Staci A. Fischer

Left Ventricular Assist Device—Related Infection: Treatment and Outcome

BACKGROUND Left ventricular assist device (LVAD) implantation has become an effective treatment option for patients with severe heart failure awaiting transplantation. Significant infection rates have been reported among LVAD recipients. However, few reports have focused specifically on device infection, its treatment, and the impact of LVAD-related infection on clinical outcome. METHODS Forty-six LVAD-related infections were diagnosed in 38 (50%) of 76 patients who underwent LVAD implantation as a bridge to transplantation. Twenty-nine episodes of LVAD-related bloodstream infection (BSI) (including 5 that were cases of LVAD endocarditis) and 17 episodes of local LVAD infection were identified. RESULTS Diabetes mellitus appeared to increase the risk of BSI among patients with LVAD infection. LVAD-related infection delayed transplantation, as reflected by longer device-support times (a mean duration +/- SEM of 182.8+/-31.1 days, compared with 66.3+/-8.8 days; P<or=.001). Continuous antimicrobial treatment before, during, and after transplantation was associated with fewer relapses than was a limited course of antibiotics (P<.001). A trend for longer hospital stays after receipt of a transplant and increased early mortality was observed in the cohort with LVAD-related infection, although long-term survival was similar to that associated with patients without LVAD-related infection. Posttransplantation invasive vancomycin-resistant Enterococcus faecium (VREF) infection was diagnosed in 6 patients with LVAD-related infection; 4 of these patients died. No VREF infections were identified in patients without LVAD-related infection. CONCLUSIONS Our observations suggest that LVAD-related infection is common and may require antimicrobial therapy before, during, and after transplantation, but that it does not prevent successful transplantation. However, patients with LVAD-related infection appear to be at increased risk for invasive VREF infection, which may contribute to early mortality after transplantation.

Propionibacterium acnes colonization of the human shoulder.

BACKGROUND Propionibacterium acnes (P. acnes) is frequently cultured in patients with wound infections after shoulder surgery. The purpose of this study was to characterize the colonization of various anatomic locations with P. acnes in order to explain this clinical observation. METHODS Culture samples were collected from the skin overlying the shoulder, hip, and knee of 20 subjects (10 male, 10 female). Semi-quantitative cultures of P. acnes and Staphylococcus species were performed to define bacterial prevalence and burden at each site. The participants completed a questionnaire that assessed skin health, hygiene, and co-morbid medical conditions. Physical examination was performed to define local skin characteristics. RESULTS Anterior and posterior acromial sites had a greater prevalence of P. acnes than the hip (anterior p=0.018; posterior p= 0.038) and knee (anterior p=0.0014; posterior p= 0.035) sites. The axilla had a greater prevalence of P. acnes than the knee (p=0.008). Males had a greater prevalence of P. acnes than females at the anterior (p=0.007) and posterior acromion sites (p=0.025). The burden of P. acnes at the anterior acromion (p=0.024), posterior acromion (p=0.035), and axilla (p=0.03) was greater than the mean burden at the hip. The burden of P. acnes at the anterior acromion (p=0.004), posterior acromion (p=0.007), and axilla (p=0.008) was greater than the mean burden at the knee. Males had a greater burden of P. acnes than females at the acromial sites (anterior p=0.0049; posterior p=0.0131). CONCLUSIONS Propionibacterium acnes colonizes the shoulder at increased rates compared to the knee and hip, and men have a higher bacterial burden than females. These findings are consistent with clinical observations of postoperative shoulder infections. LEVEL OF EVIDENCE Basic science study.

Screening of Donor and Recipient Prior to Solid Organ Transplantation

Pretransplant screening of potential organ donors and recipients is essential to the success of solid organ transplantation (1–4). The goals of pretransplant infectious disease screening are: (1) to identify conditions which may disqualify either donor or recipient, (2) to identify and treat active infection pretransplant, (3) to define the risk of infection and determine strategies for preventing and mitigating posttransplant infection and (4) to implement preventative interventions, such as updating of vaccination status. Although there is general agreement on the major infections for which screening is performed, there is some variation between centers in the types of screening used and actions taken as a result.

Guidance on novel influenza A/H1N1 in solid organ transplant recipients.

Novel influenza A/H1N1 virus has caused significant illness worldwide. In response to this global crisis, the American Society of Transplantation (AST) Infectious Diseases Community of Practice and the Transplant Infectious Diseases section of The Transplantation Society (TTS) developed a guidance document for novel H1N1. In this paper, we discuss current guidance for H1N1 as it relates to solid organ transplantation. We include discussion around clinical presentation, diagnosis, therapy and prevention specifically addressing areas such as chemoprophylaxis, immunization and donor‐derived infection. Although this document addresses conditions specific to novel H1N1, many principles could be applied to future pandemics. As new information emerges about novel H1N1, updates will be made to the electronic version of the document posted on the websites of the AST and TTS.

Nucleic acid testing (NAT) of organ donors: is the 'best' test the right test? A consensus conference report.

