) and intravenous corticosteroid administration, and concomitant immunosuppression was temporarily reduced or withdrawn. Outcome was generally good. None of the patients developed respiratory insufficiency or required mechanical ventilation. One patient died as a result of sepsis, and 3 more with preexisting advanced chronic kidney disease subsequently lost their grafts. CONCLUSION Renal transplant recipients are at risk of late-onset PCP, even at a steady state of low-dose maintenance immunosuppression. Because of its subtle clinical presentation, high suspicion of the disease is warranted. Its early recognition and proper management are essential for a successful outcome.
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Affiliation(s)
- Smaragdi Marinaki
- Nephrology and Kidney Transplantation Clinic, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - Kalliopi Vallianou
- Nephrology and Kidney Transplantation Clinic, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece.
| | - Christina Melexopoulou
- Nephrology and Kidney Transplantation Clinic, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - Sophia Lionaki
- 2nd Department of Internal Medicine, Attikon Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - Maria Darema
- Nephrology and Kidney Transplantation Clinic, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | | | - Ioannis Boletis
- Nephrology and Kidney Transplantation Clinic, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
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19
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van Delden C, Stampf S, Hirsch HH, Manuel O, Meylan P, Cusini A, Hirzel C, Khanna N, Weisser M, Garzoni C, Boggian K, Berger C, Nadal D, Koller M, Saccilotto R, Mueller NJ. Burden and Timeline of Infectious Diseases in the First Year After Solid Organ Transplantation in the Swiss Transplant Cohort Study. Clin Infect Dis 2021; 71:e159-e169. [PMID: 31915816 PMCID: PMC7583409 DOI: 10.1093/cid/ciz1113] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/11/2019] [Indexed: 12/13/2022] Open
Abstract
Background The burden and timeline of posttransplant infections are not comprehensively documented in the current era of immunosuppression and prophylaxis. Methods In this prospective study nested within the Swiss Transplant Cohort Study (STCS), all clinically relevant infections were identified by transplant–infectious diseases physicians in persons receiving solid organ transplant (SOT) between May 2008 and December 2014 with ≥12 months of follow-up. Results Among 3541 SOT recipients, 2761 (1612 kidney, 577 liver, 286 lung, 213 heart, and 73 kidney-pancreas) had ≥12 months of follow-up; 1520 patients (55%) suffered 3520 infections during the first year posttransplantation. Burden and timelines of clinically relevant infections differed between transplantations. Bacteria were responsible for 2202 infections (63%) prevailing throughout the year, with a predominance of Enterobacteriaceae (54%) as urinary pathogens in heart, lung, and kidney transplant recipients, and as digestive tract pathogens in liver transplant recipients. Enterococcus spp (20%) occurred as urinary tract pathogens in kidney transplant recipients and as digestive tract pathogens in liver transplant recipients, and Pseudomonas aeruginosa (9%) in lung transplant recipients. Among 1039 viral infections, herpesviruses predominated (51%) in kidney, liver, and heart transplant recipients. Among 263 fungal infections, Candida spp (60%) prevailed as digestive tract pathogens in liver transplant recipients. Opportunistic pathogens, including Aspergillus fumigatus (1.4%) and cytomegalovirus (6%), were rare, scattering over 12 months across all SOT recipients. Conclusions In the current era of immunosuppression and prophylaxis, SOT recipients experience a high burden of infections throughout the first year posttransplantation, with rare opportunistic pathogens and a predominance of bacteria.
