In the context of solid organ transplantation, screening of recipients and organ donors is crucial, and should be performed with great rigour to minimize the reactivation or the risk of transmission ...of certain infectious processes. This review aims to update understanding of the possible pathologies involved, as well as of emerging infections that, as a result of globalization, are gaining increasing prominence on a daily basis.
There is increasing evidence that ferritin is a key marker of macrophage activation, but its potential role in influenza infection remains unexplored. Our aim was to assess whether hyperferritinaemia ...(ferritin ≥500 ng/mL) could be a marker of poor prognosis in hospitalized patients with confirmed influenza A infection.
We prospectively recruited all hospitalized adult patients who tested positive for the influenza A rRT-PCR assay performed on respiratory samples in two consecutive influenza periods (2016–17 and 2017–18). Poor outcome was defined as the presence of at least one of the following: respiratory failure, admission to the intensive care unit, or in-hospital mortality.
Among 494 patients, 68 (14%) developed poor outcomes; 112 patients (23%) had hyperferritinaemia (39/68, 57% in the poor-outcome group versus 73/426, 17% in the remaining patients, p < 0.0001). Median serum ferritin levels were significantly higher in the subgroup of patients with poor outcomes (609 ng/mL, range 231–967 versus 217 ng/mL, range 140–394, p < 0.0001). In multivariate analysis, hyperferritinaemia was associated with a five-fold increase in the odds ratio of developing poor outcome. After adjusting for classic influenza risk factors, ferritin remained as a significant predictive factor in all exploratory models. Ferritin levels had a good discriminative capacity with an area under the ROC curve of 0.72 (95% confidence interval (CI) 0.65–0.8, p < 0.001) and an overall diagnostic accuracy for predicting poor outcome of 79.3% (95%CI 75.4–82.7%).
Serum ferritin may discriminate a subgroup of patients with influenza infection who have a higher risk of developing a poor outcome.
Summary
A poorer functional status at the time of fracture is a predictor of non-adherence to oral bisphosphonates initiated after a hip fracture, and suggests further opportunities for optimization ...of secondary fracture prevention in this high-risk population.
Introduction
Low adherence to treatment is a problem in post-fracture secondary prevention. We aimed to analyze the prognostic factors (related and predictive) associated with non-adherence to oral bisphosphonate prescription for hip fracture due to bone fragility (HFBF) 12 months after discharge from an acute geriatric unit.
Methods
Prospective study of bivariate data analyzing related and multivariate factors predicting non-adherence of oral bisphosphonates at 12 months after treatment for HFBF. The statistical study was performed with SPSS 19.0.0.
Results
We attended 368 patients with HFBF. At discharge, oral bisphosphonates were prescribed to 226 (61.42%) patients. At 12 months, we followed up 160 (70.7%) patients, 104 (65%) of whom had non-adherence to oral bisphosphonates. Bivariate analysis (adherent vs. non-adherent): age (83.79 ± 5.82 vs. 85.78 ± 5.80,
p
= .029); Lawton and Brody Index (4.29 ± 3.40 vs. 2.67 ± 3.31,
p
= .004); baseline Barthel Index (BI) (85.89 ± 21.99 vs. 74.18 ± 26.70) (
p
= .004); BI at admission (18.84 ± 10.00 vs. 14.47 ± 11.71, p = .004); BI at discharge (34.20 ± 15.40 vs. 27.45 ± 16.71,
p
= .011); baseline Functional Ambulation Classification (5.66 ± 0.98 vs. 5.43 ± 0.99,
p
= .025). Multivariate analysis: BI 0.980 (0.965–0.995,
p
= .007). Discriminatory capacity of the AUC model (± 95% CI): 0.634 (0.545–0.722).
Conclusions
At 12 months, there was low adherence to treatment with oral bisphosphonates in our model. A lower BI prior to treatment is a predictive factor for non-adherence treatment with oral bisphosphonate.
Background. To facilitate the design of strategies for prevention of invasive aspergillosis in solid-organ transplant recipients, this study investigates whether the development of early-onset and ...late-onset aspergillosis are related to different risk factors, thereby distinguishing 2 risk populations for this serious complication. Methods. A retrospective case-control study was performed, including 156 cases of proven or probable invasive aspergillosis in patients recruited from 11 Spanish centers since the start of the centers' transplantation programs. Results. Among all patients, 57% had early-onset IA (i.e., occurred during the first 3 months after transplantation). Risk factor analysis in this group identified as significantly associated risk factors a more complicated postoperative period, repeated bacterial infections or cytomegalovirus disease, and renal failure or the need for dialysis. Among patients with late-onset infections (i.e., occurred >3 months after transplantation), who comprised 43% of cases, the patients at risk were older, were in an overimmunosuppressed state because of chronic transplant rejection or allograft dysfunction, and had posttransplantation renal failure. Conclusions. Risk factors in patients with early-onset cases and patients with late-onset cases of posttransplantation invasive aspergillosis are not the same, a fact that could have implications for the preventive approaches used for this infection.
