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Werbel WA, Brown DM, Kusemiju OT, Doby BL, Seaman SM, Redd AD, Eby Y, Fernandez RE, Desai NM, Miller J, Bismut GA, Kirby CS, Schmidt HA, Clarke WA, Seisa M, Petropoulos CJ, Quinn TC, Florman SS, Huprikar S, Rana MM, Friedman-Moraco RJ, Mehta AK, Stock PG, Price JC, Stosor V, Mehta SG, Gilbert AJ, Elias N, Morris MI, Mehta SA, Small CB, Haidar G, Malinis M, Husson JS, Pereira MR, Gupta G, Hand J, Kirchner VA, Agarwal A, Aslam S, Blumberg EA, Wolfe CR, Myer K, Wood RP, Neidlinger N, Strell S, Shuck M, Wilkins H, Wadsworth M, Motter JD, Odim J, Segev DL, Durand CM, Tobian AAR. National Landscape of Human Immunodeficiency Virus-Positive Deceased Organ Donors in the United States. Clin Infect Dis 2022; 74:2010-2019. [PMID: 34453519 PMCID: PMC9187316 DOI: 10.1093/cid/ciab743] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Organ transplantation from donors with human immunodeficiency virus (HIV) to recipients with HIV (HIV D+/R+) presents risks of donor-derived infections. Understanding clinical, immunologic, and virologic characteristics of HIV-positive donors is critical for safety. METHODS We performed a prospective study of donors with HIV-positive and HIV false-positive (FP) test results within the HIV Organ Policy Equity (HOPE) Act in Action studies of HIV D+/R+ transplantation (ClinicalTrials.gov NCT02602262, NCT03500315, and NCT03734393). We compared clinical characteristics in HIV-positive versus FP donors. We measured CD4 T cells, HIV viral load (VL), drug resistance mutations (DRMs), coreceptor tropism, and serum antiretroviral therapy (ART) detection, using mass spectrometry in HIV-positive donors. RESULTS Between March 2016 and March 2020, 92 donors (58 HIV positive, 34 FP), representing 98.9% of all US HOPE donors during this period, donated 177 organs (131 kidneys and 46 livers). Each year the number of donors increased. The prevalence of hepatitis B (16% vs 0%), syphilis (16% vs 0%), and cytomegalovirus (CMV; 91% vs 58%) was higher in HIV-positive versus FP donors; the prevalences of hepatitis C viremia were similar (2% vs 6%). Most HIV-positive donors (71%) had a known HIV diagnosis, of whom 90% were prescribed ART and 68% had a VL <400 copies/mL. The median CD4 T-cell count (interquartile range) was 194/µL (77-331/µL), and the median CD4 T-cell percentage was 27.0% (16.8%-36.1%). Major HIV DRMs were detected in 42%, including nonnucleoside reverse-transcriptase inhibitors (33%), integrase strand transfer inhibitors (4%), and multiclass (13%). Serum ART was detected in 46% and matched ART by history. CONCLUSION The use of HIV-positive donor organs is increasing. HIV DRMs are common, yet resistance that would compromise integrase strand transfer inhibitor-based regimens is rare, which is reassuring regarding safety.
