Search

Background Graduate medical education programs shifted to an all-virtual recruitment in 2020. There is little published on the impact of this shift on the demographics of applicants, particularly in a field such as infectious disease where there are typically fewer applicants than available spots. Program directors were forced to make a radical change to their typical recruitment process. This study illustrates a single-center experience with virtual ID fellowship interviewing. Methods Using the Program Director Work Station on Electronic Residency Application Service (ERAS), we reviewed our program specific data from 2018-2021. We extracted the total number of applicants, the self-identified race/ethnicity of the applicants, their medical school type (US MD grad, DO grad, Non-US grad), their sex, and their location. We used simple descriptive statistics to identify trends and comparisons from in-person interviewing (2018 and 2019) and virtual interviewing (2020 and 2021). Results The number of virtual ID fellowship applicants to our program increased in 2021 by 24% compared to in-person applicants in 2019 (123 vs. 99). This exceeds what a program would expect from the 13% nation-wide increase in ID applicants in 2021 as there were a record 404 total applicants compared to 356 total applicants in 2019 We also saw an increase in Black or African American applicants; 13 Black applicants in 2021 compared to 2 Black applicants in 2019. We saw a stable rate of applicants who self-identified Hispanic, Latino, or of Spanish origin; 18 in 2019 and 17 in 2021. as Notably, we also saw an increase in geographic diversity of our applicants as we drew applicants from 22 states in 2019 (Figure 1a) and 35 states in 2021 (Figure 1b). Additionally, in 2020 we matched two applicants from geographically distant states (Ohio and Colorado) and in 2021 we matched one (Mississippi). Figure 1aFigure 1b Conclusion Virtual interviewing was advantageous for our infectious disease fellowship program at Temple University. We saw a 24% increase in applicants, had more Black applicants and more geographic diversity in our applicants. Furthermore, we were able to recruit these applicants into matched fellows. Disclosures All Authors: No reported disclosures.

BACKGROUND: Due to the ongoing opioid epidemic in the United States, deceased organ donors increasingly have a history of injection drug use (IDU), raising concerns about infectious risks to solid organ transplant (SOT) recipients. We sought to determine how recent IDU among deceased organ donors impacted donor culture results and recipient outcomes. METHODS: A retrospective cohort study was performed at three transplant centers. Exposed donors were those with “recent IDU” (in the prior 12 months). Primary outcomes included (1) positive donor cultures for bacteria or Candida species, (2) recipient bacterial or Candida infection within 3 months posttransplant, and (3) recipient graft failure or death within 12 months posttransplant. Mixed effects multivariable regression models were used to evaluate the relationship between recent donor IDU and each outcome. RESULTS: A total of 658 SOT recipients who received organs from 394 donors were included. Sixty-six (17%) donors had a history of recent IDU. Recent IDU in donors was associated with a significantly increased odds of donor culture positivity (aOR 3.65, 95% CI 1.06–12.60, p = .04) but was not associated with SOT recipient infection (aHR 0.98, 95% CI 0.71–1.36, p = .92) or graft failure or death (aHR 0.67, 95% CI 0.29–1.51, p = .33). CONCLUSION: Donors with recent IDU are more likely to have positive cultures, but their recipients’ outcomes are unaffected, suggesting organs from donors with recent IDU may be safely utilized.

The extent to which donor multidrug-resistant organisms (MDROs) affect organ utilization remains unclear. We performed a retrospective cohort study at 4 transplant centers between 2015 and 2016 to evaluate this question. All deceased donors who donated at least one organ were included. Exposed donors had at least one MDRO on culture. Unexposed donors had no MDRO-positive cultures. Only cultures obtained during the donor's terminal hospitalization were evaluated. Multivariable regression was used to determine the association between donor MDRO and (1) number of organs transplanted per donor and (2) the match run at which each organ was accepted. Subsequently, we restricted the analysis to donors with MDR-Gram-negative (GN) organisms. Of 440 total donors, 29 (7%) donors grew MDROs and 7 (2%) grew MDR-GNs. There was no significant association between donor MDRO and either measure of organ utilization. However, donor MDR-GNs were associated with a significant reduction in the number of organs transplanted per donor (incidence rate ratio 0.43, 95% confidence interval [CI] 0.39-0.48, P < .01), and organs were accepted significantly further down the match list (relative count 5.08, 95% CI 1.64-15.68, P = .01). Though donor MDR-GNs were infrequent in our study, their growing prevalence could meaningfully reduce the donor pool over time.