Cytomegalovirus (CMV) is the most frequent infectious complication following solid organ transplantation (SOT). The virus, is responsible for both direct (viral syndrome, hepatitis, pneumonitis, ...colitis, etc.) and indirect effects (rejection, infections by other microorganisms and graft dysfunction). In this evidence-based guideline we deal with the most important aspects of CMV infection in SOT recipients, including pre- and post-transplant diagnosis assessment and risk factors, with special emphasis on the prevention and treatment of this viral infection. Overall, adequate management of CMV infection is a critical aspect of transplant patient care.
Antimicrobial stewardship programmes promote excellence in the use of antimicrobials by selecting the appropriate antimicrobial agent and the correct dose, route of administration and duration of ...treatment. However, there is limited experience with such programmes targeting antifungal treatments. We present the results of a non-compulsory programme for the control of antifungals. For 12 months, prescriptions of oral voriconazole or intravenous voriconazole, caspofungin and liposomal amphotericin B were reviewed, and non-compulsory recommendations were made. The incidence and outcome of fungal infections were examined. The results for the dispensed defined daily doses (DDDs) and expenditure on antifungals were compared with those for the previous 12 months. The number of antifungal treatments reviewed was 662. A recommendation to change treatment was made in 29% of the cases, including a change from intravenous to oral treatment (15%), cessation of antifungal treatment (8%), and a change to fluconazole (6%). The DDDs of intravenous voriconazole and caspofungin were reduced by 31.4% and 20.2%, respectively. The DDDs of oral voriconazole and dispensed vials of liposomal amphotericin B were increased by 8.2% and 13.9%, respectively. Expenditure on antifungals was reduced by US$370681.78 (11.8% reduction). The programme was not related to significant increases in the incidence of candidaemia, percentage of persistent/relapsing candidaemia cases, percentage of fluconazole-resistant Candida species, incidence of infections by filamentous fungi, or 12-month mortality in patients with filamentous fungal infections. In conclusion, a stewardship programme targeting antifungals achieved a reduction in antifungal expenditure without reducing the quality of care provided.
Microbiological spectrum and outcome of infectious complications following small bowel transplantation (SBT) have not been thoroughly characterized. We performed a retrospective analysis of all ...patients undergoing SBT from 2004 to 2013 in Spain. Sixty‐nine patients underwent a total of 87 SBT procedures (65 pediatric, 22 adult). The median follow‐up was 867 days. Overall, 81 transplant patients (93.1%) developed 263 episodes of infection (incidence rate: 2.81 episodes per 1000 transplant‐days), with no significant differences between adult and pediatric populations. Most infections were bacterial (47.5%). Despite universal prophylaxis, 22 transplant patients (25.3%) developed cytomegalovirus disease, mainly in the form of enteritis. Specifically, 54 episodes of opportunistic infection (OI) occurred in 35 transplant patients. Infection was the major cause of mortality (17 of 24 deaths). Multivariate analysis identified retransplantation (hazard ratio HR: 2.21; 95% confidence interval CI: 1.02–4.80; p = 0.046) and posttransplant renal replacement therapy (RRT; HR: 4.19; 95% CI: 1.40–12.60; p = 0.011) as risk factors for OI. RRT was also a risk factor for invasive fungal disease (IFD; HR: 24.90; 95% CI: 5.35–115.91; p < 0.001). In conclusion, infection is the most frequent complication and the leading cause of death following SBT. Posttransplant RRT and retransplantation identify those recipients at high risk for developing OI and IFD.
Analysis of clinical and microbiological data of 87 small bowel transplant patients demonstrates that infection is a major complication after transplant, and retransplantation and the posttransplant requirement for renal replacement therapy are associated with a higher risk of developing opportunistic infections and invasive fungal disease.