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Affiliation(s)
- William A Werbel
- Correspondence: W. A. Werbel, Department of Medicine, Johns Hopkins School of Medicine, 725 N Wolfe St, PCTB/Second Floor, Baltimore, MD 21205 ()
| | - Diane M Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Oyinkansola T Kusemiju
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brianna L Doby
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shanti M Seaman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew D Redd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Yolanda Eby
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Reinaldo E Fernandez
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Niraj M Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jernelle Miller
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gilad A Bismut
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles S Kirby
- Department of Biochemistry, Cellular, and Molecular Biology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Haley A Schmidt
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William A Clarke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Seisa
- Laboratory Corporation of America (LabCorp), South San Francisco, California, USA
| | | | - Thomas C Quinn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York City, New York, USA
| | - Shirish Huprikar
- Department of Medicine, Division of Infectious Diseases, The Mount Sinai Hospital, New York City, New York, USA
| | - Meenakshi M Rana
- Department of Medicine, Division of Infectious Diseases, The Mount Sinai Hospital, New York City, New York, USA
| | - Rachel J Friedman-Moraco
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Aneesh K Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Peter G Stock
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jennifer C Price
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Valentina Stosor
- Division of Infectious Disease and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shikha G Mehta
- Section of Transplant Nephrology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alexander J Gilbert
- MedStar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, DC, USA
| | - Nahel Elias
- Department of Surgery, Division of Transplant Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michele I Morris
- Department of Medicine, Division of Infectious Diseases, University of Miami, Miami, Florida, USA
| | - Sapna A Mehta
- New York University Langone Transplant Institute, New York University Grossman School of Medicine, New York, New York, USA
| | - Catherine B Small
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medical College, New York, New York, USA
| | - Ghady Haidar
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Maricar Malinis
- Department of Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jennifer S Husson
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Marcus R Pereira
- Department of Medicine, Division of Infectious Diseases, Columbia University Medical Center, New York, New York, USA
| | - Gaurav Gupta
- Department of Medicine, Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jonathan Hand
- Department of Infectious Diseases, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Varvara A Kirchner
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Avinash Agarwal
- Department of Surgery, Division of Transplantation, University of Virginia, Charlottesville, Virginia, USA
| | - Saima Aslam
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Emily A Blumberg
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cameron R Wolfe
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - R Patrick Wood
- Department of Surgery, Division of Transplantation, University of Wisconsin, Madison, Wisconsin, USA
| | - Nikole Neidlinger
- Department of Surgery, Division of Transplantation, University of Wisconsin, Madison, Wisconsin, USA
- UW Health Organ Procurement Organization, Madison, Wisconsin, USA
| | - Sara Strell
- UW Health Organ Procurement Organization, Madison, Wisconsin, USA
| | | | | | | | - Jennifer D Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonah Odim
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - HOPE in Action Investigators
PiquantDominqueLinkKatherineRNHemmersbach-MillerMarionMD, PhDPearsonThomasMDTurgeonNicoleMDLyonG MarshallMD, MMScKitchensWilliamMD PhDHuckabyJerylMSCRA, CCRCLasseterA FrancieRNElbeinRivkaRN, BSNRobersonAprilRNFerryElizabethRNKlockEthanBSCochranWilla VCRNPMorrisonMichelleBSNRasmussenSarahBABollingerJuliMSSugarmanJeremyMDSmithAngela RMBAThomasMargaretBSCoakleyMargaretRNTimponeJosephMDStuckeAlyssaBSHaydelBrandyDieterRebeccaPharmDKleinElizabeth JBANeumannHenryMDGallonLorenzoMDGoudyLeahRNCallegariMichelleMarrazzoIliseRN, BSN, MPHJacksonTowandaPruettTimothyMDFarnsworthMaryCCRCLockeJayme EMD, MPH, FACS, FASTMompoint-WilliamsDarnellCRNP, DNPBasingerKatherineRN, CCRPMekeelKristinMDNguyenPhirumBSKwanJoanneSrisengfaTabChin-HongPeterMDRogersRodneySimkinsJacquesMDMunozCarlosCRCDunnTyMDSawinskiDierdreMDSilveiraFernandaMDHughesKaileyMPHPakstisDiana LynnRN, BSN, MBANagyJamieBABaldecchiMaryMuthukumarThangamaniMDEddieMelissa DMS, RNRobbKatharineRNSalsgiverElizabethMPHWittingBrittaBSAzarMarwan MVillanuevaMerceditasFormicaRichardTomlinRicardaBS, CCRP
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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2
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Mehta N, Wang T, Friedman-Moraco RJ, Carpentieri C, Mehta AK, Rouphael N, Dhere T, Larsen CP, Kraft CS, Woodworth MH. Fecal Microbiota Transplantation Donor Screening Updates and Research Gaps for Solid Organ Transplant Recipients. J Clin Microbiol 2022; 60:e0016121. [PMID: 34133889 PMCID: PMC8849208 DOI: 10.1128/jcm.00161-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
In this review, we discuss stool donor screening considerations to mitigate potential risks of pathogen transmission through fecal microbiota transplant (FMT) in solid organ transplant (SOT) recipients. SOT recipients have a higher risk for Clostridioides difficile infection (CDI) and are more likely to have severe CDI. FMT has been shown to be a valuable tool in the treatment of recurrent CDI (RCDI); however, guidelines for screening for opportunistic infections transmitted through FMT are underdeveloped. We review reported adverse effects of FMT as they pertain to an immunocompromised population and discuss the current understanding and recommendations for screening found in the literature while noting gaps in research. We conclude that while FMT is being performed in the SOT population, typically with positive results, there remain many unanswered questions which may have major safety implications and warrant further study.
