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Fayyaz A, Raja M, Natori Y. Prevention and Management of Infections in Lung Transplant Recipients. J Clin Med 2023; 13:11. [PMID: 38202018 PMCID: PMC10779253 DOI: 10.3390/jcm13010011] [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: 09/24/2023] [Revised: 11/13/2023] [Accepted: 12/01/2023] [Indexed: 01/12/2024] Open
Abstract
Anti-rejection medications are essential in preventing organ rejection amongst solid organ transplant recipients; however, these agents also cause profound immunosuppression, predisposing lung transplant recipients (LTRs) to infectious complications. The timely management including prevention, diagnosis, and treatment of such infectious complications is vital to prevent significant morbidity and mortality in solid organ transplant recipients and allograft dysfunction. LTRs are inundated with microbes that may be recognized as commensals in hosts with intact immune systems. Bacterial infections are the most common ones, followed by viral pathogens. Indications of a brewing infectious process may be subtle. Hence, the importance of adapting vigilance around isolated hints through symptomatology and signs is pivotal. Signals to suggest an infectious process, such as fever and leukocytosis, may be dampened by immunosuppressive agents. One must also be vigilant about drug interactions of antibiotics and immunosuppressive agents. Treatment of infections can become challenging, as antimicrobials can interact with immunosuppressive agents, and antimicrobial resistance can surge under antimicrobial pressure. Transplant infectious disease physicians work in concert with transplant teams to obtain specimens for diagnostic testing and follow through with source control when possible. This heavily impacts medical decisions and fosters a multidisciplinary approach in management. Furthermore, the reduction of immunosuppression, although it augments the risk of allograft rejection, is as crucial as the initiation of appropriate antimicrobials when it comes to the management of infections.
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Affiliation(s)
| | | | - Yoichiro Natori
- Miami Transplant Institute, Jackson Health System, Division of Infectious Disease, Department of Clinical Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.F.); (M.R.)
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Sweiss H, Kincaide E, Levine D, Hall R. Effect of Isavuconazonium Sulfate and Posaconazole Delayed Release Tablets on Tacrolimus Dose-to-Concentration Ratios. Prog Transplant 2023; 33:90-94. [PMID: 36503331 DOI: 10.1177/15269248221145036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Limited evidence exists on the effect of isavuconazonium sulfate and posaconazole delayed release tablets on tacrolimus dose-to-concentration ratios in lung transplant recipients. PROJECT AIMS The purpose of this evaluation was to assess the impact of novel triazoles on tacrolimus dose-to-concentration ratios. DESIGN This retrospective review included lung transplant recipient ≥18 years of age from January 1, 2017 to October 1, 2020 who received either posaconazole delayed release tablets or isavuconazonium sulfate for. A paired analysis evaluated outcomes pre-triazole and post-triazole initiation. RESULTS Forty-one patients met evaluation criteria for inclusion. A total of 34 of 41 patients received posaconazole delayed release tablets. Of these patients, 22 of 34 were transitioned from previous triazole to posaconazole delayed release tablets and experienced a 47% reduction in tacrolimus dose-to-concentration ratio. Twelve patients were newly initiated on posaconazole delayed release tablets and experienced a 50% reduction in tacrolimus dose-to-concentration ratios. Although not statistically significant, a 30% reduction in tacrolimus dose-to-concentration ratio was observed when transitioning to isavuconazonium sulfate from previous triazole therapy. CONCLUSION Limited data exists to provide guidance on tacrolimus dose adjustments with initiation and conversion of novel triazoles, however, this evaluation provides more knowledge on the drug interaction with novel triazoles and tacrolimus.
