Changing trends in infectious disease in heart transplantation

Haddad, François; Deuse, Tobias; Pham, Michael; Khazanie, Prateeti; Rosso, Fernando; Luikart, Helen; Valantine, Hannah; Leon, Sebastian; Vu, Thu A.; Hunt, Sharon A.; Oyer, Philip; Montoya, Jose G.

doi:10.1016/j.healun.2009.08.018

« Previous Next »The Journal of Heart and Lung Transplantation
Volume 29, Issue 3 , Pages 306-315, March 2010

Changing trends in infectious disease in heart transplantation

François Haddad, MD
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University, Stanford, California
- Reprint requests: François Haddad, MD, Division of Cardiovascular Medicine, Falk Cardiovascular Research Center, Stanford, CA 94305
Tobias Deuse, MD, PhD
- Division of Cardiothoracic Surgery, Stanford University Medical Center, Stanford University, Stanford, California
Michael Pham, MD, MPH
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University, Stanford, California
Prateeti Khazanie, MD, MPH
- Department of Medicine, Stanford University Medical Center, Stanford University, Stanford, California
Fernando Rosso, MD
- Division of Infectious Disease, Stanford University Medical Center, Stanford University, Stanford, California
Helen Luikart, RN
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University, Stanford, California
Hannah Valantine, MD
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University, Stanford, California
Sebastian Leon, MD
- Department of Medicine, Stanford University Medical Center, Stanford University, Stanford, California
Thu A. Vu, BSc
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University, Stanford, California
Sharon A. Hunt, MD
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University, Stanford, California
Philip Oyer, MD, PhD
- Division of Cardiothoracic Surgery, Stanford University Medical Center, Stanford University, Stanford, California
Jose G. Montoya, MD
- Division of Infectious Disease, Stanford University Medical Center, Stanford University, Stanford, California
- Jose G. Montoya, MD, Division of Infectious Disease, Stanford School of Medicine, Stanford, CA 94305

published online 26 October 2009.

Background

During the past 25 years, advances in immunosuppression and the use of selective anti-microbial prophylaxis have progressively reduced the risk of infection after heart transplantation. This study presents a historical perspective of the changing trends of infectious disease after heart transplantation.

Methods

Infectious complications in 4 representative eras of immunosuppression and anti-microbial prophylaxis were analyzed: (1) 38 in the pre-cyclosporine era (1978–1980), (2) 72 in the early cyclosporine era (1982–1984), where maintenance immunosuppression included high-dose cyclosporine and corticosteroid therapy; (3) 395 in the cyclosporine era (1988–1997), where maintenance immunosuppression included cyclosporine, azathioprine, and lower corticosteroid doses; and (4) 167 in the more recent era (2002–2005), where maintenance immunosuppression included cyclosporine and mycophenolate mofetil.

Results

The overall incidence of infections decreased in the 4 cohorts from 3.35 episodes/patient to 2.03, 1.35, and 0.60 in the more recent cohorts (p < 0.001). Gram-positive bacteria are emerging as the predominant cause of bacterial infections (28.6%, 31.4%, 51.0%, 67.6%, p = 0.001). Cytomegalovirus infections have significantly decreased in incidence and occur later after transplantation (88 ± 77 days, pre-cyclosporine era; 304 ± 238 days, recent cohort; p < 0.001). Fungal infections also decreased, from an incidence of 0.29/patient in the pre-cyclosporine era to 0.08 in the most recent era. A major decrease in Pneumocystis jiroveci and Nocardia infections has also occurred.

Conclusions

The overall incidence and mortality associated with infections continues to decrease in heart transplantation and coincides with advances in immunosuppression, the use of selective anti-microbial prophylaxis, and more effective treatment regimens.

Keywords: heart transplantation, infectious disease, cytomegalovirus, aspergillus, bacterial infection, outcome research, prophylaxis