Persistent fever after coronavirus disease 2019 in liver/kidney transplant recipient.

In this case, a 64-year-old male with a history of simultaneous orthotopic liver transplant and cadaveric renal transplant presented five years prior presented with persistent fevers two days after a positive SARS-CoV-2 nasal PCR. A CT scan of the chest on hospital day nine revealed innumerable 1-2 mm nodules in a miliary pattern throughout the lung. (1,3)-ß-D-glucan on hospital day 11 was 133 pg/mL. In this article, the approach, diagnostic and management strategies for patients with persistent fevers after diagnosis of COVID-19 in a transplant recipient are discussed.

Impact of narrowing perioperative antibiotic prophylaxis for left ventricular assist device implantation.

BACKGROUND: Although infections are a significant potential complication among patients undergoing left ventricular assist device (LVAD) implantation, standardized surgical infection prophylaxis (SIP) regimens are not well defined. At Montefiore Medical Center, a 4-drug SIP regimen containing fluconazole, ciprofloxacin, rifampin, and vancomycin was previously utilized. In January 2020, the antimicrobial stewardship program implemented a 2-drug SIP regimen of vancomycin and cefazolin to limit exposure to broad-spectrum antibiotics. This study evaluated LVAD-associated infection rates prior to and following the SIP revision. METHODS: A retrospective review of patients who underwent LVAD implantation from 1/2018 to 4/2021 was performed. Infections were classified using the International Society for Heart and Lung Transplantation definitions. Infection rates at 2 weeks, 30 days, and 90 days post-implantation in the 4-drug SIP regimen (1/2018-12/2019) and the 2-drug SIP regimen (1/2020 to 4/2021) were compared. RESULTS: A total of 71 patients were included. The number of patients with LVAD-associated infections (including surgical site infections) was not significantly different in either SIP group at 2 weeks (9% vs. 4%, p = .64), 30 days (9% vs. 11%, p = .99), or 90 days (19% vs. 14%, p = .75). There was no statistically significant difference in 30 or 90-day mortality. LVAD-associated gram-negative (7% vs. 7%; p > .99) and fungal (5% vs. 0%; p = .51) infections were uncommon. The most common organism isolated was Staphylococcus aureus, and the most common type of infection was pneumonia in both SIP groups. CONCLUSION: No significant difference in LVAD-associated infections or infection-related mortality was observed with de-escalation of perioperative antibiotics. Additional studies with larger sample sizes are needed to endorse the findings of this study.

The impact of infection among left ventricular assist device recipients on post-transplantation outcomes: A retrospective review.

INTRODUCTION: Left ventricular assist device (LVAD) infections are common, and the consequences of LVAD infections on orthotopic heart transplantation (OHT) outcomes are not well described. AIMS: The aim of this study was to describe clinical characteristics and evaluate risk factors for developing LVAD infections, and examine outcomes of LVAD-specific infections (VSI) after OHT. METHODS: We retrospectively investigated the records of 74 consecutive patients at two institutions who had undergone LVAD placement and subsequent OHT between January 2007 and December 2012. RESULTS: Forty-six of 74 (62%) LVAD recipients who underwent OHT had pre-transplant infections, and 18 (24%) had LVAD-specific infection (VSI), of which 71% were caused by gram-negative organisms. Of pre-transplant non-LVAD infections, Clostridium difficile infection (CDI) was the most common (26%) followed by urinary tract infection (UTI, 16%) and pneumonia (PNA 15%). Univariate analysis comparing subjects with VSI to those without VSI showed a significant association with time spent outside the hospital prior to transplantation (median 231.8 days vs 142.2 days, P < 0.03) and total time between VAD placement and OHT (244.0 days and 150.5 days, P < 0.002). Logistic regression was performed and significant predictors for VAD-related infection were age and the presence of diabetes, with type of device as an effect modifier. Six months post-OHT survival was not significantly affected by the presence of VSI prior to transplant. There was a trend toward an association between the presence of any infection and post-transplant rejection (P < 0.09). There were 10 post-transplant deaths by 6 months. Of these deaths, 4/10 (40%) were cardiopulmonary and 6/10 (60%) were related to infections. CONCLUSIONS: Advanced age and presence of diabetes were predictors of VSI, as well as type of VAD device, although device choice is likely affected by many clinical factors including age and comorbidities, as well as institution-specific preferences. VSI was not associated with a decrease in 6-month post-OHT survival. However, infections remain the major causes of death by 6 months post-transplant. Certain infections are associated with an increased risk of rejection, which merits further investigation.