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Affiliation(s)
- Christian van Delden
- Transplant Infectious Diseases Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Susanne Stampf
- Clinic for Transplantation Immunology and Nephrology (Swiss Transplant Cohort Study), University Hospital of Basel, Basel, Switzerland
| | - Hans H Hirsch
- Transplantation and Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland.,Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Oriol Manuel
- Infectious Diseases Service and Transplantation Center, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pascal Meylan
- Institute of Microbiology and Infectious Diseases Service, University Hospital and Medical School, Lausanne, Switzerland
| | - Alexia Cusini
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Cédric Hirzel
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nina Khanna
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Maja Weisser
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Christian Garzoni
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland.,Clinic of Internal Medicine and Infectious Diseases, Clinica Luganese, Lugano, Switzerland
| | - Katja Boggian
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Christoph Berger
- Division of Infectious Diseases and Hospital Epidemiology and Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - David Nadal
- Division of Infectious Diseases and Hospital Epidemiology and Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Michael Koller
- Clinic for Transplantation Immunology and Nephrology (Swiss Transplant Cohort Study), University Hospital of Basel, Basel, Switzerland
| | - Ramon Saccilotto
- Clinic for Transplantation Immunology and Nephrology (Swiss Transplant Cohort Study), University Hospital of Basel, Basel, Switzerland
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zürich, Switzerland
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20
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Weyant RB, Kabbani D, Doucette K, Lau C, Cervera C. Pneumocystis jirovecii: a review with a focus on prevention and treatment. Expert Opin Pharmacother 2021; 22:1579-1592. [PMID: 33870843 DOI: 10.1080/14656566.2021.1915989] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Pneumocystis jirovecii (PJ) is an opportunistic fungal pathogen that can cause severe pneumonia in immunocompromised hosts. Risk factors for Pneumocystis jirovecii pneumonia (PJP) include HIV, organ transplant, malignancy, certain inflammatory or rheumatologic conditions, and associated therapies and conditions that result in cell-mediated immune deficiency. Clinical signs of PJP are nonspecific and definitive diagnosis requires direct detection of the organism in lower respiratory secretions or tissue. First-line therapy for prophylaxis and treatment remains trimethoprim-sulfamethoxazole (TMP-SMX), though intolerance or allergy, and rarely treatment failure, may necessitate alternate therapeutics, such as dapsone, pentamidine, atovaquone, clindamycin, primaquine and most recently, echinocandins as adjunctive therapy. In people living with HIV (PLWH), adjunctive corticosteroid use in treatment has shown a mortality benefit.Areas covered: This review article covers the epidemiology, pathophysiology, diagnosis, microbiology, prophylaxis indications, prophylactic therapies, and treatments.Expert opinion: TMP-SMX has been first-line therapy for treating and preventing pneumocystis for decades. However, its adverse effects are not uncommon, particularly during treatment. Second-line therapies may be better tolerated, but often sacrifice efficacy. Echinocandins show some promise for new combination therapies; however, further studies are needed to define optimal antimicrobial therapy for PJP as well as the role of corticosteroids in those without HIV.
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Affiliation(s)
- R Benson Weyant
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dima Kabbani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Karen Doucette
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Cecilia Lau
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Carlos Cervera
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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21
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Efficacy and safety of trimethoprim-sulfamethoxazole for the prevention of pneumocystis pneumonia in human immunodeficiency virus-negative immunodeficient patients: A systematic review and meta-analysis. PLoS One 2021; 16:e0248524. [PMID: 33765022 PMCID: PMC7993619 DOI: 10.1371/journal.pone.0248524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/27/2021] [Indexed: 11/29/2022] Open
Abstract
Background Pneumocystis pneumonia (PCP) has a significant impact on the mortality of immunocompromised patients. It is not known whether the prophylactic application of trimethoprim-sulfamethoxazole (TMP-SMZ) can reduce the incidence of PCP and mortality in the human immunodeficiency virus (HIV)-negative immunodeficient population. The safety profile is also unknown. There have been few reports on this topic. The aim of this study was to systematically evaluate the efficacy and safety of the use of TMP-SMZ for the prevention of PCP in this population of patients from the perspective of evidence-based medicine. Methods A comprehensive search without restrictions on publication status or other parameters was conducted. Clinical randomized controlled trials (RCTs) or case-control trials (CCSs) of TMP-SMZ used for the prevention of PCP in HIV-negative immunocompromised populations were considered eligible. A meta-analysis was performed using the Mantel-Haenszel fixed-effects model or Mantel-Haenszel random-effects model, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and reported. Results Of the 2392 records identified, 19 studies (n = 4135 patients) were included. The efficacy analysis results indicated that the PCP incidence was lower in the TMP-SMZ group than in the control group (OR = 0.27, 95% CI (0.10, 0.77), p = 0.01); however, the rate of drug discontinuation was higher in the TMP-SMZ group than in the control group (OR = 14.31, 95% CI (4.78, 42.91), p<0.00001). In addition, there was no statistically significant difference in the rate of mortality between the two groups (OR = 0.54, 95% CI (0.21, 1.37), p = 0.19). The safety analysis results showed that the rate of adverse events (AEs) was higher in the TMP-SMZ group than in the control group (OR = 1.92, 95% CI (1.06, 3.47), p = 0.03). Conclusions TMP-SMZ has a better effect than other drugs or the placebo with regard to preventing PCP in HIV-negative immunocompromised individuals, but it may not necessarily reduce the rate of mortality, the rate of drug discontinuation or AEs. Due to the limitations of the research methodologies used, additional large-scale clinical trials and well-designed research studies are needed to identify more effective therapies for the prevention of PCP.
