Prospective population-based surveillance to assess the incidence and impact of invasive pneumococcal disease (IPD) in organ transplant patients is lacking. By using a population-based Invasive Bacterial Diseases Network surveillance program, we studied the incidence, clinical significance, serotypes and antimicrobial resistance pattern of IPD in a large cohort of adult transplant patients and the general population. Streptococcus pneumoniae isolates and patient data were collected prospectively from 1995 to 2004. We identified 21 cases of IPD (based on sterile-site isolates) in our organ transplant population over a 10-year period. This translated to an incidence rate of 146 infections per 100,000 persons per year. This compared to an incidence of 11.5 per 100,000 persons per year in the general population (R(R)=12.8; 95% CI 8.1-19.9, p<0.00001). If nonsterile-site isolates (respiratory tract) were included, the incidence rate in transplant patients was 419 of 100 000 persons per year. Serotypes 23F and 22F were most common, and 85.0% had a serotype included in the 23-valent pneumococcal vaccine. The antimicrobial resistance rates were high, especially for penicillin and trimethoprim-sulfamethoxazole (TMP/SMX), but were not significantly different from the general population. Solid organ transplant recipients are at significantly greater risk for IPD than the general population. Preventative strategies are necessary.
The COVID-19 pandemic has rapidly evolved and changed our way of life in an unprecedented manner. The emergence of COVID-19 has impacted transplantation worldwide. The impact has not been just restricted to issues pertaining to donors or recipients, but also health-care resource utilization as the intensity of cases in certain jurisdictions exceeds available capacity. Here we provide a personal viewpoint representing different jurisdictions from around the world in order to outline the impact of the current COVID-19 pandemic on organ transplantation. Based on our collective experience, we discuss mitigation strategies such as donor screening, resource planning, and a staged approach to transplant volume considerations as local resource issues demand. We also discuss issues related to transplant-related research during the pandemic, the role of transplant infectious diseases, and the influence of transplant societies for education and disseminating current information. The COVID-19 pandemic has rapidly evolved and changed our way of life in an unprecedented manner. The emergence of COVID-19 has impacted transplantation worldwide. The impact has not been just restricted to issues pertaining to donors or recipients, but also health-care resource utilization as the intensity of cases in certain jurisdictions exceeds available capacity. Here we provide a personal viewpoint representing different jurisdictions from around the world in order to outline the impact of the current COVID-19 pandemic on organ transplantation. Based on our collective experience, we discuss mitigation strategies such as donor screening, resource planning, and a staged approach to transplant volume considerations as local resource issues demand. We also discuss issues related to transplant-related research during the pandemic, the role of transplant infectious diseases, and the influence of transplant societies for education and disseminating current information.
Increased‐risk donor (IRD) organs make up a significant proportion of the deceased organ donor pool but may be declined by patients on the waiting list for various reasons. We conducted a survey of patients awaiting a liver transplant to determine the factors leading to the acceptance of an IRD organ as well as what strategies could increase the rate of acceptance. Adult liver transplant candidates who were outpatients completed a survey of 51 questions on a 5‐point Likert scale with categories related to demographics, knowledge of IRDs, and likelihood of acceptance. A total of 150 transplant candidates completed the survey (age 19‐80 years). Male patients constituted 67.3%. Many patients (58.7%) had postsecondary education. Only 23.3% of patients had a potential living donor, and 58/144 (40.3%) were not optimistic about receiving an organ in the next 3 months. The overall IRD organ acceptance rate was 41.1%, whereas 26.2% said they would decline an IRD organ. Women were more likely to accept an IRD organ (54.3% versus 34.7%; P = 0.02). Those who had a college education or higher tended to have lower IRD organ acceptability (28.3% versus 47.4%; P = 0.07). Acceptability also increased as the specified transmission risk of human immunodeficiency virus or hepatitis C virus decreased ( P < 0.001). Patients were also more likely to accept an IRD organ if they were educated on the benefits of IRD organs (eg, knowledge that an IRD organ was of better quality increased overall acceptance from 41.1% to 63.3%; P < 0.001). Our survey provides insight into liver transplant candidates who would benefit from greater education on IRD organs. Strategies targeting specific educational points are likely to increase acceptability.
As the disparity between the number of candidates listed for transplant and the number of donors continues to grow, marginal organ donors are increasingly utilized. This includes bacteremic donors which may carry an increased risk of transmission of infection. It is recommended that recipients of organs from bacteremic donors receive antibiotic prophylaxis based on the susceptibilities of the donor isolate to prevent transmission. Here, we present four cases of donor-derived bacteremia, despite appropriate antimicrobial prophylaxis, in four liver transplant recipients. Transmitted pathogens included Staphylococcus aureus in two cases, and Escherichia coli and Group B Streptococcus each in one case. Interestingly, none of the nonhepatic organs (n=10) utilized from these bacteremic donors resulted in transmissions. These cases highlight the fact that risk of transmission from bacteremic donors is not eliminated with antimicrobial therapy in the donor and recipient. As no transmissions occurred in recipients of nonhepatic organs from these donors, these cases also suggest that liver recipients may be at higher risk of donor transmitted bacteremia.