Customized order-entry sets can prevent antiretroviral prescribing errors: a novel opportunity for antimicrobial stewardship.

BACKGROUND: Patients with human immunodeficiency virus (HIV) infection on antiretroviral (ARV) therapy are at increased risk for medication errors during transitions of care between the outpatient and inpatient settings. This can lead to treatment failure or toxicity. Previous studies have emphasized the prevalence of medication errors in such patients, but few have reported initiatives to prevent errors from occurring. METHODS: The study was conducted in a 1,400-bed health care center with a state-designated Acquired Immunodeficiency Syndrome (AIDS) Center in the Bronx, New York. The antimicrobial stewardship team and HIV specialists developed customized order-entry sets (COES) to guide ARV prescribing and retrospectively reviewed their effect on error rates of initial ARV orders for inpatients before reconciliation. Patient records were reviewed in six-month periods before and after intervention. The student's t-test or Mann-Whitney U test was used to compare continuous variables; chi-square or Fisher's exact test was used for categorical variables. RESULTS: A total of 723 and 661 admissions were included in the pre-intervention and post-intervention periods, respectively. Overall, error rates decreased by 35% (38.0% to 24.8%, P < 0.01) with COES. Wrong doses and drug interactions decreased by more than 40% (P < 0.005). Error reductions were observed in protease inhibitor (PI)-based (43.6% versus 28.7%, P < 0.01) and non-PI-based (38.0% versus 24.4%, P = 0.02) regimens with COES. A shift in predominant drug-class errors was observed as there was a trend toward increased usage of non-PI regimens post-intervention. Admission in the pre-intervention period (adjusted odds ratio [AOR], 1.79; 95% confidence interval [CI], 1.39-2.31) and use of PI-based regimens (AOR, 2.03; 95% CI, 1.53-2.70) remained significantly associated with ARV prescribing errors after controlling for confounding factors. CONCLUSION: Detailed COES improved ARV prescribing habits, reduced the potential for prescribing incorrect regimens, and can prove useful and cost-effective where HIV-specific medication reconciliation is unavailable.

Gallium-67 Single-Photon Emission Computed Tomography Affects Management of Infections of Left Ventricular Assist Devices.

Our institution employs gallium-67 single-photon emission computed tomography low-dose CT (Ga-SPECT-CT) to determine the presence and extent of left ventricular assist device (LVAD) infections. We present a retrospective single-center study of 41 LVAD recipients who underwent Ga-SPECT-CT from January 2011 to June 2018 to determine whether Ga-SPECT-CT led to changes in antimicrobial therapy, LVAD revision or exchange, or application for 1A exception. The average age was 56.6 years, predominantly male (80.5%) and diabetic (68.3%), divided between ischemic (48.8%) and nonischemic (51.2%) cardiomyopathy. The majority had HeartMate II devices (82.9%). Device-related infections were classified as possible (12.2%), probable (36.6%), proven (36.6%), or rejected (14.6%). Sensitivity was 68.6% and specificity was 100%. Most VAD-specific infections were percutaneous deep driveline infections (DRIs) (34.1%), and VAD-related infections were primarily bloodstream infections (31.7%). Staphylococcus aureus was the major pathogen isolated. Gallium-67 single-photon emission computed tomography low-dose CT resulted in changes in management in more than half (53.7%) of patients: starting (24.4%) or stopping (17.1%) antimicrobial therapy, LVAD revision (22.0%) or exchange (12.2%), and the application for 1A exception for transplant listing (17.1%). We conclude that Ga-SPECT-CT is an effective modality for determining the presence and extent of LVAD DRIs, and contributed to a change in management in more than half of cases.

Continuous-Flow Left Ventricular Assist Device Survival Improves With Multidisciplinary Approach.

