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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.

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.