Background Risk factors for acquisition of vancomycin-resistant Enterococcus (VRE) include immunosuppression, antibiotic exposure, indwelling catheters, and manipulation of the gastrointestinal tract, all of which occur in liver transplant recipients. VRE infections are documented in liver transplantation (LT); however, only one single center study has assessed the impact of daptomycin-resistant Enterococcus (DRE) in this patient population. Methods We conducted a retrospective multicenter cohort study comparing liver transplant recipients with either VRE or DRE bacteremia. The primary outcome was death within 1 year of transplantation. Multivariable logistic regression analyses were performed to calculate adjusted odds ratios for outcomes of interest. Results We identified 139 cases of Enterococcus bacteremia following LT, of which 78% were VRE and 22% were DRE. When adjusted for total intensive care unit days in the first transplant year, liver-kidney transplantation, and calcineurin inhibitor use, patients with DRE bacteremia were 2.65 times more likely to die within 1 year of transplantation (adjusted odds ratio [aOR], 2.648; 95% CI, 1.025–6.840; P = .044). Prior daptomycin exposure was found to be an independent predictor of DRE bacteremia (aOR, 30.62; 95% CI, 10.087–92.955; P Conclusions In this multicenter study of LT recipients with Enterococcus bacteremia, DRE bacteremia was associated with higher 1-year mortality rates when compared with VRE bacteremia. Our data provide strong support for dedicated infection prevention and antimicrobial stewardship efforts for transplant patients. Further research is needed to support the development of better antibiotics for DRE and practical guidance focusing on identification and prevention of colonization and subsequent infection in liver transplant recipients at high risk for DRE bacteremia.

Risk factors for acquisition of vancomycin-resistantWe conducted a retrospective multicenter cohort study comparing liver transplant recipients with either VRE or DRE bacteremia. The primary outcome was death within 1 year of transplantation. Multivariable logistic regression analyses were performed to calculate adjusted odds ratios for outcomes of interest.We identified 139 cases ofIn this multicenter study of LT recipients with

Background Our case series describes three patients who have received single-lung transplantations for idiopathic pulmonary fibrosis (IPF) that develop cytomegalovirus (CMV) disease and hypoxemic respiratory failure with radiographic opacification of the native lung and sparing of the allograft. Results Hypoxemia resolved with treatment and with resolution of CMV viremia. Viral infections causing IPF exacerbations have been described in the literature, however, pulmonary CMV disease in single-lung transplant recipients has typically been observed as pneumonitis of the allograft. Conclusions These clinical scenarios are consistent with acute exacerbation of native-lung IPF and subradiographic pneumonitis of the allograft caused by CMV disease.

Donor infection or colonization with a multidrug-resistant organism (MDRO) affects organ utilization and recipient antibiotic management. Approaches to identifying donors at risk of carrying MDROs are unknown. We sought to determine the risk factors for MDROs among transplant donors. A multicenter retrospective cohort study was conducted at four transplant centers between 2015 and 2016. All deceased donors who donated at least one organ were included. Cultures obtained during the donor's terminal hospitalization and organ procurement were evaluated. The primary outcome was isolation of an MDRO on culture. Multivariable Cox regression was used to determine risk factors associated with time to donor MDRO. Of 440 total donors, 64 (15%) donors grew an MDRO on culture. Predictors of an MDRO on donor culture included hepatitis C viremia (hazard ratio [HR] 4.09, 95% confidence interval [CI] 1.71-9.78, P = .002), need for dialysis (HR 4.59, 95% CI 1.09-19.21, P = .037), prior hematopoietic cell transplant (HR 7.57, 95% CI 1.03-55.75, P = .047), and exposure to antibiotics with a narrow gram-negative spectrum (HR 1.13, 95% CI 1.00-1.27, P = .045). This is the first study to determine risk factors for MDROs among deceased donors and will be important for risk stratifying potential donors and informing transplant recipient prophylaxis.