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Affiliation(s)
- Nirja Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Tiffany Wang
- Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Rachel J. Friedman-Moraco
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Cynthia Carpentieri
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Aneesh K. Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
- Department of Surgery, Division of Transplantation, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Nadine Rouphael
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Tanvi Dhere
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Christian P. Larsen
- Department of Surgery, Division of Transplantation, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Colleen S. Kraft
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
| | - Michael H. Woodworth
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicinegrid.471395.d, Atlanta, Georgia, USA
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Adelman MW, Dean CL, Friedman-Moraco RJ. A Brain Abscess and Pulmonary Nodules in a Heart/Kidney Transplant Recipient. Clin Infect Dis 2021; 71:1795-1797. [PMID: 33095258 DOI: 10.1093/cid/ciaa106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Max W Adelman
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christina L Dean
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rachel J Friedman-Moraco
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Bonny TS, Kirby C, Martens C, Rose R, Desai N, Seisa M, Petropoulos C, Florman S, Friedman-Moraco RJ, Turgeon NA, Brown D, Segev DL, Durand CM, Tobian AAR, Redd AD. Outcomes of donor-derived superinfection screening in HIV-positive to HIV-positive kidney and liver transplantation: a multicentre, prospective, observational study. Lancet HIV 2020; 7:e611-e619. [PMID: 32730756 PMCID: PMC8073978 DOI: 10.1016/s2352-3018(20)30200-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/23/2020] [Accepted: 05/04/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND One of the primary risks of HIV-positive to HIV-positive organ transplantation is loss of virological control because of donor-derived HIV superinfection, which occurs when an HIV-positive individual becomes infected with a new distinct HIV strain. In this study, as part of the larger HIV Organ Policy Equity pilot study, HIV-positive to HIV-positive kidney and liver transplant recipients in the USA were examined for evidence of sustained donor-derived HIV superinfection. METHODS In this multicentre, prospective, observational study, HIV-positive to HIV-positive kidney and liver transplant recipients were followed in three hospitals in the USA. Candidates with well controlled HIV infection on ART, no active opportunistic infections, and minimum CD4 T-cell counts (>100 cells per μL for liver and >200 cells per μL for kidney per federal guidelines) were eligible to receive a kidney or liver from deceased HIV-positive donors without active infections or neoplasm. Peripheral blood mononuclear cells were collected from donor-recipient pairs at the time of transplantation, and from recipients at several timepoints up to 3 years after transplantation. Donor samples were assessed for HIV RNA viral load, CD4 cell count, and antiretroviral drug-resistant mutations. Donor and recipient HIV proviral DNA, and viral RNA from the viraemic timepoint were sequenced using a site-directed next-generation sequencing assay for the reverse transcriptase and gp41 genes. Neighbour-joining phylogenetic trees and direct sequence comparison were used to detect the presence of HIV superinfection. This study is registered with ClinicalTrials.gov, NCT02602262. FINDINGS 14 HIV-positive to HIV-positive kidney and eight liver transplant recipients were followed from March, 2016, to July, 2019. 17 recipients had adequate viral sequences allowing for HIV superinfection assessment. Eight donors were suppressed (viral load <400 copies per mL), and none had multiclass drug-resistant mutations detected. None of the recipients examined had evidence of HIV superinfection. One recipient had a viraemic episode (viral load of 2 080 000 copies per mL) 3 years after transplantation as a result of non-adherence to ART. Only recipient viral sequences were detected during the viraemic episode, suggesting that the donor virus, if present, was not reactivated despite temporary withdrawal of ART. INTERPRETATION These findings suggest that loss of HIV suppression due to donor-derived HIV superinfection might not be a significant clinical concern in carefully monitored ART suppressed HIV-positive organ recipients. FUNDING US National Institute of Allergy and Infectious Diseases and National Cancer Institute.
