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Antimicrobial stewardship programs (ASPs) have made immense strides in optimizing antibiotic, antifungal, and antiviral use in clinical settings. However, although ASPs are required institutionally by regulatory agencies in the United States and Canada, they are not mandated for transplant centers or programs specifically. Despite the fact that solid organ transplant recipients in particular are at increased risk of infections from multidrug-resistant organisms, due to host and donor factors and immunosuppressive therapy, there currently are little rigorous data regarding stewardship practices in solid organ transplant populations, and thus, no transplant-specific requirements currently exist. Further complicating matters, transplant patients have a wide range of variability regarding their susceptibility to infection, as factors such as surgery of transplant, intensity of immunosuppression, and presence of drains or catheters in situ may modify the risk of infection. As such, it is not feasible to have a “one-size-fits-all” style of stewardship for this patient population. The objective of this white paper is to identify opportunities, risk factors, and ASP strategies that should be assessed with solid organ transplant recipients to optimize antimicrobial use, while producing an overall improvement in patient outcomes. We hope it may serve as a springboard for development of future guidance and identification of research opportunities.

Importance: Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence.Objective: To construct a clinical guideline for pyogenic osteomyelitis management, with a new standard of evidence to resolve the gap between strength of recommendation and quality of evidence, through the use of a novel open access approach utilizing social media tools.Evidence Review: This consensus statement and systematic review study used a novel approach from the WikiGuidelines Group, an open access collaborative research project, to construct clinical guidelines for pyogenic osteomyelitis. In June 2021 and February 2022, authors recruited via social media conducted multiple PubMed literature searches, including all years and languages, regarding osteomyelitis management; criteria for article quality and inclusion were specified in the group's charter. The GRADE system for evaluating evidence was not used based on previously published concerns regarding the potential dissociation between strength of recommendation and quality of evidence. Instead, the charter required that clear recommendations be made only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were drafted to discuss pros and cons of care choices. Both clear recommendations and clinical reviews were planned with the intention to be regularly updated as new data become available.Findings: Sixty-three participants with diverse expertise from 8 countries developed the group's charter and its first guideline on pyogenic osteomyelitis. These participants included both nonacademic and academic physicians and pharmacists specializing in general internal medicine or hospital medicine, infectious diseases, orthopedic surgery, pharmacology, and medical microbiology. Of the 7 questions addressed in the guideline, 2 clear recommendations were offered for the use of oral antibiotic therapy and the duration of therapy. In addition, 5 clinical reviews were authored addressing diagnosis, approaches to osteomyelitis underlying a pressure ulcer, timing for the administration of empirical therapy, specific antimicrobial options (including empirical regimens, use of antimicrobials targeting resistant pathogens, the role of bone penetration, and the use of rifampin as adjunctive therapy), and the role of biomarkers and imaging to assess responses to therapy.Conclusions and Relevance: The WikiGuidelines approach offers a novel methodology for clinical guideline development that precludes recommendations based on low-quality data or opinion. The primary limitation is the need for more rigorous clinical investigations, enabling additional clear recommendations for clinical questions currently unresolved by high-quality data.

Purpose of review This unique review on the rationale and implementation of antimicrobial management in the solid organ transplant setting will identify strategies that can be used to improve empiric antimicrobial therapy and decrease antimicrobial use. Recent findings Most data on antimicrobial management and solid organ transplantation recipients is incorporated into ICU outcomes. Recently published guidelines for antimicrobial management programs can be tailored for this population. Strategies that are valuable to solid organ transplantation programs include postantimicrobial approval, which has shown a greater reduction in antimicrobial usage. The solid organ transplantation clinical pharmacist role can include antimicrobial management, which increases patient safety and decreases ineffective therapy. Also computerized assistance for the pharmacist has demonstrated time and cost-savings. Unit-specific antibiograms should be developed and lead to accurate empiric therapy, and the microbiology laboratory can also introduce rapid diagnostics, which have shown to improve outcomes. Lastly, a collaborative development of evidence-based guidelines can reduce antimicrobial usage reduction with resulting decrease in antimicrobial resistance. Summary Antimicrobial management can be included in solid organ transplantation practice with these strategies and benefit the programs by ensuring early appropriate antimicrobial therapy, with early discontinuation of ineffective therapy resulting in less antimicrobial resistance and improved outcomes.

West Nile virus (WNV) can cause severe central nervous system (CNS) illnesses including meningoencephalitis (MNE) and acute flaccid paralysis (AFP). Risk factors include advanced age, immunosuppression, cancer, and diabetes. In vitro studies show that tumor necrosis factor (TNF) has anti-WNV activity and is protective against WNV infection. Anti-TNF-a monoclonal antibodies may increase susceptibility to WNV by inhibiting an adequate TNF-a response, leading to prolonged viremia, viral penetration into the CNS, and fulminant WNV-CNS disease. We describe a fatal case of WNV with MNE and AFP after infliximab therapy. During WNV outbreaks, clinicians should encourage patients receiving anti-TNF-a drugs to take appropriate preventive measures because of the risk of severe WNV-CNS disease.

Patients with immunocompromised states are increasing in the world not only because of HIV infection but also as a result of better therapies in solid organ transplantation, stem cell transplantation, and leukemia. All these patients are at similar risk of gastrointestinal infections, and the subsequent morbidity and mortality from these infections makes it important to recognize the net state of immunosuppression of each person infected.This review evaluates emerging pathogens, new diagnostic tools and guidelines, and the latest therapies published in the last 12 months in HIV and solid organ transplantation. The echinocandins provide a new therapy for Candida esophagitis, whereas Mycobacterium avium complex therapy may be discontinued with immune reconstitution in patients with HIV. The emergence of antimicrobial-resistant bacteria and viruses is a new threat to managing these infections, especially in poorer countries. Also, several community viruses such as adenovirus were shown to cause significant morbidity to immunocompromised patients. Lastly, the interaction among immunosuppressive medications, diarrhea, and rejection makes an important argument for evaluating patients for infection before adjusting medications.The immunocompromised host is rapidly increasing in the world, resulting in exposures to new pathogenic organisms that cause gastrointestinal infections. New diagnostic tests and better antimicrobial therapy are improving outcomes in patients with access to health care. Unfortunately, these challenges are increasing daily with the development of multidrug-resistant bacteria and viruses that do not respond to standard therapies. The most important factor in overcoming these infections is restoration of the immune system, either by using antiretroviral therapy or decreasing immunosuppression.