T cell immunity is essential for the control of cytomegalovirus (CMV) infection after transplantation. We evaluated a CMV-specific peptide-based enzyme-linked immunosorbent spot (ELISPOT) assay to determine whether assay results could predict subsequent CMV events. Adult kidney transplant recipients at 43 centers underwent ELISPOT testing to enumerate interferon gamma (IFN-γ) binding spot-forming units (sfu) after stimulation of cells with an overlapping peptide pool of CMV phosphoprotein 65 (pp65) and immediate early-1 (IE-1) protein at the end of antiviral prophylaxis (EOP) and various time points thereafter. The primary outcome was a CMV event in the first posttransplant year. In 583 kidney transplant recipients (260 seropositive donor [D+]/seronegative recipient [R−] and 277 R+), CMV events occurred in 44 of 368 eligible patients (11.8%) at a median of 227 days (range 92-360) posttransplant. A cutoff value of >40 sfu/2.5 × 105 cells for either IE-1 or pp65 was derived as a threshold for positivity, with a negative predictive value of >97% for CMV events. CMV events were significantly lower in assay positive vs assay negative patients (3.0% vs 19.5%, P < .0001 for pp65). Time to CMV event post-EOP was significantly greater in those with sfu >40 at EOP (P < .0001). In this large, multicenter trial of kidney transplant recipients, we show that an assessment of CMV-specific immunity using a novel ELISPOT assay is able to predict protection from CMV infection.
Introduction: Transplant Infectious Diseases (TxID) as a subspecialty has gained popularity in the past decade. However, the number and characteristics of formal TxID programs are unknown, and TxID program and personnel support varies. We sought to provide insight into these issues through a survey of members of the ID Community of Practice (COP). Methods: An electronic survey was sent to ID specialists registered with the AST ID COP. Each transplant center received one survey to limit duplication. Survey questions related to transplant center demographics, TxID program structure, and sources of financial support for the TxID program. Results: Of 116 questionnaires, 51 (44.0%) were returned (41 adult, 7 pediatric centers, 3 incomplete). Of the 41 evaluable surveys from adult programs, 36 (87.8%) had a dedicated TxID program. The median number of solid organ transplants (SOT) annually was 250 (range 0 - 565), hematopoietic stem cell transplants (HCT) 55 (range 0-450), and total transplants 260 (range 50 to 780). In programs that provided staffing details, there was a range of 1 to 12 TxID specialists (median 3.0, mean 3.8). Ratio of TxID staff per SOT per year was calculated (mean 60, range 15-254), but no association was seen between ratio and institutional salary support. There was a greater likelihood of salary support for TxID in larger SOT programs (>250 SOT/year) as compared with small or medium sized programs (13/15 large programs vs. 1/6 small programs), provided as direct funds (47.6%) or full-time equivalents (FTE) (52.4%). Non-salary support was more common in larger programs and included office space (37.2%), administrative (27.9%), and research support (16.3%). The majority of support came from the medical center or the ID division. Five programs offered a TxID fellowship program. Conclusions: Larger transplant programs were more likely to offer institutional support for TxID Programs, via FTEs as well as non-salary support. Analysis of these patterns may offer prospects for obtaining assistance to programs lacking support, with the goal of improving outcomes after SOT and HCT transplantation.
The aim of the American Journal of Transplantation is the rapid publication of new high quality data in organ and tissue transplantation and the related sciences.The journal reflects the field and is an agent for advancing it through critical reviews and news features, and consensus documents and guidelines.The journal is directed at scientists and clinicians in transplantation but also at those in other fields who wish to follow transplantation.The scope is the international discipline of transplantation.This includes organ and tissue donation and preservation; tissue injury, repair, inflammation, and aging; immune recognition, regulation, effector mechanisms, and opportunities for induction of tolerance; histocompatibility; drugs and pharmacology relevant to transplantation; graft survival and prevention of graft dysfunction and failure; clinical trials and population analyses; transplant complications; xenotransplantation; and ethical and societal issues.The sciences includes relevant aspects of cell biology, medicine, surgery, pediatrics, and infectious diseases.The journal includes thoracic transplantation (heart, lung), abdominal transplantation (kidney, liver, pancreas, islets), transplantation of tissues and related topics.The American Journal of Transplantation serves as a forum for debate and reassessment, an agent of change, and a major platform for promoting understanding, improving results, and advancing science in this dynamic field.
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