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22
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Peterson K, Berrigan L, Popovic K, Wiebe C, Sun S, Ho J. Lifelong, universal Pneumocystis jirovecii pneumonia prophylaxis: Patient uptake and adherence after kidney transplant. Transpl Infect Dis 2020; 23:e13509. [PMID: 33171008 DOI: 10.1111/tid.13509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/14/2020] [Accepted: 10/11/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PJP) is a significant cause of morbidity and mortality in transplant patients yet little is known about their adherence to prophylaxis. The goal of this study was to evaluate patient uptake and long-term adherence after implementing universal, lifelong PJP prophylaxis. MATERIALS AND METHODS This retrospective cohort study evaluated an adult kidney transplant program 18-months after initiating trimethoprim-sulfamethoxazole (TMP-SMX) 80/400 mg thrice-weekly following a cluster of PJP cases. The protocol incorporated multi-modal patient education and drug tolerability strategies to improve adherence, including a modified re-challenge strategy for TMP-SMX intolerance. Adherence was independently confirmed by the transplant pharmacist and nurse for each patient, with an a priori target ≥ 75% population on prophylaxis. RESULTS Initial uptake was high with 237/250 (94.8%) patients starting prophylaxis. Long-term maintenance was high with 192/237 (81.0%) patients remaining on prophylaxis at 18-months. Of the remaining 45 patients who initiated prophylaxis, 36/237 (15.2%) were non-adherent and 9/237 (3.8%) discontinued prophylaxis by 18-months. Reasons for non-adherence included gastrointestinal upset, fear of drug reactions and cost; but the majority of reasons were not delineated by the patients (31/36, 86.1%). There was a statistically significant increase in serum creatinine 3.3 µmol/L (0.3-6.3 µmol/L 95% CI) and potassium 0.08 mmol/L (0.03-0.15 mmol/L 95% CI) in those prescribed TMP-SMX with only 3/237 (1.3%) patients discontinuing TMP-SMX for an increase in creatinine. CONCLUSION High rates of patient uptake (94.8%) and long-term adherence (81.0%) were observed after implementing universal lifelong PJP prophylaxis. This may be due in part to the in-depth patient education and drug tolerability strategies employed.
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Affiliation(s)
| | - Liam Berrigan
- Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | | | - Christopher Wiebe
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Department of Immunology, University of Manitoba, Winnipeg, MB, Canada.,Shared Health Services Manitoba, Winnipeg, MB, Canada
| | - Siyao Sun
- Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Julie Ho
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
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23
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Fortea JI, Cuadrado A, Puente Á, Álvarez Fernández P, Huelin P, Álvarez Tato C, García Carrera I, Cobreros M, Cagigal Cobo ML, Calvo Montes J, Ruiz de Alegría Puig C, Rodríguez SanJuán JC, Castillo Suescun FJ, Fernández Santiago R, Echeverri Cifuentes JA, Casafont F, Crespo J, Fábrega E. Is Routine Prophylaxis Against Pneumocystis jirovecii Needed in Liver Transplantation? A Retrospective Single-Centre Experience and Current Prophylaxis Strategies in Spain. J Clin Med 2020; 9:jcm9113573. [PMID: 33171962 PMCID: PMC7694638 DOI: 10.3390/jcm9113573] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/19/2022] Open
Abstract
In liver transplant (LT) recipients, Pneumocystis jirovecii pneumonia (PJP) is most frequently reported before 1992 when immunosuppressive regimens were more intense. It is uncertain whether universal PJP prophylaxis is still applicable in the contemporary LT setting. We aimed to examine the incidence of PJP in LT recipients followed at our institution where routine prophylaxis has never been practiced and to define the prophylaxis strategies currently employed among LT units in Spain. All LT performed from 1990 to October 2019 were retrospectively reviewed and Spanish LT units were queried via email to specify their current prophylaxis strategy. During the study period, 662 LT procedures were carried out on 610 patients. Five cases of PJP were identified, with only one occurring within the first 6 months. The cumulative incidence and incidence rate were 0.82% and 0.99 cases per 1000 person transplant years. All LT units responded, the majority of which provide prophylaxis (80%). Duration of prophylaxis, however, varied significantly. The low incidence of PJP in our unprophylaxed cohort, with most cases occurring beyond the usual recommended period of prophylaxis, questions a one-size-fits-all approach to PJP prophylaxis. A significant heterogeneity in prophylaxis strategies exists among Spanish LT centres.
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Affiliation(s)
- José Ignacio Fortea
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (A.C.); (Á.P.); (P.Á.F.); (P.H.); (C.Á.T.); (I.G.C.); (M.C.); (F.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
- Correspondence: or ; Tel./Fax: +34-(94)-2202520 (ext. 72929)
| | - Antonio Cuadrado
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (A.C.); (Á.P.); (P.Á.F.); (P.H.); (C.Á.T.); (I.G.C.); (M.C.); (F.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Ángela Puente
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (A.C.); (Á.P.); (P.Á.F.); (P.H.); (C.Á.T.); (I.G.C.); (M.C.); (F.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Paloma Álvarez Fernández
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (A.C.); (Á.P.); (P.Á.F.); (P.H.); (C.Á.T.); (I.G.C.); (M.C.); (F.C.); (J.C.); (E.F.)
