Janice L Kaczmarek

Calcineurin Inhibitor Minimization, Conversion, Withdrawal, and Avoidance Strategies in Renal Transplantation: A Systematic Review and Meta-Analysis.

Despite their clinical efficacy, concerns about calcineurin inhibitor (CNI) toxicity make alternative regimens that reduce CNI exposure attractive for renal transplant recipients. In this systematic review and meta‐analysis, we assessed four CNI immunosuppression strategies (minimization, conversion, withdrawal, and avoidance) designed to reduce CNI exposure and assessed the impact of each on patient and allograft survival, acute rejection and renal function. We evaluated 92 comparisons from 88 randomized controlled trials and found moderate‐ to high‐strength evidence suggesting that minimization strategies result in better clinical outcomes compared with standard‐dose regimens; moderate‐strength evidence indicating that conversion to a mammalian target of rapamycin inhibitor or belatacept was associated with improved renal function but increased rejection risk; and moderate‐ to high‐strength evidence suggesting planned CNI withdrawal could result in improved renal function despite an association with increased rejection risk. The evidence base for avoidance studies was insufficient to draw meaningful conclusions. The applicability of the review is limited by the large number of studies examining cyclosporine‐based strategies and low‐risk populations. Additional research is needed with tacrolimus‐based regimens and higher risk populations. Moreover, research is necessary to clarify the effect of induction and adjunctive agents in alternative immunosuppression strategies and should include more comprehensive and consistent reporting of patient‐centered outcomes.

Cleaning Hospital Room Surfaces to Prevent Health Care–Associated Infections

The cleaning of hard surfaces in hospital rooms is critical for reducing health care-associated infections. This review describes the evidence examining current methods of cleaning, disinfecting, and monitoring cleanliness of patient rooms, as well as contextual factors that may affect implementation and effectiveness. Key informants were interviewed, and a systematic search for publications since 1990 was done with the use of several bibliographic and gray literature resources. Studies examining surface contamination, colonization, or infection with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci were included. Eighty studies were identified-76 primary studies and 4 systematic reviews. Forty-nine studies examined cleaning methods, 14 evaluated monitoring strategies, and 17 addressed challenges or facilitators to implementation. Only 5 studies were randomized, controlled trials, and surface contamination was the most commonly assessed outcome. Comparative effectiveness studies of disinfecting methods and monitoring strategies were uncommon. Future research should evaluate and compare newly emerging strategies, such as self-disinfecting coatings for disinfecting and adenosine triphosphate and ultraviolet/fluorescent surface markers for monitoring. Studies should also assess patient-centered outcomes, such as infection, when possible. Other challenges include identifying high-touch surfaces that confer the greatest risk for pathogen transmission; developing standard thresholds for defining cleanliness; and using methods to adjust for confounders, such as hand hygiene, when examining the effect of disinfecting methods.

Effectiveness of indoor allergen reduction in asthma management: A systematic review

Background This review will inform updated National Asthma Education and Prevention Program clinical practice guidelines. Objective We sought to evaluate the effectiveness of allergen reduction interventions on asthma outcomes. Methods We systematically searched the “gray literature” and 5 bibliographic databases. Eligible studies included systematic reviews, randomized controlled trials, and nonrandomized interventional studies. Risk of bias was assessed by using the Cochrane Risk of Bias instrument and the Newcastle‐Ottawa scale. The evidence base was assessed by using the approach of the Agency for Healthcare Research and Qualitys Evidence–based Practice Center program. Results Fifty‐nine randomized and 8 nonrandomized trials addressed 8 interventions: acaricide, air purification, carpet removal, high‐efficiency particulate air filtration (HEPA) vacuums, mattress covers, mold removal, pest control, and pet removal. Thirty‐seven studies evaluated single‐component interventions, and 30 studies assessed multicomponent interventions. Heterogeneity precluded meta‐analysis. For most interventions and outcomes, the evidence base was inconclusive or showed no effect. No interventions were associated with improvement in validated asthma control measures or pulmonary physiology. Exacerbations were diminished in multicomponent studies that included HEPA vacuums or pest control (moderate strength of evidence [SOE] for both). Quality of life improved in studies of air purifiers (SOE: low) and in multicomponent studies that included HEPA vacuums (SOE: moderate) or pest control (SOE: low). Conclusions Single interventions were generally not associated with improvement in asthma measures, with most strategies showing inconclusive results or no effect. Multicomponent interventions improved various outcomes, but no combination of specific interventions appears to be more effective. The evidence was often inconclusive because of a lack of studies. Further research is needed comparing the effect of indoor allergen reduction interventions on validated asthma measures, with sufficient population sizes to detect clinically meaningful differences. Graphical abstract Figure. No Caption available.

Systematic Review of Calcineurin Inhibitor Monitoring and Dosing Strategies in Renal Transplantation: Notice of a New Report Funded by the Agency for Healthcare Research and Quality

The calcineurin inhibitors (CNIs)6 tacrolimus (TAC) and cyclosporine A (CsA) are effective immunosuppressive agents for renal transplantation but require careful management to avoid toxicity. Routine therapeutic monitoring guides dosing, but uncertainty surrounds different monitoring methods and time points. Additionally, the effectiveness of strategies to reduce CNI exposure is unclear. A recent report commissioned by the Agency for Healthcare Research and Quality (AHRQ) based on research conducted by the ECRI Institute–Penn Medicine Evidence-based Practice Center to address these questions is now available (https://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports). The systematic review evaluates the evidence for 3 questions. The first question compared immunoassay analysis with liquid chromatographic or mass spectrometric analytical techniques for therapeutic monitoring of CNIs. The second question examined CsA monitoring time points, and the third question evaluated alternatives to full-dose CNI regimens. The review included 105 studies. Eleven studies addressing the analytic validity of monitoring …