Pneumonia in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

Abstract

Pneumonia is a frequent infectious complication of solid organ transplantation (SOT). The occurrence of post-transplant pneumonia adversely impacts both graft and recipient survival, as well as the cost of care for SOT recipients. 1 Numerous micro-organisms can cause pneumonia in the SOT recipient with some etiologies resulting in self-limited infection and others causing significant morbidity and mortality. As a result of the varied clinical presentations and etiologies of pneumonia in SOT recipients, arriving at a specific microbiologic diagnosis can be challenging but is important for optimal care, especially with complicated or refractory pneumonias. In this section, the clinical presentation, differential diagnosis, diagnostic testing, and empiric antimicrobial treatment of pneumonia in SOT recipients are reviewed. Pathogen-specific sections within the AST ID Guidelines are referenced for further information regarding the diagnosis and treatment of specific pathogens that cause pneumonia in this vulnerable population. AbstractThese guidelines from the AST Infectious Diseases Community of Practice review the diagnosis and management of pneumonia in the post-transplant period. Clinical presentations and differential diagnosis for pneumonia in the solid organ transplant recipient are reviewed. A two-tier approach is proposed based on the net state of immunosuppression and the severity of presentation. With a lower risk of opportunistic, hospital-acquired, or exposure-specific pathogens and a non-severe presentation, empirical therapy may be initiated under close clinical observation. In all other patients, or those not responding to the initial therapy, a more aggressive diagnostic approach including sampling of tissue for microbiological and pathological testing is warranted. Given the broad range of potential pathogens, a microbiological diagnosis is often key for optimal care. Given the limited literature comparatively evaluating diagnostic approaches to pneumonia in the solid organ transplant recipient, much of the proposed diagnostic algorithm reflects clinical experience rather than evidencebased data. It should serve as a template which may be modified according to local needs. The same holds true for the suggested empiric therapies, which need to be adapted to the local resistance patterns. Further study is needed to comparatively evaluate diagnostic and empiric treatment strategies in SOT recipients. K E Y W O R D Sdiagnosis, pneumonia, transplantation

Infections in the solid-organ transplant recipients

“…SOTRs from a deceased donor with non-bacteremic, localized infection not involving the transplanted organ do not require treatment, with the exception of meningitis, in which occult bacteremia frequently occurs. For potential lung donors, bronchoscopy with cultures should be performed and appropriate antibiotics initiated in the recipient to cover recovered bacteria [39]. Treponema pallidum has rarely been transmitted by transplantation, but it is not a contraindication to deceased organ donation if the recipient is treated post-transplant with an appropriate course of penicillin [12].…”

“…Trimethoprim/sulfamethoxazole prophylaxis for the first 6 months after transplantation is recommended to protect against urinary tract infections. This regimen also protects against infection with Pneumocystis jirovecii, Listeria monocytogenes, Nocardia species and Toxoplasma gondii [16,18,35,39]. SOTRs with positive PPD test results and a high risk of tuberculosis reactivation should be given 9-12 months of isoniazid therapy after transplantation.…”

Pulmonary Syndromes in Transplantation

“…Factors to consider include the timing after transplantation, the degree of immunosuppression, donor and recipient exposures, and hospital and regional epidemiology [4]. Given the high morbidity and mortality associated with pulmonary infections, an aggressive approach is required including the early use of diagnostics and prompt initiation of empiric antimicrobial therapy [1][2][3]. Establishing a specific diagnosis is essential for de-escalation to targeted antimicrobial therapy with avoidance of adverse effects (including the development of antimicrobial resistance) from broad-spectrum antibiotics.…”

“…• Chest X-ray is recommended for immunocompromised patients presenting with pulmonary symptoms. Chest computed tomography (CT) may be indicated in the initial evaluation based on patients with prolonged respiratory symptoms, high acuity clinical presentations, and a high net state of immunosuppression [1,3].…”

“…Infectious and noninfectious pulmonary syndromes remain significant contributors to morbidity and mortality after solid organ and hematopoietic stem cell transplantation [1][2][3]. Multiple factors increase the risk pulmonary complications including the surgical trauma from solid organ transplantation (SOT), chemotherapy and radiation therapy prior to hematopoietic stem cell transplantation (HSCT), the degree of immunosuppression, and the immune responses leading to organ rejection and graft-versus-host disease (GVHD) [1,2]. The first section of the chapter reviews the timeline of pulmonary syndromes among SOT and HSCT patients.…”