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Cryptococcosis is a global invasive mycosis associated with significant morbidity and mortality. These guidelines for its management have been built on the previous Infectious Diseases Society of America guidelines from 2000 and include new sections. There is a discussion of the management of cryptococcal meningoencephalitis in 3 risk groups: (1) human immunodeficiency virus (HIV)-infected individuals, (2) organ transplant recipients, and (3) non-HIVinfected and nontransplant hosts. There are specific recommendations for other unique risk populations, such as children, pregnant women, persons in resource-limited environments, and those with Cryptococcus gattii infection. Recommendations for management also include other sites of infection, including strategies for pulmonary cryptococcosis. Emphasis has been placed on potential complications in management of cryptococcal infection, including increased intracranial pressure, immune reconstitution inflammatory syndrome (IRIS), drug resistance, and cryptococcomas. Three key management principles have been articulated: (1) induction therapy for meningoencephalitis using fungicidal regimens, such as a polyene and flucytosine, followed by suppressive regimens using fluconazole; (2) importance of early recognition and treatment of increased intracranial pressure and/or IRIS; and (3) the use of lipid formulations of amphotericin B regimens in patients with renal impairment. Cryptococcosis remains a challenging management issue, with little new drug development or recent definitive studies. However, if the diagnosis is made early, if clinicians adhere to the basic principles of these guidelines, and if the underlying disease is controlled, then cryptococcosis can be managed successfully in the vast majority of patients. [ABSTRACT FROM AUTHOR]

Comments on the controversy related to the use of anti-fungal prophylaxis for solid organ transplant recipients in the United States. Statistics on the rate of transplantation procedures during the period 1990 through 1993; High-risk patient populations and epidemiological considerations; Approaches to prophylaxis and anti-fungal agents.

Impact of model for end-stage liver disease (MELD) scoring system on post-transplant infections and associated risk factors are unknown. Infections <90 d post-transplant were assessed in 277 consecutive liver transplant recipients from 1999 to 2008. "High-risk" factors for infections were pre-defined as MELD score >30, ICU stay >48 h prior to transplant, intraoperative transfusion ≥15 units, retransplantation, post-transplant dialysis, or reoperation. Of the 240 recipients in the MELD era (2002-2008), 48.5% had any high-risk factor. The OR for infection was 1.69, 2.00, 18.00, and 4.50 in recipients with any 1, 2, 3, and ≥4 high-risk factors, respectively (χ(2) for trend, p < 0.001). In logistic regression model, recipient age (OR 1.12, p < 0.05) and any high-risk factor (OR 2.42, p < 0.05) were associated with infections. Compared with 37 pre-MELD recipients, the overall infections and mortality at 12 months did not differ in the two eras. In Cox regression model, recipient age (OR 1.09, p < 0.05) and any high-risk factor (OR 2.42, p < 0.05) remained associated with infections. The overall frequency of infections did not increase in the MELD era. Pre-defined risk factors accurately predicted the risk of infections in these patients., (© 2010 John Wiley & Sons A/S.)

Background: Whether there are geographic differences in clinical presentation of cryptococcosis in solid organ transplant (SOT) recipients in the United States (US) is not known., Material/methods: Patients comprised a cohort of 120 SOT recipients from US transplant centers who fulfilled the EORTC/MSG criteria for cryptococcal disease., Results: Central nervous system, pulmonary, and cutaneous cryptococcal disease were observed in 51% (61/120), 64% (77/120), and 15% (18/120) of the patients, respectively. Cutaneous disease was documented in 9% (3/32) of the patients from South Atlantic region, 19% (6/32) from Mid Atlantic, 26% (6/23) from Southern, 7% (2/29) from Midwestern, and in 1 of 4 patients from the Northwestern region of the US. When controlled for age, immunosuppressive regimen, type of transplant, and renal failure at baseline, patients from the Southern compared with other regions of the US were significantly more likely to have cutaneous cryptococcal disease (OR 3.8, 95% CI 1.1-14, P=0.045)., Conclusions: Post-transplant cryptococcosis is more likely to present with cutaneous disease in the Southern region compared with other regions in the US. This predilection for cutaneous cryptococcosis could not be explained on the basis of differences in immunosuppression or the type of transplant. Whether our findings are related to strain-related variations in characteristics of the yeast or other transplant variables remains to be determined.