| | - Patricia Huelin
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (A.C.); (Á.P.); (P.Á.F.); (P.H.); (C.Á.T.); (I.G.C.); (M.C.); (F.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Carmen Álvarez Tato
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (A.C.); (Á.P.); (P.Á.F.); (P.H.); (C.Á.T.); (I.G.C.); (M.C.); (F.C.); (J.C.); (E.F.)
| | - Inés García Carrera
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (A.C.); (Á.P.); (P.Á.F.); (P.H.); (C.Á.T.); (I.G.C.); (M.C.); (F.C.); (J.C.); (E.F.)
| | - Marina Cobreros
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (A.C.); (Á.P.); (P.Á.F.); (P.H.); (C.Á.T.); (I.G.C.); (M.C.); (F.C.); (J.C.); (E.F.)
| | - María Luisa Cagigal Cobo
- Department of Pathological Anatomy, University Hospital Marqués de Valdecilla. 39008 Santander, Spain;
| | - Jorge Calvo Montes
- Department of Microbiology, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (J.C.M.); (C.R.d.A.P.)
| | - Carlos Ruiz de Alegría Puig
- Department of Microbiology, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (J.C.M.); (C.R.d.A.P.)
| | - Juan Carlos Rodríguez SanJuán
- Department of General Surgery, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (J.C.R.S.); (F.J.C.S.); (R.F.S.); (J.A.E.C.)
| | - Federico José Castillo Suescun
- Department of General Surgery, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (J.C.R.S.); (F.J.C.S.); (R.F.S.); (J.A.E.C.)
| | - Roberto Fernández Santiago
- Department of General Surgery, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (J.C.R.S.); (F.J.C.S.); (R.F.S.); (J.A.E.C.)
| | - Juan Andrés Echeverri Cifuentes
- Department of General Surgery, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (J.C.R.S.); (F.J.C.S.); (R.F.S.); (J.A.E.C.)
| | - Fernando Casafont
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (A.C.); (Á.P.); (P.Á.F.); (P.H.); (C.Á.T.); (I.G.C.); (M.C.); (F.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Javier Crespo
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (A.C.); (Á.P.); (P.Á.F.); (P.H.); (C.Á.T.); (I.G.C.); (M.C.); (F.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Emilio Fábrega
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (A.C.); (Á.P.); (P.Á.F.); (P.H.); (C.Á.T.); (I.G.C.); (M.C.); (F.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
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24
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Kaminski H, Belliere J, Burguet L, Del Bello A, Taton B, Poirot-Mazères S, Accoceberry I, Delhaes L, Visentin J, Gregori M, Iriart X, Charpentier E, Couzi L, Kamar N, Merville P. Identification of Predictive Markers and Outcomes of Late-onset Pneumocystis jirovecii Pneumonia in Kidney Transplant Recipients. Clin Infect Dis 2020; 73:e1456-e1463. [DOI: 10.1093/cid/ciaa1611] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/19/2020] [Indexed: 12/18/2022] Open
Abstract
Abstract
Background
In the era of prophylaxis, Pneumocystis pneumonia (PCP) has become a late-onset opportunistic infection requiring indications for prolonged prophylaxis to be defined. The primary objective of our study was therefore to evaluate risk factors associated with late-onset PCP. The secondary objective was to assess the impact of this infection on graft and patient survival.
Methods
We conducted a French case-control study in Bordeaux and Toulouse center by matching 1 case to 1–2 controls from the same center based on the transplant date and the type of induction treatment.
Results
Seventy cases and 134 controls were included. PCP occurred at a median of 3 years after transplantation. The total lymphocyte count and CD4+ and CD8+ T-lymphocyte values were lower in the cases than in their matched controls on the day of infection and annually up to 4 years earlier. The covariables independently associated with PCP were the total lymphocyte count 1 year before Pneumocystis, mTOR inhibitors used as maintenance immunosuppressive drugs, and the administration of corticosteroid boluses used in acute rejection. A total lymphocyte count threshold <1000/µL offered the best predictive value for infection occurrence. PCP was associated with high incidence of graft loss and patient death (30% and 17% respectively, 3 years after PCP).
Conclusions
Pneumocystis pneumonia has dramatic consequences in kidney transplant recipients; a targeted prophylaxis based on simple criteria, such as chronic lymphopenia and/or history of corticosteroid boluses, could be useful to avoid life-threatening complications.