Nucleic acid testing (NAT) for HIV, HBV and HCV shortens the time between infection and detection by available testing. A group of experts was selected to develop recommendations for the use of NAT in the HIV/HBV/HCV screening of potential organ donors. The rapid turnaround times needed for donor testing and the risk of death while awaiting transplantation make organ donor screening different from screening blood‐or tissue donors. In donors with no identified risk factors, there is insufficient evidence to recommend routine NAT, as the benefits of NAT may not outweigh the disadvantages of NAT especially when false‐positive results can lead to loss of donor organs. For donors with identified behavioral risk factors, NAT should be considered to reduce the risk of transmission and increase organ utilization. Informed consent balancing the risks of donor‐derived infection against the risk of remaining on the waiting list should be obtained at the time of candidate listing and again at the time of organ offer. In conclusion, there is insufficient evidence to recommend universal prospective screening of organ donors for HIV, HCV and HBV using current NAT platforms. Further study of viral screening modalities may reduce disease transmission risk without excessive donor loss.

Emerging viruses in transplantation: there is more to infection after transplant than CMV and EBV.

Transplant physicians and surgeons are familiar with the risks, clinical behavior, and management of cytomegalovirus in transplant recipients. Donor-transmitted viral infections are uncommon but in recent years have brought to light the clinical manifestations of rabies, West Nile virus, and lymphocytic choriomeningitis virus in the early posttransplant period. Later posttransplant, infection with viruses circulating in the community can occur with a number of pathogens, including some vaccine-preventable illnesses such as measles and mumps. Recent advances in molecular microbiology have made it possible to diagnose a growing number of community-acquired viral pathogens infecting transplant recipients. This article reviews some of the emerging and reemerging viral pathogens infecting solid organ and hematopoietic stem-cell recipients, including adenovirus, bocavirus, coronavirus, human herpesvirus-6, lymphocytic choriomeningitis virus, measles, mumps, metapneumovirus, parainfluenza, rotavirus, respiratory syncytial virus, and West Nile virus.

Methicillin-resistant Staphylococcus aureus in orthopaedic surgery

Methicillin-resistant Staphylococcus aureus (MRSA) has become a ubiquitous bacterium in both the hospital and community setting. There are two major subclassifications of MRSA, community-acquired and healthcare-acquired, each with differing pathogenicity and management. MRSA is increasingly responsible for infections in otherwise healthy, active adults. Local outbreaks affect both professional and amateur athletes and there is increasing public awareness of the issue. Health-acquired MRSA has major cost and outcome implications for patients and hospitals. The increasing prevalence and severity of MRSA means that the orthopaedic community should have a basic knowledge of the bacterium, its presentation and options for treatment. This paper examines the evolution of MRSA, analyses the spectrum of diseases produced by this bacterium and presents current prevention and treatment strategies for orthopaedic infections from MRSA.

Screening of Donor and Recipient in Solid Organ Transplantation

Pretransplant screening of potential organ donors and recipients is essential to the success of solid organ transplantation (1–4). The goals of pretransplant infectious disease screening are to identify conditions which may disqualify either donor or recipient; identify and treat active infection pretransplant; recognize and (if possible) define the risk of infection and develop strategies for preventing and mitigating posttransplant infection; and implement preventative measures, including immunizations (5). While there is general agreement on the major infections for which routine screening is performed, centers vary in the extent of infectious diseases investigation and the actions taken as a result.

Infections Transmitted by Transplantation

Infections are frequently transmitted through solid-organ and, to a lesser extent, stem cell transplantation. There are 2 major types of donor-derived infections that are transmitted: those that would be expected secondary to donor and recipient screening (ie, transmission of cytomegalovirus, Epstein-Barr virus, or toxoplasmosis from a seropositive donor to a seronegative recipient) and those that are unexpected despite routine donor screening (ie, human immunodeficiency virus and hepatitis C virus transmitted from a seronegative donor). Expected transmissions occur frequently and screening and prophylaxis strategies are applied to at-risk individuals in nearly all transplant centers globally. Several high profile donor-derived infectious disease transmissions have been recognized; these reports have raised awareness of this rare complication of transplantation. Issues related to the epidemiology of, screening for, and management of proven or probable donor-derived infections are reviewed in this article.

Approval and Perceived Impact of Duty Hour Regulations: Survey of Pediatric Program Directors

OBJECTIVES: To determine pediatric program director (PD) approval and perception of changes to resident training and patient care resulting from 2011 Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements. METHODS: All US pediatric PDs (n = 181) were identified from the ACGME. Functional e-mail addresses were identified for 164 (90.6%). Three individualized e-mail requests were sent to each PD to complete an anonymous 32-question Web-based survey. RESULTS: A total of 151 responses were obtained (83.4%). Pediatrics PDs reported approval for nearly all of the 2011 ACGME duty hour regulations except for 16-hour intern shift limits (72.2% disapprove). Regarding the perceived impact of the new standards, many areas were reportedly unchanged, but most PDs reported negative effects on resident education (74.7%), preparation for senior roles (79.9%), resident ownership of patients (76.8%), and continuity of care (78.8%). There was a reported increase in PD workload (67.6%) and use of physician extenders (62.7%). Finally, only 48.3% of PDs reported that their residents are “always” compliant with 2011 requirements. CONCLUSIONS: Pediatric PDs think there have been numerous negative consequences of the 2011 Common Program Requirements. These include declines in resident education and preparation to take on more senior roles, as well as diminished resident accountability and continuity of care. Although they support individual aspects of duty hour regulation, almost three-quarters of pediatric PDs say there should be fewer regulations. The opinions expressed by PDs in this study should prompt research using quantitative metrics to assess the true impact of duty hour regulations.