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For the purposes of this chapter, we will discuss the management of infections of devices used in solid organ transplant (SOT). Post transplantation, SOT recipients frequently require additional interventions including central venous access catheters (CVC) or, occasionally, temporary support with extracorporeal membrane oxygenation (ECMO) intervention. Infections in these devices will be addressed. Furthermore, we will review infections associated with ventricular assist devices (VAD) when used as bridges to heart transplant (HT). Infection remains a significant complication of LVAD implantation and is associated with inferior clinical prognosis. This is especially true in patients who develop more serious systemic infections, such as sepsis, where the mortality in the following 2 years can be greater than 50%. Furthermore, the development of multi-organ dysfunction (especially cardiac and renal) is also frequently seen as sequelae of infection and complicates morbidity and mortality considerably. The ongoing management of mechanical circulatory device (MCS) infections in patients who proceed to transplant will also be discussed in this chapter, as these patients suffer more frequent relapse associated with retained material from their infected device.

Institutional Affiliations Co-chairs Feldman D: Minneapolis Heart Institute, Minneapolis, Minnesota, Georgia Institute of Technology and Morehouse School of Medicine; Pamboukian SV: University of Alabama at Birmingham, Birmingham, Alabama; Teuteberg JJ: University of Pittsburgh, Pittsburgh, Pennsylvania Task force chairs Birks E: University of Louisville, Louisville, Kentucky; Lietz K: Loyola University, Chicago, Maywood, Illinois; Moore SA: Massachusetts General Hospital, Boston, Massachusetts; Morgan JA: Henry Ford Hospital, Detroit, Michigan Contributing writers Arabia F: Mayo Clinic Arizona, Phoenix, Arizona; Bauman ME: University of Alberta, Alberta, Canada; Buchholz HW: University of Alberta, Stollery Children’s Hospital and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Deng M: University of California at Los Angeles, Los Angeles, California; Dickstein ML: Columbia University, New York, New York; El-Banayosy A: Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Elliot T: Inova Fairfax, Falls Church, Virginia; Goldstein DJ: Montefiore Medical Center, New York, New York; Grady KL: Northwestern University, Chicago, Illinois; Jones K: Alfred Hospital, Melbourne, Australia; Hryniewicz K: Minneapolis Heart Institute, Minneapolis, Minnesota; John R: University of Minnesota, Minneapolis, Minnesota; Kaan A: St. Paul’s Hospital, Vancouver, British Columbia, Canada; Kusne S: Mayo Clinic Arizona, Phoenix, Arizona; Loebe M: Methodist Hospital, Houston, Texas; Massicotte P: University of Alberta, Stollery Children’s Hospital, Edmonton, Alberta, Canada; Moazami N: Minneapolis Heart Institute, Minneapolis, Minnesota; Mohacsi P: University Hospital, Bern, Switzerland; Mooney M: Sentara Norfolk, Virginia Beach, Virginia; Nelson T: Mayo Clinic Arizona, Phoenix, Arizona; Pagani F: University of Michigan, Ann Arbor, Michigan; Perry W: Integris Baptist Health Care, Oklahoma City, Oklahoma; Potapov EV: Deutsches Herzzentrum Berlin, Berlin, Germany; Rame JE: University of Pennsylvania, Philadelphia, Pennsylvania; Russell SD: Johns Hopkins, Baltimore, Maryland; Sorensen EN: University of Maryland, Baltimore, Maryland; Sun B: Minneapolis Heart Institute, Minneapolis, Minnesota; Strueber M: Hannover Medical School, Hanover, Germany Independent reviewers Mangi AA: Yale University School of Medicine, New Haven, Connecticut; Petty MG: University of Minnesota Medical Center, Fairview, Minneapolis, Minnesota; Rogers J: Duke University Medical Center, Durham, North Carolina

Shahid Husain, MD, MS, Martha L. Mooney, MD, MS, FACP, Lara Danziger-Isakov, MD, MPH, Frauke Mattner, MD, PhD, Nina Singh, MD, Robin Avery, MD, FIDSA, Michael Ison, MD, MS, Atul Humar, MD, MSc, Robert F. Padera, MD, PhD, Leo P. Lawler, MD, FRCR, Andy Fisher, PhD, FRCP, Richard J. Drew, MD, Kate F. Gould, MBBS, MRCP, FRCP, Amparo Sole, MD, PhD, Sean Studer, MD, MSc, Patricia Munoz, MD, Lianne G. Singer, MD, FRCPC, and Margaret Hannan, MD, FRCP, FRCPath, for the ISHLT Infectious Diseases Council Working Group on Definitions From the Division of Infectious Diseases, Transplant Infectious Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada; Eastern Virginia Medical School, Sentara Norfolk Transplant Center, Norfolk, Virginia; Center for Pediatric Infectious Diseases, Department of Infectious Disease, Medicine Institute, The Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio; Infection Control and Hospital Epidemiology, Institute for Medical Microbiology, Hannover Medical School, Hannover, Germany; Division of Infectious Diseases, Veteran Affairs Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania; Divisions of Infectious Diseases and Organ Transplantation, Northwestern University, Feinberg School of Medicine, Chicago, Illinois; Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada; Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Respiratory Transplant Medicine, Newcastle University, Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, UK; Mater Misericordiae University Hospital, Dublin, Ireland; Health Protection Agency Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK; Hospital Universitario La Fe, Valencia, Spain; Division of Pulmonary & Critical Care, Newark Beth Israel Medical Center, Newark, New Jersey; and Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Maranon, Universidad Complutense, Madrid, Spain.

