White paper on antimicrobial stewardship in solid organ transplant recipients

Abstract

Antimicrobial stewardship programs (ASPs) have made immense strides in optimizing antibiotic, antifungal, and antiviral use in clinical settings. However, although ASPs are required institutionally by regulatory agencies in the United States and Canada, they are not mandated for transplant centers or programs specifically. Despite the fact that solid organ transplant recipients in particular are at increased risk of infections from multidrug-resistant organisms, due to host and donor factors and immunosuppressive therapy, there currently are little rigorous data regarding stewardship practices in solid organ transplant populations, and thus, no transplant-specific requirements currently exist. Further complicating matters, transplant patients have a wide range of variability regarding their susceptibility to infection, as factors such as surgery of transplant, intensity of immunosuppression, and presence of drains or catheters in situ may modify the risk of infection. As such, it is not feasible to have a "one-size-fitsall" style of stewardship for this patient population. The objective of this white paper is to identify opportunities, risk factors, and ASP strategies that should be assessed with solid organ transplant recipients to optimize antimicrobial use, while producing an overall improvement in patient outcomes. We hope it may serve as a springboard for development of future guidance and identification of research opportunities. K E Y W O R D S antibiotic prophylaxis, ethics and public policy, health services and outcomes research, infection and infectious agents, organ transplantation in general How to cite this article: So M, Hand J, Forrest G, et al. White paper on antimicrobial stewardship in solid organ transplant recipients.

Risk factors for high level cytomegalovirus viremia in liver transplant recipients and associated outcomes

“…18 Unique risk factors in liver transplantation have been suggested Stewardship initiatives in the immunocompromised host are increasing. 19 An area of particular interest is CMV stewardship, given the association of CMV with graft and patient survival. 20 Abbreviations: CMV, cytomegalovirus; D, donor; DBD, donation after brain death; DCD, donation after circulatory death; NASH, nonalcoholic steatohepatitis; PSC, primary sclerosing cholangitis; R, recipient; UC, ulcerative colitis; VL, viral load.…”

“…Stewardship initiatives in the immunocompromised host are increasing 19 . An area of particular interest is CMV stewardship, given the association of CMV with graft and patient survival 20 .…”

Perioperative antibiotic stewardship in the organ transplant setting

“…10 SOT recipients can benefit from traditional AMS activities directed to improve judicious perioperative prescribing and management, but evidence is lacking, although urgently advocated considering the great impact of MDRO in SOT population. 11,12 AMS programs in immunocompetent hosts have shown good results in lowering antimicrobials use, improving patients' outcome, appropriateness and duration of empiric and targeted therapy decreasing CDI rates, shortening length of hospital stay and, as final consequence, reducing health care costs. [13][14][15][16] AMS programs in SOT should also make a step further into personalizing perioperative prophylaxis (PP) and treatments according to the type of transplantation and to the donor-recipient couple, always different and unique.…”

Shorter is better: The case for short antibiotic courses for common infections in solid organ transplant recipients

“…Limiting antimicrobial duration may mitigate detrimental effects of antibiotics and are a potential target for antimicrobial stewardship intervention. 3 In the last two decades, a number of studies have demonstrated the efficacy of shorter courses of antibiotics for a variety of clinical syndromes. [4][5][6][7] However, most of the studies conducted to date either explicitly excluded immunocompromised patients (including SOTRs) [8][9][10][11][12][13][14][15][16][17][18][19] did not report whether immunocompromised subjects were enrolled, [20][21][22][23][24][25][26][27][28][29][30] or recruited too few patients to draw conclusions about antibiotic duration in this subset.…”