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Affiliation(s)
- Tania S Bonny
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles Kirby
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Craig Martens
- Genomic Unit, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, USA
| | - Rebecca Rose
- Bioinfoexperts, Shreveport, Los Angeles, CA, USA
| | - Niraj Desai
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael Seisa
- Laboratory Corporation of America (LabCorp), South San Francisco, CA, USA
| | | | - Sander Florman
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Diane Brown
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Andrew D Redd
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; International HIV Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, MD, USA.
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Cheng YW, Phelps E, Ganapini V, Khan N, Ouyang F, Xu H, Khanna S, Tariq R, Friedman-Moraco RJ, Woodworth MH, Dhere T, Kraft CS, Kao D, Smith J, Le L, El-Nachef N, Kaur N, Kowsika S, Ehrlich A, Smith M, Safdar N, Misch EA, Allegretti JR, Flynn A, Kassam Z, Sharfuddin A, Vuppalanchi R, Fischer M. Fecal microbiota transplantation for the treatment of recurrent and severe Clostridium difficile infection in solid organ transplant recipients: A multicenter experience. Am J Transplant 2019; 19:501-511. [PMID: 30085388 PMCID: PMC6349556 DOI: 10.1111/ajt.15058] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 02/06/2023]
Abstract
Fecal microbiota transplant (FMT) is recommended for Clostridium difficile infection (CDI) treatment; however, use in solid organ transplantation (SOT) patients has theoretical safety concerns. This multicenter, retrospective study evaluated FMT safety, effectiveness, and risk factors for failure in SOT patients. Primary cure and overall cure were defined as resolution of diarrhea or negative C difficile stool test after a single FMT or after subsequent FMT(s) ± anti-CDI antibiotics, respectively. Ninety-four SOT patients underwent FMT, 78% for recurrent CDI and 22% for severe or fulminant CDI. FMT-related adverse events (AE) occurred in 22.3% of cases, mainly comprising self-limiting conditions including nausea, abdominal pain, and FMT-related diarrhea. Severe AEs occurred in 3.2% of cases, with no FMT-related bacteremia. After FMT, 25% of patients with underlying inflammatory bowel disease had worsening disease activity, while 14% of cytomegalovirus-seropositive patients had reactivation. At 3 months, primary cure was 58.7%, while overall cure was 91.3%. Predictors of failing a single FMT included inpatient status, severe and fulminant CDI, presence of pseudomembranous colitis, and use of non-CDI antibiotics at the time of FMT. These data suggest FMT is safe in SOT patients. However, repeated FMT(s) or additional antibiotics may be needed to optimize rates of cure with FMT.
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Affiliation(s)
- Yao-Wen Cheng
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Emmalee Phelps
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Vincent Ganapini
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Noor Khan
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Fangqian Ouyang
- Department of Biostatistics, The Richard M. Fairbanks School of Public Health and School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Huiping Xu
- Department of Biostatistics, The Richard M. Fairbanks School of Public Health and School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Sahil Khanna
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Raseen Tariq
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Michael H. Woodworth
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Tanvi Dhere
- Division of Digestive Diseases, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Colleen S. Kraft
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia, USA,Department of Pathology, Emory University, Atlanta, Georgia, USA
| | - Dina Kao
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Justin Smith
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lien Le
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Najwa El-Nachef
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nirmal Kaur
- Division of Gastroenterology, Department of Medicine, Henry Ford Medical Center, Detroit, MI, USA
| | - Sree Kowsika
- Division of Gastroenterology, Department of Medicine, Henry Ford Medical Center, Detroit, MI, USA
| | - Adam Ehrlich
- Division of Gastroenterology, Department of Medicine, Temple University, Philadelphia, PA, USA
| | - Michael Smith
- Division of Gastroenterology, Department of Medicine, Temple University, Philadelphia, PA, USA
| | - Nasia Safdar
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA,William S. Middleton Memorial Veterans Hospital, Madison WI, USA
| | - Elizabeth Ann Misch
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jessica R. Allegretti
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Ann Flynn
- Division of Gastroenterology, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | | | - Asif Sharfuddin
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Raj Vuppalanchi
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Monika Fischer
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Pouch SM, Friedman-Moraco RJ. Prevention and Treatment of Clostridium difficile-Associated Diarrhea in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2018; 32:733-748. [PMID: 30146033 DOI: 10.1016/j.idc.2018.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection is a significant cause of morbidity and mortality in solid organ transplant recipients. Risk factors in this population include frequent hospitalizations, receipt of immunosuppressive agents, and intestinal dysbiosis triggered by several factors, including exposure to broad-spectrum antimicrobials. The incidence and potential for significant adverse outcomes among solid organ transplant recipients with C difficile infection highlight the evolving need for strategic C difficile infection risk factor modification and novel approaches to disease management in this patient population. This review focuses on current concepts related to the prevention and treatment of C difficile infection in solid organ transplant recipients.