In 2009, the International Society for Heart and Lung Transplantation (ISHLT) recognized the importance of infectionrelated morbidity and mortality in patients using ventricular assist devices (VADs) and the growing need for a consensusbased expert opinion to provide standard definitions of infections in these patients. The aim of these standard definitions is to improve clinical-investigator communication, allowing meaningful comparison in practice and outcomes between different centers and different VAD devices. In 2010, a core group of experts, including infectious diseases specialists, cardiologists, pathologists, radiologists, and cardiothoracic surgeons, formed an ISHLT Infectious Diseases Working Group to develop agreed criteria for definitions of infections in VAD patients. These definitions have been created by adapting and expanding on existing standardized definitions, which are based on the pathophysiology of equivalent infectious processes in prosthetic devices, such as cardiac prosthetic valve infections, intravascular catheter-related infections, and prosthetic joint infections. These definitions have been divided into 3 sections: VAD-specific infections, VAD-related infections, and non-VAD infections. Owing to the constant shortage of donor organs, new allocation systems, and improved medical therapies for congestive cardiac failure, the overwhelming trend in cardiac transplantation has been toward listing principally the most critically ill patients, that is, those requiring inpatient inotropic therapy for mechanical circulatory support (MCS). The ventricular assist device (VAD) has an expanding role in the management of these patients, both as a bridge to transplantation and as a destination therapy (ie, alternative to transplantation). According to United Network of Organ Sharing (UNOS) registry data, 9,000 transplant candidates have undergone MCS since 1999, comprising 33% of all listed patients and 75% of all listed inpatients. 1

The emergence of the novel 2009 H1N1 influenza virus highlights unique aspects of transplant care that will require heightened vigilance in coming months. Recognition of the syndrome, aggressive diagnosis and early treatment should be paired with active preventative measures to stem the impact of infection in the transplant population. This special advisory addresses issues relevant to cardiothoracic transplant candidates, selection of donors, recipient management and those patients with mechanical circulatory support devices.

Clostridium difficile infection (CDI) is now the leading cause of healthcare-associated diarrhea in the hospitalized population (1% to 2%). The change in epidemiology of CDI has been dramatic in recent years with an increasing incidence and severity in several countries according to the Centers for Disease Control (CDC)—in fact, the CDC has described CDI as a “global health challenge.” Over the past decade, solid-organ transplant recipients (SOTr) have been identified as a high-risk group. The incidence of CDI in SOTr ranges from 2% to 30%, depending on the organ type, with the greatest incidence in lung transplant recipients (LTr; 7% to 31%). An alarmingly high associated mortality of CDI in LTr (odds ratio 3.02, 95% confidence interval 2.71 to 3.36, p o 0.001) was demonstrated using multivariable regression analysis in a multi-institutional database of 449,000 SOTr with a 2.7% incidence of CDI. Gunderson and colleagues linked early CDI with the development of bronchiolitis obliterans syndrome in a single-center study; however, other outcome data, specifically in LTr with CDI, are currently lacking. After transplantation, diarrhea is a common non-specific symptom that can be caused by various etiologies, including medications and infection. If CDI is the cause, rapid and accurate diagnosis followed by prompt initiation of effective infection control and treatment measures is paramount to its eradication in LTr. In this issue of the journal, Lee and colleagues report on the impact of CDI on LTr in the largest single-center analysis to date. Again, an alarmingly high mortality was found to be associated with CDI in LTr in their study. Mortality correlated with early (o6 months) and late (46 months) CDI. The entire LTr cohort received prophylactic antibiotics, proton-pump inhibitors (PPIs) and immunosuppression as common denomi

Purpose Infection is common complication associated with significant morbidity and mortality after implantation of mechanical circulatory support (MCS) devices. Standardized infection prevention practices have not been established. Methods and Materials An international survey to investigate the current infection prevention (IP) practices with MCS was conducted through an electronic survey. Through an ISHLT mailing, 210 centers identified a representative to complete the survey managed by the Research Survey Center at Mayo Clinic. Data regarding pre, peri, and post-implantation practices was collected. Results Representatives from 56 centers have completed the survey by November 2012. 37 (66.1%) centers routinely evaluate for pre-implant bacterial colonization; 35 for MRSA by nasal swab, 14 for MSSA and 7 for resistant gram-negatives. Pre-implant IP included antiseptics (94.6%) and pre-op chlorhexidine bath (62.6%). Pre-implant antibiotics given within 1 hour (60%) included vancomycin (82.1%), rifampin (32.1%), ciprofloxacin (21.4%) and antifungal (47.3%). The majority report antimicrobials duration for 24-48h (56%). Operative techniques reported included placing velour driveline portion subcutaneously (78.2%) and contralateral placement of driveline exit from device (61.5%). In addition, most centers reported willingness to participate in future IP trials. Conclusions Common IP practices were reported in the majority of MCS centers though subtle differences exist. Future consensus building and design of multi-center intervention studies in MCS may be developed based on this survey.