Antibiotic use in deceased organ donors has not been previously described. In a retrospective cohort of 440 donors, we found 427 (97%) received at least one antibiotic course, 312 (71%) received broad-spectrum antibiotics, and 61 (14%) received potentially redundant antibiotics during their terminal hospitalization, suggesting a need for stewardship.

Patients undergoing thoracic organ transplantation procedures involving the heart or lung are at increased risk for developing a wide variety of infections due to their underlying immunosuppression and/or other factors. Lung transplant recipients are at high risk for developing infections caused by bacteria, viruses, and opportunistic fungi, whereas heart transplant recipients are at risk for developing infections caused by these same microorganisms, as well as parasitic infections, including toxoplasmosis and New World trypanosomiasis. This review will highlight the various infections that thoracic organ transplant recipients may develop following their procedures.

Remediation of struggling learners is a challenge faced by all educators. In recognition of this reality, and in light of contemporary challenges facing infectious diseases (ID) fellowship program directors, the Infectious Diseases Society of America Training Program Directors’ Committee focused the 2018 National Fellowship Program Directors’ Meeting at IDWeek on “Remediation of the Struggling Fellow.” Small group discussions addressed 7 core topics, including feedback and evaluations, performance management and remediation, knowledge deficits, fellow well-being, efficiency and time management, teaching skills, and career development. This manuscript synthesizes those discussions around a competency-based framework to provide program directors and other educators with a roadmap for addressing common contemporary remediation challenges., Helping to remediate struggling learners is a common challenge for educators. Here ID fellowship training program directors provide tangible, actionable resources to assist with these efforts, which demand clear and objective data, thoughtful review and reflection, and collaboration among stakeholders.

Background With the ongoing opioid epidemic in the US, there has been an increase in the proportion of deceased organ donors with a history of injection drug use (IDU), raising concern for additional infectious risks to transplantation.We sought to determine how recent IDU among deceased organ donors impacted donor culture results. Methods A retrospective cohort study was conducted at four transplant centers in Philadelphia between 1/1/2015 and 6/30/2016. All deceased organ donors who donated ≥ 1 organ to one of the centers were included. Exposed donors were those with a recent history of IDU (defined by use in the prior 12 months based on donor chart review). Unexposed donors were those with no recent history of IDU. The primary outcome was any positive donor culture (taken during the terminal hospitalization or at the time of organ procurement) for bacteria or Candida. Multivariable logistic regression was used to determine the association between recent IDU and donor culture positivity. Secondarily, the association between donor IDU and isolation of (1) a multidrug-resistant organism (MDRO) on culture, (2) Staphylococcus aureus on culture, (3) Candida on non-respiratory culture, and (4) bacteria or Candida on blood culture were determined. Results Of 394 total donors, 66 (17%) had a history of recent IDU and 343 (87%) had at least one positive donor culture. On multivariable analysis, recent IDU was associated with significantly increased odds of having at least one positive donor culture (aOR 3.6, 95% CI 1.1-11.9, P=0.04) and Candida on non-respiratory culture (aOR 2.6, 95% CI 1.1-6.2, P=0.03). However, recent IDU was not significantly associated with increased odds of MDRO on culture (OR 0.90, 95% CI 0.41-1.93, P=0.79), S. aureus on culture (OR 1.35, 95% CI 0.79-2.28, P=0.27), or positive blood culture (OR 0.79, 95% CI 0.32-1.95, P=0.60). Conclusion Donors with a recent history of IDU are more likely to have bacteria or Candida identified on cultures taken during their terminal hospitalization or at organ procurement. This increase does not appear to be driven by MDROs, S. aureus, or bloodstream infections but rather by Candida isolated from non-respiratory sites, potentially alleviating some fears surrounding the acceptance of solid organs from donors with a history of recent IDU. Disclosures Ebbing Lautenbach, MD, MPH, MSCE, Merck (Other Financial or Material Support, Member of Data and Safety Monitoring Board (DSMB)) Emily Blumberg, MD, Amplyx (Other Financial or Material Support, Member of Data and Safety Monitoring Board (DSMB))Hologic (Research Grant or Support)Merck (Grant/Research Support, Other Financial or Material Support, Member of Scientific Advisory Committee)Takeda (Research Grant or Support, Other Financial or Material Support, Member of Scientific Advisory Committee) Jennifer Han, MD, MSCE, GlaxoSmithKline (Employee, Shareholder) Judith A. Anesi, MD, MSCE, Nothing to disclose