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Affiliation(s)
- Helen Sweiss
- Department of Pharmacotherapy & Pharmacy Services, 43159University Health System, San Antonio, TX, USA.,University Health Transplant Institute, 43159University Health System, San Antonio, TX, USA.,Pharmacotherapy Education and Research Center, 14742The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Pharmacotherapy Division, The University of Texas at Austin, College of Pharmacy, Austin, TX, USA
| | - Elisabeth Kincaide
- Department of Pharmacotherapy & Pharmacy Services, 43159University Health System, San Antonio, TX, USA.,University Health Transplant Institute, 43159University Health System, San Antonio, TX, USA.,Pharmacotherapy Education and Research Center, 14742The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Pharmacotherapy Division, The University of Texas at Austin, College of Pharmacy, Austin, TX, USA
| | - Deborah Levine
- University Health Transplant Institute, 43159University Health System, San Antonio, TX, USA.,Department of Medicine Pulmonology and Critical Care Medicine, 14742The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Reed Hall
- Department of Pharmacotherapy & Pharmacy Services, 43159University Health System, San Antonio, TX, USA.,University Health Transplant Institute, 43159University Health System, San Antonio, TX, USA.,Pharmacotherapy Education and Research Center, 14742The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Pharmacotherapy Division, The University of Texas at Austin, College of Pharmacy, Austin, TX, USA
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Pennington KM, Aversa M, Martinu T, Johnson B, Husain S. Fungal infection and colonization in lung transplant recipients with chronic lung allograft dysfunction. Transpl Infect Dis 2022; 24:e13986. [PMID: 36380578 DOI: 10.1111/tid.13986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/29/2022] [Accepted: 10/24/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The incidence and impact of de novo fungal airway colonization and infection in lung transplant recipients (LTRs) with known chronic lung allograft dysfunction (CLAD) has not been established. We aimed to determine the 1-year cumulative incidence and risk factors of de novo fungal colonization or infection in LTRs with CLAD and assess the impact of colonization or infection on post-CLAD survival. METHODS Prospectively collected Toronto Lung Transplant Program database and chart review were used for double-LTRs who were diagnosed with CLAD from January 1, 2016 to January 1, 2020 and who were free of airway fungi within 1 year prior to CLAD onset. International Society for Heart and Lung Transplantation definitions were used to define clinical syndromes. Cox-Proportional Hazards Models were used for risk-factor analysis. Survival analysis could not be completed secondary to low number of fungal events; therefore, descriptive statistics were employed for survival outcomes. RESULTS We found 186 LTRs diagnosed with CLAD meeting our inclusion criteria. The 1-year cumulative incidence for any fungal event was 11.8% (7.0% for infection and 4.8% for colonization). Aspergillus fumigatus was a causative pathogen in eight of 13 (61.5%) patients with infection and six of nine (66.7%) patients with colonization. No patients with fungal colonization post-CLAD developed fungal infection. Peri-CLAD diagnosis (3 months prior or 1 month after) methylprednisolone bolus (hazards ratio: 8.84, p = .001) increased the risk of fungal events. Most patients diagnosed with fungal infections (53.8%) died within 1-year of CLAD onset. CONCLUSION De novo IFIs and fungal colonization following CLAD onset were not common. Fungal colonization did not lead to fungal infection. Methylprednisolone bolus was a significant risk factors for post-CLAD fungal events.
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Affiliation(s)
- Kelly M Pennington
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Meghan Aversa
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
| | - Bradley Johnson
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Shahid Husain
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada.,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Samanta P, Clancy CJ, Nguyen MH. Fungal infections in lung transplantation. J Thorac Dis 2022; 13:6695-6707. [PMID: 34992845 PMCID: PMC8662481 DOI: 10.21037/jtd-2021-26] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 07/14/2021] [Indexed: 12/18/2022]
Abstract
Lung transplant is a potential life-saving procedure for chronic lung diseases. Lung transplant recipients (LTRs) are at the greatest risk for invasive fungal infections (IFIs) among solid organ transplant (SOT) recipients because the allograft is directly exposed to fungi in the environment, airway and lung host defenses are impaired, and immunosuppressive regimens are particularly intense. IFIs occur within a year of transplant in 3-19% of LTRs, and they are associated with high mortality, prolonged hospital stays, and excess healthcare costs. The most common causes of post-LT IFIs are Aspergillus and Candida spp.; less common pathogens are Mucorales, other non-Aspergillus moulds, Cryptococcus neoformans, Pneumocystis jirovecii, and endemic mycoses. The majority of IFIs occur in the first year following transplant, although later onset is observed with prolonged antifungal prophylaxis. The most common manifestations of invasive mould infections (IMIs) include tracheobronchial (particularly at anastomotic sites), pulmonary and disseminated infections. The mortality rate of tracheobronchitis is typically low, but local complications such as bronchomalacia, stenosis and dehiscence may occur. Mortality rates associated with lung and disseminated infections can exceed 40% and 80%, respectively. IMI risk factors include mould colonization, single lung transplant and augmented immunosuppression. Candidiasis is less common than mould infections, and manifests as bloodstream or other non-pulmonary invasive candidiasis; tracheobronchial infections are encountered uncommonly. Risk factors for and outcomes of candidiasis are similar to those of non lung transplant recipients. There is evidence that IFIs and fungal colonization are risk factors for allograft failure due to chronic rejection. Mould-active azoles are frontline agents for treatment of IMIs, with local debridement as needed for tracheobronchial disease. Echinocandins and azoles are treatments for invasive candidiasis, in keeping with guidelines in other patient populations. Antifungal prophylaxis is commonly administered, but benefits and optimal regimens are not defined. Universal mould-active azole prophylaxis is used most often. Other approaches include targeted prophylaxis of high-risk LTRs or pre-emptive therapy based on culture or galactomannan (GM) (or other biomarker) results. Prophylaxis trials are needed, but difficult to perform due to heterogeneity in local epidemiology of IFIs and standard LT practices. The key to devising rational strategies for preventing IFIs is to understand local epidemiology in context of institutional clinical practices.
