tacrolimus and Cross-Infection

Immunosuppression is a known risk for post-transplant infections. Little data exist on the risk contributions of specific agents for various infections.. A triply robust propensity score-adjusted analysis was performed in a renal transplant cohort between February 2006 and January 2014. The study was performed to identify the incidence and the risk factors for developing a post-transplant infection. After initial bivariate analysis, a triply robust propensity score-adjusted multivariate logistic regression was performed.. The mean age of the 717 renal transplant recipients was 50.0 ± 13.3 years, with the majority being male (61.6%) and 349 (48.7%) experiencing at least 1 post-transplant infection. Neither race, graft type, nor insurance status was associated with an increased incidence or risk of infection. In a fully adjusted regression model, the immunosuppressants mycophenolic acid mofetil (OR 0.38, 95% CI 0.21-0.71; P < .001) and alemtuzumab (OR 0.40, 95% CI 0.19-0.85; P = .020) were protective.. Alemtuzumab and mycophenolic acid mofetil as immunosuppressant agents in a multiagent protocol appear to decrease the incidence of infection. Cytomegalovirus antigenemia was the greatest risk for infection and mycophenolic acid mofetil possessed the greatest protective effect on viral infections.

Topics: Adult; Alemtuzumab; Case-Control Studies; Community-Acquired Infections; Cross Infection; Female; Glucocorticoids; Humans; Immunosuppressive Agents; Infections; Kidney Transplantation; Male; Middle Aged; Mycophenolic Acid; Opportunistic Infections; Propensity Score; Retrospective Studies; Risk Factors; Tacrolimus; Virus Diseases

The Allgemeines Krankenhaus Informations Management (AKIM) project was started at the Vienna General Hospital (VGH) several years ago. This led to the introduction of a new hospital information system (HIS), and the installation of the expert system platform (EXP) for the integration of Arden-Syntax-based clinical decision support systems (CDSSs). In this report we take a look at the milestones achieved and the challenges faced in the creation and modification of CDSSs, and their integration into the HIS over the last three years.. We introduce a three-stage development method, which is followed in nearly all CDSS projects at the Medical University of Vienna and the VGH. Stage one comprises requirements engineering and system conception. Stage two focuses on the implementation and testing of the system. Finally, stage three describes the deployment and integration of the system in the VGH HIS. The HIS provides a clinical work environment for healthcare specialists using customizable graphical interfaces known as parametric medical documents. Multiple Arden Syntax servers are employed to host and execute the CDSS knowledge bases: two embedded in the EXP for production and development, and a further three in clinical routine for production, development, and quality assurance.. Three systems are discussed; the systems serve different purposes in different clinical areas, but are all implemented with Arden Syntax. MONI-ICU is an automated surveillance system for monitoring healthcare-associated infections in the intensive care setting. TSM-CDS is a CDSS used for risk prediction in the formation of cutaneous melanoma metastases. Finally, TacroDS is a CDSS for the manipulation of dosages for tacrolimus, an immunosuppressive agent used after kidney transplantation. Problems in development and integration were related to data quality or availability, although organizational difficulties also caused delays in development and integration.. Since the inception of the AKIM project at the VGH and its ability to support standards such as Arden Syntax and integrate CDSSs into clinical routine, the clinicians' interest in, and demand for, decision support has increased substantially. The use of Arden Syntax as a standard for CDSSs played a substantial role in the ability to rapidly create high-quality CDSS systems, whereas the ability to integrate these systems into the HIS made CDSSs more popular among physicians. Despite these successes, challenges such as lack of (consistent and high-quality) electronic data, social acceptance among healthcare personnel, and legislative issues remain. These have to be addressed effectively before CDSSs can be more widely accepted and adopted.

Topics: Artificial Intelligence; Cross Infection; Decision Support Systems, Clinical; Expert Systems; Hospital Information Systems; Humans; Intensive Care Units; Kidney Transplantation; Medical Informatics; Melanoma; Neoplasm Metastasis; Programming Languages; Risk Assessment; Tacrolimus

Pulmonary infections are a significant cause of morbidity after liver transplantation; Gram-negative bacilli, cytomegalovirus, and Pneumocystis carinii were the usual pulmonary pathogens in the earlier studies in liver transplant recipients receiving cyclosporine. We prospectively assessed the impact of pulmonary infection in 101 consecutive liver transplant recipients receiving the new immunosuppressive agent tacrolimus (FK506). Fifteen percent (15/101) of the patients had 19 episodes of pneumonia; 58% (11/19) of the pneumonias were bacterial, 37% (7/19) were fungal, and 5% (1/19) were protozoal (Toxoplasma gondii). Twenty-seven percent of the bacterial pneumonias were due to Legionella. None of the patients had cytomegalovirus or P carinii pneumonia. Seven percent (7/10) of the study patients had fungal pneumonitis; 4% had invasive aspergillosis and 3% had cryptococcosis. Mortality was significantly higher (53%, 8/15) for patients with pneumonia than for patients without pneumonia (10%, 9/86, P = 0.0004). Only fungal pneumonias were the direct cause of death; 63% (5/8) of the deaths were in patients with fungal pneumonitis. Our data suggest a changing pattern of microbial etiologies of pneumonitis in the era of modern immunosuppressive agents. We show that P carinii pneumonia and cytomegalovirus can be effectively curtailed with appropriate prophylaxis. Fungal infections, on the contrary, not only constituted a major proportion of the pneumonia, but also carried the highest pneumonia-associated mortality. Legionella infections can be overlooked unless specialized laboratory methodology (cultured on selective media, urinary antigen) are applied routinely on all cases of pneumonia. We recommend routine culture on the water supply for Legionella in all transplant centers.

Topics: Adult; Aged; Community-Acquired Infections; Cross Infection; Female; Humans; Immunosuppressive Agents; Legionnaires' Disease; Liver Transplantation; Lung Diseases, Fungal; Lung Diseases, Parasitic; Male; Middle Aged; Pneumonia; Pneumonia, Bacterial; Prospective Studies; Risk Factors; Tacrolimus; Toxoplasmosis