BACKGROUND Bronchial stenosis is a known complication of lung transplantation, but there are limited data regarding whether transplant recipients with bronchial stenosis develop more infectious complications than those without bronchial stenosis. METHODS We conducted a retrospective single-center observational cohort study between January 1, 2011 and September 29, 2016 of 35 lung transplant recipients diagnosed with bronchial stenosis and a random sample of 35 lung transplant recipients without bronchial stenosis. Data collected included donor/recipient demographic and anatomic information, respiratory cultures, episodes of respiratory infections diagnosed using CDC-NNIS criteria, hospitalizations, and 1-year all-cause mortality. Patients were followed up to 1 year after transplant. RESULTS Bronchial stenosis occurred at a median of 54 days post-transplant (range 5-365 days). Bronchial stenosis patients spent more time in the hospital (87.4 vs 46.8 days, P = 0.011) and had more total hospitalizations (4.54 vs 2.37, P

Nocardia species are strictly aerobic, gram-positive, branching, filamentous rods which are beaded appearing and stained variably with the modified acid-fast Kinyoun stain. They can fragment into pleomorphic, rod-shaped, or coccoid pieces. Nocardia are sometimes difficult to recognize and identify in the laboratory, leading to delays in clinical diagnosis. Their relatively slow growth can result in the cultures being discarded before the colonies can be seen. Nocardia are found most often in the environment in soil, water, and vegetation. More than half of the time, these organisms are opportunistic pathogens, causing disease in both solid organ and stem cell transplantations. Less recognized as opportunistic pathogens are Actinomyces species, gram-positive, anaerobic bacilli which are not acid-fast. These organisms are morphologically similar to Nocardia species and can be confused on Gram staining. Nocardia and Actinomycetes cause distinct syndromes which will be reviewed here.

Background Clostridium difficile infection is a serious and common illness affecting almost 500,000 people in the United States each year. Solid-organ transplant recipients are at increased risk for this infection, with lung transplant patients being at the highest risk. Temple University Hospital (TUH) in Philadelphia has performed the most lung transplants in the United States over the last 2 years. Methods A retrospective case–control study was performed to identify patients diagnosed with C. difficile following lung transplantation at our institution between January 1, 2014 and April 30, 2018 (N = 35). We randomly selected control patients (N = 35) who had lung transplantation performed during this time but did not develop C. difficile infection. The study objectives were to characterize risk factors that are associated with C. difficile infection in lung transplant recipients and compare clinical outcomes in recipients with and without C. difficile. Statistical analysis was performed using Epi Info (CDC, Atlanta GA). Results The average age was 62.4 years, 64.7% were male, 75% were white and 69.1% of transplants were performed for underlying idiopathic pulmonary fibrosis. 52.9% of patients had “non-severe” C. difficile infection as defined by the 2018 Infectious Disease Society of America guidelines. Patients with C. difficile infection were more likely to have been treated for cytomegalovirus (CMV) viremia (OR 8.2, 95% CI 2.4–28.2, P = 0.0006) and were more likely to have received third- to fifth-generation cephalosporins (OR 4.0, 95% CI 1.4–11.2, P = 0.01) and/or carbapenems (OR 3.7, 95% CI 1.4–9.9, P = 0.02). Patients with C. difficile infection were more likely to experience multiple hospitalizations when compared with C. difficile-negative patients (3.6 vs. 8.4, P = 0.003). 22 of the 68 evaluable patients died during the study period, 9 of whom had C. difficile infection (P = NS). Conclusion Patients who received lung transplants and developed C. difficile infection were more likely to be treated for CMV viremia, receive antibiotics including cephalosporins and/or carbapenems and require repeat hospitalizations when compared with control patients who did not develop C. difficile infection following transplant. Disclosures All authors: No reported disclosures.

Patients who need abdominal organ transplantation are at high risk for community-acquired, nosocomial, and opportunistic infections. In part, this is due to the invasive procedures they undergo, as well as the immunosuppression they require. This review highlights the infections that these vulnerable patients may develop. The current epidemiology, diagnosis, and management of common infections in liver, kidney, pancreas, and intestinal transplant (IT) recipients are summarized here.

