Antimicrobial stewardship – Transplant style

Reviewed by Erica Stohs, MD, MPH, University of Nebraska, and Hannah Imlay, MD, MS, University of Utah

The October 2022 issue of Transplant Infectious Disease featured 39 articles dedicated to antimicrobial stewardship in transplantation, including original articles, viewpoints, and reviews. The relative paucity of original research in solid organ transplant (SOT) stewardship highlights the need for more work and attention in this area.

Original research

Seven original single-center research studies were included. Three studies concerned beta lactam allergy labels (BLALs):

  • Motzer et al: outcomes of 109 lung recipients with a diagnosis of pneumonia were compared between those with and without BLALs. 16.5% were identified to have a BLAL and were found to have lower utilization of beta lactams and a trend towards higher use of carbapenems and aztreonam. Patients with BLALs were observed to have a higher rate of CDI but a lower rate of AKI, but analyses were unable to be adjusted for potential confounders.
  • Mowrer et al: incidence of post-transplant surgical site infections was examined among 691 organ recipients (116 heart, 400 kidney, 175 liver) with and without BLALs. 17% reported BLAL. The use of preferred SSI prophylaxis was significantly different between patients with BLA (11% with preferred prophylaxis) vs no BLAL (92% with preferred prophylaxis), but there was no difference in SSI incidence between the groups (4.2% vs 4.3%).
  • Gorsline et al: safety and 6-month post-transplant antibiotic use in 26 of 27 transplant recipients who underwent antibiotic allergy de-labeling (mostly beta lactam and sulfa). There were no reported side effects to the de-labeled antibiotic within 6 months post transplant, and there were substantial cost savings associated with sulfa de-labeling.

The remainder assessed other antibiotic use in organ transplant:

  • Allen et al. examined surgical site infections following left ventricular assist device placement in 71 patients before and after a protocol change for perioperative prophylaxis (fluconazole, ciprofloxacin, rifampin, vancomycin changed to vancomycin and cefazolin). Authors determined that neither mortality nor the number of LVAD-associated infections were significantly different between groups before and after the protocol change.
  • Greenlee et al. applied NHSN-AU metrics to 530 organ transplant recipients within 12 months of their transplant over a two-year study period. These observational data may help to establish organ-specific benchmarks for DOT/1000 days that could be compared across centers.
  • Santos et al. compared their center’s NHSN’s AU:AR ratio pre-COVID-19 and during COVID-19 and reported their AU:AR ratio in the pre-COVID surgical ICU in which organ transplant and LVAD recipients are cared for.
  • Vu et al. reviewed their 42 C. auris fungemia cases in 2020-21 and described in depth the 5 cases that occurred in organ transplant recipients (n=5).


  • Global perspectives on current state of antimicrobial stewardship in 10 different countries from all regions of the globe
  • Organizational viewpoints on antimicrobial resistance and stewardship (European Society of Clinical Microbiology and Infectious Diseases, Veterans Affairs Medical Center, and the Transplant Quality Improvement Program).


A large fraction of the edition offers reviews of stewardship issues as they apply to organ transplant: appropriate metrics, diagnostic stewardship, rapid molecular diagnostics, shorter antimicrobial durations, antiviral and antifungal use, antibiotic allergy labels, stewarding in pediatric transplantation, use of desirability of outcome ranking, machine learning approaches, and implementation science.

Reference: “Special Issue: The urgent need for antimicrobial stewardship in transplantation.” Transplant Infectious Disease 2022;24(5).

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