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Affiliation(s)
- Stephanie M Pouch
- Division of Infectious Diseases, Emory University School of Medicine, 101 Woodruff Circle, WMB #2101, Atlanta, GA 30322, USA.
| | - Rachel J Friedman-Moraco
- Division of Infectious Diseases, Emory University School of Medicine, 101 Woodruff Circle, WMB #2101, Atlanta, GA 30322, USA
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7
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Woodworth MH, Kraft CS, Meredith EJ, Mehta AK, Wang T, Mamo YT, Dhere T, Sitchenko KL, Patzer RE, Friedman-Moraco RJ. Tacrolimus concentration to dose ratio in solid organ transplant patients treated with fecal microbiota transplantation for recurrent Clostridium difficile infection. Transpl Infect Dis 2018; 20:e12857. [PMID: 29446866 PMCID: PMC5891373 DOI: 10.1111/tid.12857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 10/16/2017] [Accepted: 11/26/2017] [Indexed: 12/29/2022]
Abstract
Fecal microbiota transplantation (FMT) is increasingly being performed for Clostridium difficile infection in solid organ transplant (SOT) patients; however, little is known about the potential pharmacokinetic or pharmacomicrobial effects this may have on tacrolimus levels. We reviewed the medical records of 10 SOT patients from September 2012-December 2016 who were taking tacrolimus at time of FMT for recurrent C. difficile infection. We compared the differences in tacrolimus concentration/dose ratio (C/D ratio) 3 months prior to FMT vs 3 months after FMT. The mean of the differences in C/D ratio calculated as (ng/mL)/(mg/kg/d) was -17.65 (95% CI -1.25 to 0.58) (ng/mL)/(mg/kg/d), P-value .43 by Wilcoxon signed-rank test. The mean of the differences in C/D ratio calculated as (ng/mL)/(mg/d) was -0.33 (95% CI -1.25 to 0.58) (ng/mL)/(mg/d), P-value .28 by Wilcoxon signed-rank test. Of these patients, 2/10 underwent allograft biopsy for allograft dysfunction in the year after FMT, with no evidence of allograft rejection on pathology. These preliminary data suggest that FMT may not predictably alter tacrolimus levels and support its safety for SOT patients however further study in randomized trials is needed.
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Affiliation(s)
- Michael H. Woodworth
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Colleen S. Kraft
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
- Department of Pathology, Emory University Hospital
| | | | - Aneesh K. Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
- Department of Surgery, Division of Transplantation, Emory University School of Medicine
| | | | | | - Tanvi Dhere
- Department of Medicine, Division of Digestive Diseases Medicine, Emory University School of Medicine
| | - Kaitlin L. Sitchenko
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine
- Department of Epidemiology, Rollins School of Public Health
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Lo DJ, Friedman-Moraco RJ, Hinrichs BH, Adams AB. Acute liver failure in a pregnant patient. Am J Transplant 2017. [DOI: 10.1111/ajt.14512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Denise J. Lo
- Department of Surgery; Emory Transplant Center; Emory University School of Medicine; Atlanta GA USA
| | - Rachel J. Friedman-Moraco
- Division of Infectious Diseases; Department of Medicine; Emory University School of Medicine; Atlanta GA USA
| | | | - Andrew B. Adams
- Department of Surgery; Emory Transplant Center; Emory University School of Medicine; Atlanta GA USA
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Abstract
As understanding of the human microbiome improves, novel therapeutic targets to improve human health with microbial therapeutics will continue to expand. We outline key considerations of balancing risks and benefits, optimising access, returning key results to research participants, and potential conflicts of interest.