The American Society of Transplantation Infectious Diseases (ID) Community of Practice has established an education workgroup to identify core components of a curriculum for training specialists in transplant ID. Clinical, laboratory, and research training form the triad of components on which an additional year of ID training, dedicated to the care of solid organ and hematopoietic stem cell transplant recipients, should be based. The recommended training environment would have access to adequate numbers of transplant patients, along with qualified faculty committed to teaching specialized fellows in this area. The learning objectives for both inpatient and outpatient clinical training are presented. The laboratory component requires trainees to attain expertize in utilizing and interpreting cutting-edge diagnostics used in transplant medicine. The research component may involve basic science, and translational or clinical research individualized to the trainee. Finally, suggestions for evaluation of both the fellows and the training program are provided.

Prosthetic joint infection (PJI) occurs with significant morbidity and health care expenditure. Transplant recipients on immunosuppressive medications are at increased risk for infections caused by less common organisms at unusual sites. Here we report a case of isolated PJI with Mycobacterium avium complex (MAC) in an immunosuppressed failed kidney transplant recipient and review the literature on this unique infection. We discuss the likely pathogenesis of PJI with MAC including the role of biofilm formation by non-tuberculous mycobacteria. The possible role of cytokine milieu alteration by immunosuppressive therapy, particularly the reduction in interferon-gamma levels, as a predisposing factor for non-tuberculous mycobacterial infections in transplant recipients is explored. Lastly, we review the role of immune cell function assay in predicting the susceptibility to infection in our patient specifically and in solid organ transplant recipients in general.

The foodborne pathogen Listeria monocytogenes has a particular tropism for the central nervous system and can produce infection in the meninges and brain substance. Well-recognized clinical syndromes include meningitis, brain abscess, rhombencephalitis, and spinal cord abscess; simultaneous infection of the meninges and brain is common. Although it is an uncommon cause of infection in the population at large, L. monocytogenes is an important cause of central nervous system infection in those with impaired cell-mediated immunity, whether due to underlying disease or treatment with immunosuppressive therapeutic agents; it is the etiology in 20% of bacterial meningitis cases in neonates and in 20% of cases in those older than 50 years. Ampicillin is considered the treatment of choice, and trimethoprim-sulfamethoxazole is recommended for those allergic to penicillin. At-risk patients should be advised to avoid unpasteurized milk and soft cheeses along with deli-style, ready-to-eat prepared meats, particularly poultry products.

Organ transplantation is an acceptable option for human immunodeficiency virus (HIV)-infected patients with end-stage kidney or liver disease. With worse outcomes on the waitlist, HIV-infected patients may actually be disproportionately affected by the organ shortage in the United States. One potential solution is the use of HIV-infected deceased donors (HIVDD), recently legalized by the HIV Organ Policy Equity (HOPE) Act. This is the first analysis of patient-specific data from potential HIVDD, retrospectively examining charts of HIV-infected patients dying in care at six HIV clinics in Philadelphia, Pennsylvania from January 1, 2009 to June 30, 2014. Our data suggest that there are four to five potential HIVDD dying in Philadelphia annually who might yield two to three kidneys and three to five livers for transplant. Extrapolated nationally, this would approximate 356 potential HIVDD yielding 192 kidneys and 247 livers annually. However, several donor risk indices raise concerns about the quality of kidneys that could be recovered from HIVDD as a result of older donor age and comorbidities. On the other hand, livers from these potential HIVDD are of similar quality to HIV-negative donors dying locally, although there is a high prevalence of positive hepatitis C antibody.

Without proper treatment, the mortality of pulmonary mucormycosis is nearly 100%. Although the diagnosis is often made histologically, it can be suspected when patients have a reverse halo sign on computed tomography (CT) of the chest, along with the right clinical findings. We describe the case of a woman 7 months post renal transplant who presented with fevers, malaise, and chest pain. Her chest CT revealed a round, focal area of ground-glass attenuation surrounded by a complete rim of consolidation in the left upper lobe, consistent with the reverse halo sign. Pulmonary mucormycosis was diagnosed by transbronchial lung biopsy. She was successfully treated with combined medical and surgical therapies. In the context of this case, we provide a brief review of the diagnosis of pulmonary mucormycosis, with a focus on radiographic and pathologic findings.