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Affiliation(s)
- Palash Samanta
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Hong Nguyen
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
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Joean O, Welte T, Gottlieb J. Chest Infections after Lung Transplantation. Chest 2021; 161:937-948. [PMID: 34673023 DOI: 10.1016/j.chest.2021.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/21/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
Despite substantial progress in the long-term follow-up strategies for lung transplant recipients, morbidity and mortality remain high mostly due to the elevated infectious risk and to the development of chronic lung allograft dysfunction. The high immunosuppressive levels necessary to prevent acute rejection and the graft's constant exposure to the environment come at the high price of frequent infectious complications. Moreover, some infectious agents have been shown to trigger acute rejection or chronic allograft dysfunction. A rapid diagnostic approach followed by an early treatment and follow-up strategy are of paramount importance. They are, however, challenging endeavors due to the vast spectrum of possible pathogens and to the discrete clinical features as a consequence of transplant recipients' impaired immune response. This review proposes a stratified diagnostic strategy, discusses the most relevant pathogens and the corresponding therapeutic approaches while also offering an insight in the infection prevention strategies: vaccination, prophylaxis, preemptive therapy, antibiotic stewardship.
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Affiliation(s)
- Oana Joean
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease, Member of the German Center for Lung Research, Hannover, Germany.
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease, Member of the German Center for Lung Research, Hannover, Germany
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Fungal Infection and Prevention in Lung Transplant. CURRENT FUNGAL INFECTION REPORTS 2021. [DOI: 10.1007/s12281-021-00424-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kennedy CC, Pennington KM, Beam E, Razonable RR. Fungal Infection in Lung Transplantation. Semin Respir Crit Care Med 2021; 42:471-482. [PMID: 34030208 DOI: 10.1055/s-0041-1729173] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Invasive fungal infections threaten lung transplant outcomes with high associated morbidity and mortality. Pharmacologic prophylaxis may be key to prevent posttransplant invasive fungal infections, but cost, adverse effects, and absorption issues are barriers to effective prophylaxis. Trends in fungal infection diagnostic strategies utilize molecular diagnostic methodologies to complement traditional histopathology and culture techniques. While lung transplant recipients are susceptible to a variety of fungal pathogens, Candida spp. and Aspergillus spp. infections remain the most common. With emerging resistant organisms and multiple novel antifungal agents in the research pipeline, it is likely that treatment strategies will continue to evolve.
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Affiliation(s)
- Cassie C Kennedy
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Kelly M Pennington
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Elena Beam
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota.,Division of Infectious Disease, Mayo Clinic, Rochester, Minnesota
| | - Raymund R Razonable
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota.,Division of Infectious Disease, Mayo Clinic, Rochester, Minnesota
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Reply: Antifungal Prophylaxis. Ann Am Thorac Soc 2021; 18:1755-1756. [PMID: 33901414 PMCID: PMC8522291 DOI: 10.1513/annalsats.202104-445le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Antifungal Prophylaxis. Ann Am Thorac Soc 2021; 18:1755-1756. [PMID: 33901407 PMCID: PMC8522285 DOI: 10.1513/annalsats.202103-300le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Strategies for the Prevention of Invasive Fungal Infections after Lung Transplant. J Fungi (Basel) 2021; 7:jof7020122. [PMID: 33562370 PMCID: PMC7914704 DOI: 10.3390/jof7020122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/31/2021] [Accepted: 02/04/2021] [Indexed: 12/18/2022] Open
Abstract
Long-term survival after lung transplantation is lower than that associated with other transplanted organs. Infectious complications, most importantly invasive fungal infections, have detrimental effects and are a major cause of morbidity and mortality in this population. Candida infections predominate in the early post-transplant period, whereas invasive mold infections, usually those related to Aspergillus, are most common later on. This review summarizes the epidemiology and risk factors for invasive fungal diseases in lung transplant recipients, as well as the current evidence on preventive measures. These measures include universal prophylaxis, targeted prophylaxis, and preemptive treatment. Although there is consensus that a preventive strategy should be implemented, current data show no superiority of one preventive measure over another. Data are also lacking regarding the optimal antifungal regimen and the duration of treatment. As all current recommendations are based on observational, single-center, single-arm studies, it is necessary that this longstanding debate is settled with a multicenter randomized controlled trial.
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