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Affiliation(s)
- Hannah Kaminski
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
- Centre National de Recherche Scientifique- Unité Mixte de Recherche 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Julie Belliere
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire Toulouse, Toulouse, France
- Paul Sabatier University, Toulouse, France
| | - Laure Burguet
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - Benjamin Taton
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
- Mathematics Modeling for Oncology, Institute of Bordeaux Mathematics, Institut National de Recherche en Informatique et en automatique-Unité Mixte de Recherche 5251, Talence, France
| | - Stéphane Poirot-Mazères
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
| | - Isabelle Accoceberry
- Laboratory of Parasitology-Mycology, Pellegrin University Hospital, Bordeaux, France
| | - Laurence Delhaes
- Laboratory of Parasitology-Mycology, Pellegrin University Hospital, Bordeaux, France
| | - Jonathan Visentin
- Centre National de Recherche Scientifique- Unité Mixte de Recherche 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
- Laboratory of Immunology and Immunogenetics, Pellegrin University Hospital, Bordeaux, France
| | - Marco Gregori
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
| | - Xavier Iriart
- Department of Parasitology-Mycology, Toulouse University Hospital Toulouse, France
- Institut national de la santé et de la recherche médicale U1043, Institut Fédératif de Recherche Bio-Médicale de Toulouse, Toulouse, France
| | - Elena Charpentier
- Department of Parasitology-Mycology, Toulouse University Hospital Toulouse, France
- Institut national de la santé et de la recherche médicale U1043, Institut Fédératif de Recherche Bio-Médicale de Toulouse, Toulouse, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
- Centre National de Recherche Scientifique- Unité Mixte de Recherche 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire Toulouse, Toulouse, France
- Paul Sabatier University, Toulouse, France
- Institut national de la santé et de la recherche médicale U1043, Institut Fédératif de Recherche Bio-Médicale de Toulouse, Toulouse, France
| | - Pierre Merville
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
- Centre National de Recherche Scientifique- Unité Mixte de Recherche 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
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25
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Cervera C, Yaskina M, Kabbani D. Targeted Prophylaxis to Prevent Late-Onset Pneumocystis jirovecii Pneumonia in Kidney Transplantation: Are We There Yet? Clin Infect Dis 2020; 73:e1464-e1466. [DOI: 10.1093/cid/ciaa1619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Carlos Cervera
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, Alberta, Canada
| | - Maryna Yaskina
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Dima Kabbani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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26
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Lum J, Echenique I, Athans V, Koval CE. Alternative pneumocystis prophylaxis in solid organ transplant recipients at two large transplant centers. Transpl Infect Dis 2020; 23:e13461. [PMID: 32894607 DOI: 10.1111/tid.13461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/03/2020] [Accepted: 08/20/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice for Pneumocystis jirovecii pneumonia (PJP) prophylaxis and has activity against other opportunistic infections (OIs) after solid organ transplant (SOT). We aimed to describe the incidence, reasons for and outcomes of use of alternative prophylactic agents (APAs) across SOT programs in our high volume centers. METHODS Solid organ transplant recipients (SOTRs) at our centers from 1/2015-12/2016 were identified. Pharmacy records identified APA (pentamidine, atovaquone, or dapsone) use within 1 year. Records were reviewed for allergies, laboratory values at APA initiation, diagnostic tests for TMP-SMX-preventable OIs, and APA side effects. RESULTS An APA was initiated in 105/1173 (8.9%) SOTRs. Of these, 51 (48.6%) were because of sulfonamide allergy recorded pre-SOT, mostly rash/hives (58.8%). The remaining 54 (51.4%) had TMP-SMX discontinued post-SOT, mostly for neutropenia (48%) and renal effects (34%). Differences occurred across programs, with kidney transplant never stopping TMP-SMX for renal issues. Of those changed to APAs post-transplant, 19 (35%) were later successfully re-challenged with TMP-SMX. With thresholds in mind, 67 (64%) received an APA unnecessarily, accounting for up to $100 000/y excess cost. Potential TMP-SMX-preventable OIs occurred in 7 (5 Nocardia; 2 PJP). APA side effects occurred in 14/105 (13.3%). CONCLUSIONS Use of APAs for PJP prophylaxis after SOT is less than previously reported but often unwarranted. Such decisions require scrutiny to avoid TMP-SMX-preventable OIs, cost and important APA side effects. Use of reasonable thresholds for cessation of TMP-SMX and data-driven approaches to re-challenge would substantially reduce APA use.