The Centers for Disease Control and Prevention (CDC) recommends offering HIV testing to persons admitted to emergency departments (EDs). Whether by opt-in or opt-out, many EDs (including our own) have found a seroprevalence of 0.8-1.5% when rapid testing is offered. The true seropositivity rate is unknown. We performed a retrospective chart analysis upon all patients presenting to our ED over a 2-week period in the fall of 2007 who had serum drawn as a part of their emergency care. Demographics and clinical characteristics were linked via de-identified serum, which was sent for HIV testing. Nine hundred fifty nine patients had sera available for rapid HIV testing. One hundred twenty one (13%) samples were reactive via the OraQuick(®) test (OraSure Technologies, Bethlehem, PA), a point of care rapid antibody test. Due to concerns about the appropriateness of sera as substrate for the OraQuick(®) technology, reactive samples were retested via standard enzyme immunoassay (EIA)/Western blot. One hundred twelve analyzable samples were retested-38 were positive and 27 of these were from patients who reported a history of HIV infection. The rate of undiagnosed HIV infection was 1.2% (11/914 potentially analyzable samples). Of all patients with HIV in our ED, 29% of them were presumably unaware of their diagnosis. In conclusion, HIV seroprevalence in our urban ED is high, and a large fraction of the patients appears to be unaware of the infection.

The bacterium Listeria monocytogenes infrequently causes illness in the general population. In some groups, however, including pregnant women, newborns, elderly persons, and those with impaired cell-mediated immunity, including many cancer patients, it is an important cause of invasive disease, particularly bacteremia, meningitis, encephalitis, and brain abscess. Nocardia species are aerobic, Gram-positive, branching, filamentous, bacterial rods, which are most often found in the environment in soil, water, and vegetable matter. The key host defense against developing nocardiosis is cell-mediated immunity; the humoral immune response offers little protection. These organisms are considered opportunistic pathogens, causing infection in patients with impaired cell-mediated immune response, including patients with lymphoreticular neoplasia, organ transplantation, HIV/AIDS, diabetes mellitus, and alcoholism. In particular, there is a well-documented association between nocardiosis and chronic granulomatous disease (CGD). In this chapter, we present a detailed review of epidemiology, clinical presentation, and management of these opportunistic infections in immunosuppressed patients with cancer.

Simultaneous mold infections in heart transplant recipients have not been previously reported. Here we describe early onset post-transplant pulmonary aspergillosis and cutaneous zygomycosis in a 46-year-old heart transplant recipient who was also treated with basiliximab. Along with surgical debridement, medical treatment of his cutaneous abdominal wall zygomycosis at the former left ventricular assist device driveline site with liposomal amphotericin B and voriconazole also led to cure of his pulmonary aspergillosis.

Introduction Strongyloides is a helminthic intestinal parasite that is common in tropical regions. In immunosuppressed individuals it may cause a hyperinfection syndrome with fatal complications. We present one such case. Case Report A 60 year old Hispanic male presents 2 months after heart transplantation (HT) with fatigue. His post transplant course was complicated by recurrent rejection requiring intravenous steroids. His immunosuppression included tacrolimus, mycophenolate mofetil and prednisone. On presentation, he underwent endomyocardial biopsy which demonstrated 1R rejection. Echocardiography revealed normal allograft function. He developed respiratory distress requiring intubation, followed by profound hypotension necessitating vasopressor and broad spectrum antimicrobial support. Due to difficulty with oxygenation, he underwent urgent bronchoscopy. Over the next 72 hours, he became increasingly unstable. On hospital day 4, Papanicolaou staining identified Strongyloides in the bronchoalveolar lavage specimen. [ figure 1 ] Ivermectin 200mg was initiated and on hospital day 7 with the patient continuing to do poorly, albendazole was added. This resulted in improvement in his hemodynamic and respiratory status, however, his mental status failed to recover. Lumbar puncture revealed Strongyloides in the cerebro-spinal fluid. On hospital day 26 life sustaining support was withdrawn and the patient passed away. Summary Atypical symptoms and rapid deterioration in HT patients without a clear cause should prompt an early investigation for strongyloides. Screening of high risk populations, such as those from endemic areas, of both potential donors and recipients should be discussed as pre-treatment may prevent catastrophic complications.