BACKGROUND: Continuous-flow left ventricular assist devices have revolutionized the management of advanced heart failure. Device complications continue to limit survival, but enhanced management strategies have shown promise. This study compared outcomes for HeartMate II recipients before and after implementation of a multidisciplinary continuous support heart team (HTMCS) strategy. METHODS: Between January 2012 and December 2016, 124 consecutive patients underwent primary HeartMate II implantation at our institution. In January 2015, we instituted a HTMCS approach consisting of (1) daily simultaneous cardiology/cardiac surgery/critical care/pharmacy/coordinator rounds, (2) pharmacist-directed anticoagulation, (3) speed optimization echocardiogram before discharge, (4) comprehensive device thrombosis screening and early intervention, (5) blood pressure clinic with pulsatility-adjusted goals, (6) early follow-up after discharge and individual long-term coordinator/cardiologist assignment, and (7) systematic basic/advanced/expert training and credentialing of ancillary in-hospital providers. All patients completed 1-year of follow-up. RESULTS: Demographic characteristics for pre-HTMCS (n = 71) and HTMCS (n = 53) groups, including age (55.8 ± 12.1 versus 52.5 ± 14.1 years, p = not significant), percentage of men (77.5% versus 71.7%, p = not significant), and Interagency Registry for Mechanically Assisted Circulatory Support class 3 (84.5% versus 83.0%, p = not significant), were comparable. One-year survival was 74.6% versus 100% for the pre-HTMCS and HTMCS groups, respectively (p = 0.0002). One-year survival free of serious adverse events (reoperation to replace device or disabling stroke) was 70.4% versus 84.9% for the pre-HTMCS and HTMCS groups, respectively (p = 0.059). Event per patient-year rates for disabling stroke (0.15 versus 0, p = 0.019), gastrointestinal bleeding (0.87 versus 0.51, p = 0.11), and driveline infection (0.24 versus 0.10, p = 0.18) were lower for the HTMCS group, whereas pump thrombosis requiring device exchange was higher (0.09 versus 0.18, p = 0.14). CONCLUSIONS: Implementing a comprehensive multidisciplinary approach substantially improved outcomes for recipients of continuous-flow left ventricular assist devices.

False positive hepatitis C antibody test results in left ventricular assist device recipients: increased risk with age and transfusions.

Left ventricular assist devices (LVADs) have been successfully used in patients with heart failure. However, LVADs may trigger immune activation, leading to higher frequencies of autoantibodies. We describe the clinical, epidemiological, and laboratory characteristics of LVAD recipients with false positive hepatitis C (FPHC) serology among 39 consecutive adult LVAD recipients who bridged to heart transplantation from January 2007 to January 2013 at Montefiore Medical Center. FPHC patients were identified as those with post-LVAD positive hepatitis C ELISA antibody tests and negative confirmatory testing with hepatitis C RNA PCR and/or radioimmunoblot assay. Ten (26%) patients previously seronegative for hepatitis C were found to have FPHC after device placement. Of the 39 patients, 32 had HeartMate II devices. The mean age at LVAD placement was 55 years. FPHC correlated with older age at the time of LVAD implantation and with receipt of packed red blood cell transfusions, but not with gender, fresh frozen plasma transfusions, panel reactive antibodies, globulin fraction, rheumatoid factor, or anticardiolipin antibodies. Clinicians should be aware of this increased risk of FPHC in older LVAD patients and those more heavily transfused in order to avoid unnecessary apprehension and possible delay in transplantation. Further studies should be done to evaluate the possible relationship between transfused blood products and immunomodulation.

Role of gallium SPECT-CT in the diagnosis of left ventricular assist device infections.

Infection remains a well-established complication after the placement of left ventricular assist devices (LVADs). Defining the extent of infection is a challenging task as there are few effective imaging modalities and no standardized guidelines regarding imaging in the diagnosis of device-related infections (DRIs). The use of gallium with single photon emission tomography-computed tomography (Ga-SPECT-CT) has not been previously reported in localizing DRIs. We reviewed the charts and images of five patients with LVADs who underwent Ga-SPECT-CT for the diagnosis of various types of DRIs. Gallium SPECT-CT further clarified the extent of infections among LVAD patients, allowing for patient-specific tailored treatments including surgical debridement. Gallium SPECT-CT is a useful tool when diagnosing LVAD infections and could potentially be the imaging modality of choice in the near future. With improved imaging studies, such as Ga-SPECT-CT, allowing for earlier and more accurate diagnoses of DRIs, the outcome of such infections is likely to improve.

Enterococcus faecalis: an unusual cause of meningitis in HIV-infected patients.

A case of a severely immunosuppressed HIV-infected man with meningitis caused by Enterococcus faecalis is presented. E faecalis is a distinctly unusual cause of bacterial meningitis in patients with HIV infection and should be considered in the differential diagnosis of purulent meningitis in such patients to ensure optimal empiric treatment.