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Affiliation(s)
- Jessica Lum
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Ignacio Echenique
- Department of Infectious Diseases, Cleveland Clinic Florida, Weston, FL, USA.,Teva Pharmaceuticals, Miramar, FL, USA
| | - Vasilios Athans
- Department of Pharmacy, University of Pennsylvania, Philadelphia, PA, USA
| | - Christine E Koval
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
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27
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Buil JB, Meijer EFJ, Denning DW, Verweij PE, Meis JF. Burden of serious fungal infections in the Netherlands. Mycoses 2020; 63:625-631. [PMID: 32297377 PMCID: PMC7318641 DOI: 10.1111/myc.13089] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 12/19/2022]
Abstract
Background Fungal diseases have an ever‐increasing global disease burden, although regional estimates for specific fungal diseases are often unavailable or dispersed. Objectives Here, we report the current annual burden of life‐threatening and debilitating fungal diseases in the Netherlands. Methods The most recent available epidemiological data, reported incidence and prevalence of fungal diseases were used for calculations. Results Overall, we estimate that the annual burden of serious invasive fungal infections in the Netherlands totals 3 185 patients, including extrapulmonary or disseminated cryptococcosis (n = 9), pneumocystis pneumonia (n = 740), invasive aspergillosis (n = 1 283), chronic pulmonary aspergillosis (n = 257), invasive Candida infections (n = 684), mucormycosis (n = 15) and Fusarium keratitis (n = 8). Adding the prevalence of recurrent vulvo‐vaginal candidiasis (n = 220 043), allergic bronchopulmonary aspergillosis (n = 13 568) and severe asthma with fungal sensitisation (n = 17 695), the total debilitating burden of fungal disease in the Netherlands is 254 491 patients yearly, approximately 1.5% of the country's population. Conclusion We estimated the annual burden of serious fungal infections in the Netherlands at 1.5% of the population based on previously reported modelling of fungal rates for specific populations at risk. With emerging new risk groups and increasing reports on antifungal resistance, surveillance programmes are warranted to obtain more accurate estimates of fungal disease epidemiology and associated morbidity and mortality.
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Affiliation(s)
- Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Eelco F J Meijer
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands
| | - David W Denning
- The National Aspergillosis Center, Education and Research Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Global Action Fund for Fungal Infections, Geneva, Switzerland.,Manchester Fungal Infection Group, Core Technology Facility, The University of Manchester, Manchester, UK
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Center for Infectious Diseases Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Jacques F Meis
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands.,Bioprocess Engineering and Biotechnology Graduate Program, Federal University of Paraná, Curitiba, Brazil
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28
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Hanisch B, Sprott K, Ardura MI. Pneumocystis jirovecii and toxoplasmosis prophylaxis strategies among pediatric organ transplantation recipients: A US National Survey. Transpl Infect Dis 2020; 22:e13290. [PMID: 32278336 DOI: 10.1111/tid.13290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/10/2020] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
There is a paucity of pediatric-specific data to guide consensus recommendations for the prevention of Pneumocystis jirovecii pneumonia (PCP) and toxoplasmosis after solid organ transplantation. We surveyed pediatric transplantation providers and found considerable variability in prophylaxis strategies, despite current guideline recommendations that are based primarily on adult data.
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Affiliation(s)
- Benjamin Hanisch
- Division of Infectious Diseases, Department of Pediatrics, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Kathleen Sprott
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA
| | - Monica I Ardura
- Division of Infectious Diseases and Host Defense Program, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
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29
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Abstract
Transplants have become common with excellent patient and graft outcomes owing to advances in surgical technique, immunosuppression, and antimicrobial prophylaxis. In 2017, 34,770 solid organ transplants were performed in the United States. For solid organ transplant recipients, infection remains a common complication owing to the regimens required to prevent rejection. Opportunistic infections, which are infections that are generally of lower virulence within a healthy host but cause more severe and frequent disease in immunosuppressed individuals, typically occur in the period 1 month to 1 year after transplantation. This article focuses on opportunistic infections in the solid organ transplant recipient.
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Affiliation(s)
- Rebecca Kumar
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael G Ison
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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30
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Kim YH, Kim JY, Kim DH, Ko Y, Choi JY, Shin S, Jung JH, Park SK, Kim SH, Kwon H, Han DJ. Pneumocystis pneumonia occurrence and prophylaxis duration in kidney transplant recipients according to perioperative treatment with rituximab. BMC Nephrol 2020; 21:93. [PMID: 32160881 PMCID: PMC7066802 DOI: 10.1186/s12882-020-01750-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 02/28/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pneumocystis pneumonia (PCP) is a life-threatening fungal infection that can occur in kidney transplantation (KT) recipients. A growing number of KT recipients are receiving perioperative treatment with rituximab, which is associated with prolonged B-cell depletion and possible risk of PCP occurrence; however, the optimal prophylaxis duration according to rituximab treatment is yet unknown. We compared the occurrence of PCP and the duration of prophylaxis in KT recipients according to rituximab treatment. METHODS We retrospectively analyzed 2110 patients who underwent KT between January 2009 and December 2016, who were divided into non-Rituximab group (n = 1588, 75.3%) and rituximab group (n = 522, 24.7%). RESULTS In the rituximab group, the estimated number needed to treat (NNT) for prophylaxis prolongation from 6 to 12 months was 29.0 with a relative risk reduction of 90.0%. In the non-rituximab group, the estimated NNT value was 133.3 and the relative risk reduction was 66.4%. Rituximab treatment (hazard ratio (HR) = 3.09; P < 0.01) and acute rejection (HR = 2.19; P = 0.03) were significant risk factors for PCP in multivariate analysis. CONCLUSIONS Our results suggest that maintaining PCP prophylaxis for 12 months may be beneficial in KT recipients treated with rituximab for desensitization or acute rejection treatment.