We assessed predictive factors and characteristics of patients with late-onset invasive aspergillosis in the current era of novel immunosuppressive agents. Forty transplant recipients with invasive aspergillosis were included in this prospective, observational study initiated in 2003 at our institutions. In 50% (20/40) of these patients, the infections were late-occurring. Receipt of sirolimus in conjunction with tacrolimus for refractory rejection or cardiac allograft vasculopathy (P=0.047) was significantly associated with late-onset infection. The use of depleting or non-depleting T or B-cell antibodies, either as induction or as antirejection therapy did not correlate with time to onset of invasive aspergillosis. Mortality at 90 days was 20% (4/20) for the patients with early-onset infection and 45% (9/20) for those with late-onset infection (P=0.17). Thus, nearly one-half of the Aspergillus infections in transplant recipients in the current era are late-occurring. These data have implications relevant for prophylactic strategies and guiding clinical management of transplant recipients presenting with pulmonary infiltrates.

Background: Methicillin-resistant Staphylococcus aureus has emerged as a leading pathogen in transplant recipients and has become endemic in many institutions where transplantation is performed. The role of active surveillance programs based on the detection of colonization in the prevention of S. aureus infection in liver transplant recipients has not been defined., Methods: A total of 47 consecutive patients who underwent liver transplantation during 1996-1999 were compared with 97 patients who received a liver transplant during 2000-2004 after implementation of an intensive intervention program that included use of surveillance cultures to detect nasal and rectal colonization, use of cohorting and contact isolation precautions, and decolonization with intranasal mupirocin therapy., Results: The rate of new acquisition of S. aureus colonization of nares after transplantation decreased from 45.6% (21 of 46 patients) during the preintervention period to 9.9% (9 of 91 patients) during the postintervention period (P<.001). An increased length of hospital stay (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; P<.002) was associated with new carriage acquisition, and transplantation during the postintervention period (odds ratio, 0.21; 95% confidence interval, 0.08-0.51; P<.001) was independently protective against new carriage. The rate of infection due to S. aureus decreased from 40.4% (19 of 47 patients) during the preintervention period to 4.1% (4 of 97 patients) during the postintervention period (P<.001), and the rate of bacteremia decreased from 25.5% (12 of 47 patients) to 4.1% (4 of 97 patients), respectively (P<.001). Overall, S. aureus infections occurred more frequently among patients with new carriage than among patients who were carriers at the time of transplantation (P<.001) or patients who were noncarriers (P<.001)., Conclusions: Use of active surveillance cultures to detect colonization and implementation of targeted infection control interventions proved to be effective in curtailing new acquisition of S. aureus colonization and in decreasing the rate of S. aureus infection that was endemic in our population of liver transplant recipients.

Background: This study determines whether the recipient and donor characteristics that influence the cytomegalovirus (CMV) infection rate after liver transplantation have changed., Methods: The recipient and donor characteristics that may affect the rate of CMV infection were assessed in 232 liver transplant recipients at our institution during a 14-year period (1989-2003)., Results: Since 1989, the age of recipients (P=0.0001) and donors (P=0.0001) has increased significantly. Pretransplant CMV seropositivity in recipients has decreased significantly (P=0.0001, 86.4% [1989-1992] to 53.7% [2000-2003]), whereas donor CMV seropositivity has remained unchanged (P>0.20). As a result, there has been a significant increase in the proportion of high-risk (CMV recipient-/donor+) patients (P=0.012); 10.6% of recipients from 1989 to 1992 versus 24.1% of recipients from 2000 to 2003 were CMV recipient-/donor+. The Child-Pugh scores of recipients have remained unchanged over time. However, the proportion of patients undergoing transplantation while being cared for in the intensive care unit has decreased significantly over time (P=0.0002). Despite an increase in the rate of CMV infection (P=0.09), the incidence of CMV disease has decreased significantly (P=0.0004)., Conclusions: The proportion of high-risk patients (CMV recipient-/donor+) has increased significantly over time, attributable largely to a declining rate of CMV seropositivity in recipients before transplantation. These data have implications for guiding prophylactic practices and resource use after liver transplantation.