Although hematological abnormalities have been described among patients with influenza virus infection, little is known about their impact on the outcome of the patients. The aim of this study was to ...assess the frequency and clinical impact of severe hematological abnormalities in patients with confirmed influenza virus infection. This was an observational retrospective study including all adult patients with diagnosis of influenza virus infection hospitalized from January to May 2016 in our institution. Influenza virus infection was diagnosed by means of rRT-PCR assay performed on respiratory samples. Poor outcome was defined as a composite endpoint in which at least one of the following criteria had to be fulfilled: (a) respiratory failure, (b) SOFA ≥2, or (c) death. Two hundred thirty-nine patients were included. Applying the HLH-04 criteria for the diagnosis of hemophagocytic syndrome, cytopenias (hemoglobin ≤9 g/dl, platelets <100,000/μl or neutrophils <1,000/μl) were present in 51 patients (21%). Patients with hematological abnormalities showed higher SOFA scores, respiratory failure, septic shock and in-hospital mortality than the remaining patients. The composite endpoint was present in 33.3% in the cytopenias group vs. 13.3% in the group without cytopenias (p=0.001). In a multivariate analysis, variables associated with the composite endpoint were: use of steroids prior to present admission (OR: 0.12; 95% CI: 0.015–0.96, p=0.046), presence of any hematological abnormality (OR: 3.54; 95% CI:1.66–7.51, p= 0.001), and LDH>225 U/l (OR:4.45; CI:1–19.71, p=0.049). Hematological abnormalities are not uncommon among hospitalized patients with influenza virus infection, and they are associated with a poorer outcome.
We aimed to analyze the incidence, risk factors and impact of hypogammaglobulinemia (HGG) in 226 kidney transplant (KT) recipients in which serum immunoglobulin (Ig) levels were prospectively ...assessed at baseline, month 1 (T1), and month 6 (T6). The prevalence of IgG HGG increased from 6.6% (baseline) to 52.0% (T1) and subsequently decreased to 31.4% (T6) (p < 0.001). The presence of IgG HGG at baseline (odds ratio OR 26.9; p = 0.012) and a positive anti‐HCV status (OR 0.17; p = 0.023) emerged as risk factors for the occurrence of posttransplant IgG HGG. Patients with HGG of any class at T1 had higher incidences of overall (p = 0.018) and bacterial infection (p = 0.004), bacteremia (p = 0.054) and acute pyelonephritis (p = 0.003) in the intermediate period (months 1–6). Patients with HGG at T6 had higher incidences of overall (p = 0.004) and bacterial infection (p < 0.001) in the late period (>6 month). A complementary log–log model identified posttransplant HGG as an independent risk factor for overall (hazard ratio HR 2.03; p < 0.001) and bacterial infection (HR 2.68; p < 0.0001). Monitoring of humoral immunity identifies KT recipients at high risk of infection, offering the opportunity for preemptive immunoglobulin replacement therapy.
The authors analyze the incidence and clinical impact of hypogammaglobulinemia in kidney transplant recipients, and conclude that the systematic monitoring of humoral immunity identifies patients at high risk of posttransplant infection, offering the opportunity for preemptive immunoglobulin replacement therapy.
Information describing the incidence and clinical characteristics of late infection (LI) in solid organ transplantation (SOT) is scarce. The aim of this study was to define the incidence, clinical ...characteristics and risk factors for LI (>6 months) as compared with infection in the early period (<6 months) after SOT. By the online database of the Spanish Network of Infection in Transplantation (RESITRA) we prospectively analyzed 2702 SOT recipients from September 2003 to February 2005. Univariate and multivariate analysis using logistic regression were performed to calculate the risk factors associated with the development of LI. A total of 131 patients developed 176 LI episodes (8%). Global incidence of LI was 0.4 per 1000 transplant‐days, ranging from 0.3/1000 in kidney transplants to 1.4 in lung transplants. Independent risk factors for LI in were: acute rejection in the early period (OR 1.5; CI 95%: 1.1–2.3), chronic graft malfunction (OR 2; CI 95%: 1.4–3), re‐operation (OR 1.9; CI 95%: 1.3–2.8) relapsing viral infection apart from CMV (OR 1.9; CI 95%: 1.1–3.5), previous bacterial infection (OR 1.8; CI 95%: 1.2–2.6) and lung transplantation (OR 4.5; CI 95%: 2.6–7.8). Severe LI occurs in a subgroup of high‐risk SOT recipients who deserve a more careful follow‐up and could benefit from prolonged prophylactic measures similar to that performed in the early period after transplantation.
Severe late infection occurs in a subgroup of high risk SOT recipients who deserve a more careful follow‐up and could benefit from prolonged prophylactic measures similar to that performed in the early period after transplantation.
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