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Bring it on: Top five antimicrobial stewardship challenges in transplant infectious diseases and practical strategies
Miranda So1,2, Helen Tsai3, Neeraja Swaminathan3
1Sinai Health-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada.
Abstract:
Antimicrobial therapies are essential tools for transplant recipients who are at high risk for infectious complications. However, judicious use of antimicrobials is critical to preventing the development of antimicrobial resistance. Treatment of multidrug-resistant organisms is challenging and potentially leads to therapies with higher toxicities, intravenous access, and intensive drug monitoring for interactions. Antimicrobial stewardship programs are crucial in the prevention of antimicrobial resistance, though balancing these strategies with the need for early and frequent antibiotic therapy in these immunocompromised patients can be challenging. In this review, we summarize 5 frequently encountered transplant infectious disease stewardship challenges, and we suggest strategies to improve practices for each clinical syndrome. These 5 challenging areas are: asymptomatic bacteriuria in kidney transplant recipients, febrile neutropenia in hematopoietic stem cell transplantation, antifungal prophylaxis in liver and lung transplantation, treatment of left-ventricular assist device infections, and Clostridioides difficile infection in solid-organ and hematopoietic stem-cell transplant recipients. Common themes contributing to these challenges include limited data specific to transplant patients, shortcomings in diagnostic testing, and uncertainties in pharmacotherapy.
Insights
Antimicrobial stewardship is vital for transplant patients to prevent resistance. This review addresses five key challenges in managing infections in these high-risk individuals, offering strategies for improved care.
Area of Science:
- Infectious Diseases
- Transplant Medicine
- Antimicrobial Stewardship
Background:
- Transplant recipients face high infectious complication risks.
- Antimicrobial resistance necessitates judicious antimicrobial use.
- Managing multidrug-resistant organisms presents significant clinical challenges.
Purpose of the Study:
- To review five common infectious disease stewardship challenges in transplant recipients.
- To propose strategies for improving clinical practices in these areas.
- To highlight common themes contributing to stewardship difficulties.
Main Methods:
- Literature review focusing on transplant infectious disease stewardship.
- Identification and analysis of five frequently encountered clinical challenges.
- Synthesis of current data and expert opinion to suggest management strategies.
Main Results:
- Identified challenges include asymptomatic bacteriuria (kidney), febrile neutropenia (HSCT), antifungal prophylaxis (liver/lung), LVAD infections, and C. difficile (SOT/HSCT).
- Common contributing factors identified: limited transplant-specific data, diagnostic test limitations, and pharmacotherapy uncertainties.
- Strategies for improving stewardship practices were proposed for each syndrome.
Conclusions:
- Effective antimicrobial stewardship is critical for balancing infection prevention and resistance management in transplant patients.
- Addressing data gaps, diagnostic limitations, and pharmacotherapy uncertainties is essential for optimizing care.
- Implementing targeted strategies can improve outcomes for transplant recipients facing complex infections.
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