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Affiliation(s)
- Michael H Woodworth
- a Department of Medicine, Division of Infectious Diseases , Emory University School of Medicine , Atlanta , GA , USA
| | - Kaitlin L Sitchenko
- a Department of Medicine, Division of Infectious Diseases , Emory University School of Medicine , Atlanta , GA , USA
| | - Cynthia Carpentieri
- a Department of Medicine, Division of Infectious Diseases , Emory University School of Medicine , Atlanta , GA , USA
| | - Rachel J Friedman-Moraco
- a Department of Medicine, Division of Infectious Diseases , Emory University School of Medicine , Atlanta , GA , USA
| | - Tiffany Wang
- b Emory University School of Medicine , Atlanta , GA , USA
| | - Colleen S Kraft
- a Department of Medicine, Division of Infectious Diseases , Emory University School of Medicine , Atlanta , GA , USA.,c Department of Pathology , Emory University Hospital , Atlanta , GA , USA
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Phadke VK, Friedman-Moraco RJ, Quigley BC, Farris AB, Norvell JP. Concomitant herpes simplex virus colitis and hepatitis in a man with ulcerative colitis: Case report and review of the literature. Medicine (Baltimore) 2016; 95:e5082. [PMID: 27759636 PMCID: PMC5079320 DOI: 10.1097/md.0000000000005082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Herpesvirus infections often complicate the clinical course of patients with inflammatory bowel disease; however, invasive disease due to herpes simplex virus is distinctly uncommon. METHODS We present a case of herpes simplex virus colitis and hepatitis, review all the previously published cases of herpes simplex virus colitis, and discuss common clinical features and outcomes. We also discuss the epidemiology, clinical manifestations, diagnosis, and management of herpes simplex virus infections, focusing specifically on patients with inflammatory bowel disease. RESULTS A 43-year-old man with ulcerative colitis, previously controlled with an oral 5-aminosalicylic agent, developed symptoms of a colitis flare that did not respond to treatment with systemic corticosteroid therapy. One week later he developed orolabial ulcers and progressive hepatic dysfunction, with markedly elevated transaminases and coagulopathy. He underwent emergent total colectomy when imaging suggested bowel micro-perforation. Pathology from both the colon and liver was consistent with herpes simplex virus infection, and a viral culture of his orolabial lesions and a serum polymerase chain reaction assay also identified herpes simplex virus. He was treated with systemic antiviral therapy and made a complete recovery. CONCLUSIONS Disseminated herpes simplex virus infection with concomitant involvement of the colon and liver has been reported only 3 times in the published literature, and to our knowledge this is the first such case in a patient with inflammatory bowel disease. The risk of invasive herpes simplex virus infections increases with some, but not all immunomodulatory therapies. Optimal management of herpes simplex virus in patients with inflammatory bowel disease includes targeted prophylactic therapy for patients with evidence of latent infection, and timely initiation of antiviral therapy for those patients suspected to have invasive disease.
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MESH Headings
- Adult
- Colitis/complications
- Colitis/diagnosis
- Colitis/virology
- Colitis, Ulcerative/complications
- Colitis, Ulcerative/diagnosis
- Colonoscopy
- DNA, Viral/analysis
- Hepatitis, Viral, Human/complications
- Hepatitis, Viral, Human/diagnosis
- Hepatitis, Viral, Human/virology
- Herpes Simplex/complications
- Herpes Simplex/diagnosis
- Herpes Simplex/virology
- Humans
- Male
- Simplexvirus/genetics
- Tomography, X-Ray Computed
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Affiliation(s)
- Varun K. Phadke
- Division of Infectious Diseases, Emory University School of Medicine
- Correspondence: Varun K. Phadke, 49 Jesse Hill Jr. Drive, Atlanta 30303, GA (e-mail: )
| | | | - Brian C. Quigley
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Emory University Hospital
| | - Alton B. Farris
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Emory University Hospital
| | - J. P. Norvell
- Division of Digestive Diseases, Emory University School of Medicine
- Emory Transplant Center, Atlanta, GA
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11
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Aldrete SDM, Magee MJ, Friedman-Moraco RJ, Chan AW, Banks GG, Burd EM, Kraft CS. Characteristics and Antibiotic Use Associated With Short-Term Risk of Clostridium difficile Infection Among Hospitalized Patients. Am J Clin Pathol 2015; 143:895-900. [PMID: 25972333 DOI: 10.1309/ajcp9ewi6qpvtpqy] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Polymerase chain reaction (PCR) has been shown to have an excellent sensitivity and specificity for the detection of Clostridium difficile infection (CDI). Little is known about risk factors for CDI within 14 days of an initial negative test. We sought to determine the characteristics among hospitalized patients associated with risk of short-term acquisition of CDI. METHODS A case-control study was conducted. Cases were patients who converted from PCR negative to positive within 14 days. Each case was matched with three controls. Conditional logistic regression was used to estimate the association between patient characteristics and CDI. RESULTS Of the 30 patients in our study who had a positive PCR within 14 days of a first negative PCR (cases), 15 (50%) occurred within 7 days of the initial test. Cases had a higher proportion of intravenous vancomycin use in the previous 8 weeks (odds ratio [OR], 3.38; 95% confidence interval [CI], 1.34-8.49) and were less likely to have recent antiviral agent use (OR, 0.30; 95% CI, 0.11-0.83) compared with controls. CONCLUSIONS In hospitalized patients, treatment with intravenous vancomycin within the prior 8 weeks of a first negative PCR test for C difficile is a risk factor for short-term risk for hospital-acquired CDI. Repeat testing guidelines for C difficile PCR should take into consideration patients who may be at high risk for short-term acquisition of CDI.
