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Post-transplant Pneumocystis jirovecii pneumonia--a re-emerged public health problem?
Jeremy R Chapman1, Deborrah J Marriott, Sharon C-A Chen
1Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia. Jeremy.chapman@swahs.health.nsw.gov.au
Abstract:
Pneumocystis jirovecii is a unicellular organism that in individuals with impaired immunity may cause pneumonia that can progress from minor illness to severe inflammatory pneumonia (PCP) with respiratory failure and death. Despite antimicrobial prophylaxis, which has reduced the incidence of PCP, clusters of late infections have been reported among kidney transplant recipients worldwide. A nosocomial PCP cluster was first recognized in 2010 at a Sydney hospital, but PCP clusters have since occurred in almost half of the renal transplant units on the eastern Australian seaboard, refocussing attention on optimal prophylaxis regimens and the likelihood of patient-to-patient transmission. A consensus meeting was conducted to derive the lessons from this experience for responding to PCP outbreaks. These included: (1) acting quickly--clusters of PCP in kidney transplant recipients with patient-to-patient transmission required transplant programs to act quickly to institute prophylactic and treatment measures; (2) instituting universal prophylaxis for all patients seen in the affected unit; (3) reducing patient-to-patient transmission via airborne droplets in the outpatient waiting areas; (4) examining the P. jirovecii genotypes. The meeting also considered recommendations for the duration of prophylaxis following de novo transplant and, for the individuals in whom long term prophylaxis is required, separating units with and without clusters of PCP.
Insights
Clusters of Pneumocystis pneumonia (PCP) in kidney transplant recipients highlight the need for rapid response and universal prophylaxis. Lessons learned emphasize prompt action, transmission reduction, and genotype examination to manage outbreaks effectively.
Area of Science:
- Mycology and Infectious Diseases
- Immunocompromised Host Pathogens
- Transplant Infectious Disease Management
Background:
- Pneumocystis jirovecii pneumonia (PCP) poses a severe risk to immunocompromised individuals, particularly kidney transplant recipients.
- Despite antimicrobial prophylaxis, clusters of late-onset PCP have emerged globally in this vulnerable population.
- Nosocomial PCP outbreaks in Australian renal transplant units underscore the urgency of optimizing prophylaxis and understanding transmission dynamics.
Framework:
- A consensus meeting convened to analyze experiences with PCP outbreaks in kidney transplant recipients.
- Key lessons derived include the critical need for rapid intervention and comprehensive management strategies.
- The meeting focused on actionable insights for responding to and preventing future PCP clusters.
Implementation:
- Promptly instituting prophylactic and treatment measures is crucial upon recognizing PCP clusters.
- Universal prophylaxis for all patients within affected units is recommended.
- Strategies to minimize patient-to-patient transmission, such as airborne droplet control in waiting areas, are essential.
- Investigating Pneumocystis jirovecii genotypes can aid in understanding transmission pathways.
Implications:
- Effective management of PCP outbreaks requires swift, coordinated action from transplant programs.
- Optimized prophylaxis regimens and transmission control are vital for protecting kidney transplant recipients.
- Understanding P. jirovecii transmission dynamics informs future prevention and treatment strategies.
- Recommendations address prophylaxis duration for de novo and long-term patients, including cohort separation during outbreaks.
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