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Affiliation(s)
- Young Hoon Kim
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Jee Yeon Kim
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Dong Hyun Kim
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Youngmin Ko
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Ji Yoon Choi
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Sung Shin
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Joo Hee Jung
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Su-Kil Park
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyunwook Kwon
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
| | - Duck Jong Han
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
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31
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Lee S, Park Y, Kim SG, Ko EJ, Chung BH, Yang CW. The impact of cytomegalovirus infection on clinical severity and outcomes in kidney transplant recipients with Pneumocystis jirovecii pneumonia. Microbiol Immunol 2020; 64:356-365. [PMID: 31994768 DOI: 10.1111/1348-0421.12778] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/21/2020] [Accepted: 01/25/2020] [Indexed: 02/06/2023]
Abstract
Cytomegalovirus (CMV) infection is associated with Pneumocystis jirovecii pneumonia (PJP) in kidney transplant recipients (KTRs), but its impact on clinical severity and outcomes in KTRs with PJP is unknown. We reviewed 1994 medical records of KTRs from January 1997 to March 2019. PJP or CMV infection was diagnosed by polymerase chain reaction or culturing using blood or respiratory specimens. We divided patients into PJP and PJP+CMV groups, and evaluated the clinical severity and outcomes. Fifty two patients had PJP (2.6%) in the whole study cohort. Among patients with PJP, 38 (73.1%) had PJP alone and 14 (26.9%) had combined PJP and CMV co-infection. The PJP+CMV group showed worse laboratory findings (serum albumin and C-reactive protein, P = 0.010 for both) and higher requirement of continuous renal replacement therapy than the PJP group (P = 0.050). The pneumonia severity was worse in the PJP+CMV group than in the PJP group (P < 0.05), and CMV infection was a high risk factor of pneumonia severity (odds ratio 16.0; P = 0.002). The graft function was worse in the PJP+CMV group (P < 0.001), and the incidence of graft failure was higher in the PJP+CMV group than in the PJP group (85.7% vs 36.8%; P < 0.001). Mortality was double in the PJP+CMV group than in the PJP group, but not statistically significant (21.4% vs 10.5%; P = 0.370). Our results show that approximately one in four patients with PJP after kidney transplantation develops CMV with increased clinical severity and risk of graft failure. The possibility of increased clinical severity and worse clinical outcomes by CMV co-infection should be considered in KTRs with PJP.
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Affiliation(s)
- Sua Lee
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Yohan Park
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Seong Gyu Kim
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Eun Jeong Ko
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Byung Ha Chung
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Chul Woo Yang
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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32
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White PL, Price JS, Backx M. Pneumocystis jirovecii Pneumonia: Epidemiology, Clinical Manifestation and Diagnosis. CURRENT FUNGAL INFECTION REPORTS 2019. [DOI: 10.1007/s12281-019-00349-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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33
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m-TOR inhibitors and risk of Pneumocystis pneumonia after solid organ transplantation: a systematic review and meta-analysis. Eur J Clin Pharmacol 2019; 75:1471-1480. [DOI: 10.1007/s00228-019-02730-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 07/20/2019] [Indexed: 12/22/2022]
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34
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Gudiol C, Sabé N, Carratalà J. Is hospital-acquired pneumonia different in transplant recipients? Clin Microbiol Infect 2019; 25:1186-1194. [PMID: 30986554 DOI: 10.1016/j.cmi.2019.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 12/25/2022]
Abstract
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are serious complications in transplant patients. The aim of this review is to summarize the evidence regarding nosocomial pneumonia in transplant recipients, including HAP in non-ventilated patients and VAP, and to identify future directions for improvement.A comprehensive literature search in the PubMed/MEDLINE database was performed. Articles written in English and published between 1990 and November 2018 were included. HAP/VAP in transplant patients usually occurs early post-transplant, particularly during neutropenia in haematopoietic stem cell transplant recipients. Bacteria are the leading cause of nosocomial pneumonia for both immunocompetent and transplant recipients, being Gram negative organisms, and especially Pseudomonas aeruginosa, highly prevalent. Multidrug-resistant bacteria are of special concern. Pneumonia in the transplant setting may be caused by opportunistic pathogens, and the differential diagnosis needs to be extended to other non-infectious complications. The most relevant opportunistic pathogens are Aspergillus fumigatus, Pneumocystis jirovecii and cytomegalovirus. Nevertheless, they are an exceptional cause of nosocomial pneumonia, and usually occur in severely immunosuppressed patients not receiving antimicrobial prophylaxis. Performing bronchoalveolar lavage may improve the rate of aetiological diagnosis, leading to a change in therapeutic management and improved outcomes. The optimal length of antibiotic therapy for bacterial HAP/VAP has not been well defined, but it should perhaps be longer than in the general population. Mortality associated with HAP/VAP is high. HAP/VAP in transplant patients is frequent and is associated with increased mortality. There is room for improvement in gaining knowledge about the management of HAP/VAP in this population.