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Affiliation(s)
- Sol del Mar Aldrete
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - Matthew J. Magee
- Division of Epidemiology and Biostatistics, Georgia State University School of Public Health, Atlanta
| | | | - Austin W. Chan
- Division of Infectious Diseases, Duke University, Durham, NC
| | | | - Eileen M. Burd
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | - Colleen S. Kraft
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
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12
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Kraft CS, Hewlett AL, Koepsell S, Winkler AM, Kratochvil CJ, Larson L, Varkey JB, Mehta AK, Lyon GM, Friedman-Moraco RJ, Marconi VC, Hill CE, Sullivan JN, Johnson DW, Lisco SJ, Mulligan MJ, Uyeki TM, McElroy AK, Sealy T, Campbell S, Spiropoulou C, Ströher U, Crozier I, Sacra R, Connor MJ, Sueblinvong V, Franch HA, Smith PW, Ribner BS. The Use of TKM-100802 and Convalescent Plasma in 2 Patients With Ebola Virus Disease in the United States. Clin Infect Dis 2015; 61:496-502. [PMID: 25904375 DOI: 10.1093/cid/civ334] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 03/21/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The current West Africa Ebola virus disease (EVD) outbreak has resulted in multiple individuals being medically evacuated to other countries for clinical management. METHODS We report two patients who were transported from West Africa to the United States for treatment of EVD. Both patients received aggressive supportive care measures, as well as an investigational therapeutic (TKM-100802) and convalescent plasma. RESULTS While one patient experienced critical illness with multi-organ failure requiring mechanical ventilation and renal replacement therapy, both patients recovered without serious long-term sequelae to date. CONCLUSIONS It is unclear what role the experimental drug and convalescent plasma had in the recovery of these patients. Prospective clinical trials are needed to delineate the role of investigational therapies in the care of patients with EVD.
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Affiliation(s)
- Colleen S Kraft
- Department of Pathology and Laboratory Medicine Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Angela L Hewlett
- Division of Infectious Diseases, Department of Internal Medicine
| | | | | | | | | | - Jay B Varkey
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Aneesh K Mehta
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - G Marshall Lyon
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Rachel J Friedman-Moraco
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Vincent C Marconi
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | | | - James N Sullivan
- Division of Critical Care, Department of Anesthesiology, University of Nebraska Medical Center, Omaha
| | - Daniel W Johnson
- Division of Critical Care, Department of Anesthesiology, University of Nebraska Medical Center, Omaha
| | - Steven J Lisco
- Division of Critical Care, Department of Anesthesiology, University of Nebraska Medical Center, Omaha
| | - Mark J Mulligan
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Timothy M Uyeki
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anita K McElroy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tara Sealy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Ute Ströher
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ian Crozier
- World Health Organization, Kenema Hospital, Sierra Leone
| | - Richard Sacra
- University of Massachusetts Medical School, Worcester
| | - Michael J Connor
- Division of Pulmonary, Allergy and Critical Care Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia
| | | | - Harold A Franch
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia
| | - Philip W Smith
- Division of Infectious Diseases, Department of Internal Medicine
| | - Bruce S Ribner
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
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