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Affiliation(s)
- C Gudiol
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Spain; REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
| | - N Sabé
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Spain; REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
| | - J Carratalà
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Spain; REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain.
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35
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Diagnostic and therapeutic approach to infectious diseases in solid organ transplant recipients. Intensive Care Med 2019; 45:573-591. [PMID: 30911807 PMCID: PMC7079836 DOI: 10.1007/s00134-019-05597-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 03/06/2019] [Indexed: 12/18/2022]
Abstract
Purpose Prognosis of solid organ transplant (SOT) recipients has improved, mainly because of better prevention of rejection by immunosuppressive therapies. However, SOT recipients are highly susceptible to conventional and opportunistic infections, which represent a major cause of morbidity, graft dysfunction and mortality. Methods Narrative review. Results We cover the current epidemiology and main aspects of infections in SOT recipients including risk factors such as postoperative risks and specific risks for different transplant recipients, key points on anti-infective prophylaxis as well as diagnostic and therapeutic approaches. We provide an up-to-date guide for management of the main syndromes that can be encountered in SOT recipients including acute respiratory failure, sepsis or septic shock, and central nervous system infections as well as bacterial infections with multidrug-resistant strains, invasive fungal diseases, viral infections and less common pathogens that may impact this patient population. Conclusion We provide state-of the art review of available knowledge of critically ill SOT patients with infections.
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36
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Garg N, Jorgenson M, Descourouez J, Saddler CM, Parajuli S, Astor BC, Djamali A, Mandelbrot D. Pneumocystis jiroveci pneumonia in kidney and simultaneous pancreas kidney transplant recipients in the present era of routine post-transplant prophylaxis: risk factors and outcomes. BMC Nephrol 2018; 19:332. [PMID: 30463516 PMCID: PMC6249739 DOI: 10.1186/s12882-018-1142-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/15/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The goal of this study was to identify predictors for development of Pneumocystis jirovecii pneumonia (PJP) in kidney and simultaneous kidney and pancreas transplant recipients in the present era of universal primary prophylaxis. METHODS We reviewed adult recipients of kidney transplant or simultaneous pancreas and kidney transplant at the University of Wisconsin between January 1, 1994 and December 31, 2016. Patients diagnosed with PJP during this time frame were included. Controls were randomly selected from among those whose post-transplant course was not complicated by PJP, matched on time since transplant through incidence density sampling with a 3:1 ratio. RESULTS 28 (0.45%) of 6270 recipients developed PJP between 1994 and 2016. Median time since transplant was 4.6 years (interquartile range (IQR): 1.4-9.6 years). Affected recipients were older, had more HLA mismatches, and were more likely to have had BK viremia, CMV viremia and invasive fungal infections than matched controls. CMV viremia remained the only significant risk factor in multivariate analysis, and was a strong predictor (OR 6.27; p = 0.002). Ninety percent of the cases with prior CMV viremia had been diagnosed in the year preceding the diagnosis of PJP; among these, median time from diagnosis of CMV to diagnosis of PJP was 3.4 months (IQR: 1.74-11.5 months) and median peak CMV viral load prior to diagnosis of PJP was 3684.5 IU/mL (IQR: 1034-93,300 IU/mL). Additionally, 88.9% of patients with CMV in the preceding year had active infection at time of PJP diagnosis. Patient and graft survival were significantly worse at 2 years in recipients with PJP than our control group (42.4% vs. 88.5, and 37.9% vs. 79.9%; p < 0.001). CONCLUSIONS Despite the low overall incidence of PJP in the era of universal prophylaxis, outcomes are poor. We suggest extending or re-initiating PJP prophylaxis for at least 6 months in the setting of CMV viremia due to the relatively low risk of therapy and potential significant impact on disease prevention.
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Affiliation(s)
- Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, 4177 Medical Foundation Centennial Building, Madison, WI, 53705, USA
| | - Margaret Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Jillian Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Christopher M Saddler
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, 4177 Medical Foundation Centennial Building, Madison, WI, 53705, USA
| | - Brad C Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, 4177 Medical Foundation Centennial Building, Madison, WI, 53705, USA.,Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, 4177 Medical Foundation Centennial Building, Madison, WI, 53705, USA.,Division of Transplant Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, 4177 Medical Foundation Centennial Building, Madison, WI, 53705, USA.
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