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Acute graft-versus-host disease (aGvHD) is a rare complication of liver transplantation associated with high morbidity and mortality. Death typically occurs due to complications related to severe infection, shock, and multiorgan failure. The clinical presentation involves dysfunction of multiple organ systems with overlapping symptoms that often results in a diagnostic delay. As there are a limited number of cases reported in the literature, there are no clear guidelines for treatment. Many different therapeutic measures have been utilized that target various immune system pathways, but steroids remain the first line of therapy. We report on two patients who developed aGvHD after liver transplantation who were treated with ruxolitinib, a novel Janus kinase 1/2 (JAK) inhibitor that has been shown to improve outcomes in steroid refractory cases of aGvHD after allogenic hematopoietic stem cell transplantation. We reviewed the literature to discuss various therapeutic options currently available for aGvHD after liver transplantation.

A novel coronavirus has had global impact on individual health and health care delivery. In this C4 article, contributors discuss various aspects of transplantation including donor and recipient screening, management of infected patients, and prevention of coronavirus disease (COVID). Donor screening with SARS-CoV-2 nucleic acid testing (NAT) close to the time of procurement is recommended. Many programs are also screening all potential recipients at the time of admission. The management of COVID has evolved with remdesivir emerging as a new potential option for transplant recipients. Dexamethasone has also shown promise and convalescent plasma is under study. Prevention strategies for transplant candidates and recipients are paramount. Pediatric-specific issues are also discussed. Strategies for the psychological well-being of patients and providers are also imperative, in addition to future research priorities for transplantation.

Organ procurement organizations (OPO) test potential deceased organ donors for infectious diseases required by policy, but many also perform testing for additional infections. The current state of donor testing in the United States is unknown. We sent an IRB approved survey to all 57 U.S. OPOs using REDCap. Descriptive statistics were performed. From the 57 OPOs, we received 46 (80.7%) unique responses with all 11 United Network of Organ Sharing regions represented. Forty of 46 (87%) OPO respondents consulted an Infectious Diseases physician when needed. Eighteen of 46 (39%) tested for West Nile virus (WNV) and 17 of 18 (94%) tested year-round. Eleven of 46 (23.9%) tested for Strongyloides infection while 17 of 46 (37%) tested for Chagas disease. All OPOs performed prospective nucleic acid testing (NAT) for HIV, hepatitis B and hepatitis C on all donors. OPO testing of additional infections has increased since prior surveys but remains variable. Standardization of organ donor infectious diseases evaluation should be considered.

Candida auris is a yeast that is difficult to eradicate and has caused outbreaks in health care facilities. We report a cluster of 5 patients in 1 intensive care unit who were colonized or infected in 2017. The initial 2 patients were recipients of liver transplants who had cultures that grew C auris within 3 days of each other in June 2017 (days 43 and 30 posttransplant). Subsequent screening cultures identified 2 additional patients with C auris colonization. Respiratory and urine cultures from a fifth patient yielded C auris. All isolates were fluconazole resistant but susceptible to echinocandins. Whole genome sequencing showed the strains were clonal, suggesting in-hospital transmission, and related but distinct from New York/New Jersey strains, consistent with a separate introduction. However, no source or contact was found. Two of the 5 patients died. C auris infection likely contributed to 1 patient death by infecting a vascular aneurysm at the graft anastomosis. Strict infection control precautions were initiated to control the outbreak. Our experience reveals that although severe disease from C auris can occur in transplant recipients, outbreaks can be controlled using recommended infection control practices. We have had no further patients infected with C auris to date.

Background: Vancomycin-resistant Enterococcus faecium (VRE) in particular has evolved as an important cause of hospital acquired infection, especially in immunocompromised hosts. Methods: We present a complex case of a patient with relapsed acute myeloid leukemia who underwent allogenic hematopoietic stem cell transplantation complicated by persistent VRE bacteremia and meningitis. To optimize therapy, various blood and cerebrospinal fluid (CSF) samples were sent to a research laboratory for extensive susceptibility testing, pharmacokinetic analyses, and time-kill experiments. Results: In vitro testing revealed resistance to all first-line treatment options and CSF sampling demonstrated sub-optimal central nervous system concentrations achieved by each antimicrobial agent administered in relation to their respective MIC value. Time-kill analyses at observed CSF concentrations confirmed the lack of bactericidal activity despite use of a four-drug combination regimen. Conclusions: This work is the first to report CSF concentrations of oritavancin and tedizolid in humans and adds to the limited data regarding in vitro susceptibility of new antimicrobial agents such as eravacycline, omadacycline, and lefamulin against VRE. Our study provides new insights into various aspects of treatment of extensively drug-resistant Enterococcus faecium meningitis and bacteremia and supports the continued pursuit of precision medicine for these challenging cases.

Despite emerging data suggesting reduced antibody responses among solid organ transplant recipients following SARS‐CoV‐2 vaccine, critical unanswered questions remain. The clinical implications of the reduced humoral response need to be assessed through prospective studies. Studies are likewise needed to inform which vaccine dosing strategies result in improved immunity and if such approaches maximize protection against severe infection in the vulnerable transplant population.

Hepatitis A virus can cause liver damage ranging from mild illness to fulminant hepatic failure, constituting 0.35% of all cases of fulminant liver failure. While rates of spontaneous remission are higher for hepatitis A, recent outbreaks attributable to vaccine shortages in highly populated urban cities plagued by insufficient affordable housing and inaccessible sanitation, and changes in the epidemiology of viral strains have resulted in increased hospitalizations and deaths. While the prognosis for patients with FHF has improved since the introduction of transplantation, the decision to transplant is often difficult to reach. We present five patients with HAV and subsequent FHF, one of whom successfully received a liver transplant. We have reviewed all published cases of HAV FHF in the literature and report ten patients, seven of whom received liver transplantation. There are few predictive models that attempt to distinguish between fulminant hepatitis A and spontaneous recovery. Patients found to have positive hepatitis A IgM, encephalopathy, worsening LFT's and coagulation should be monitored closely and referred to transplant centers urgently for management.

There are numerous case reports and a handful of single1–5 center studies reporting on COVID‐19 in kidney transplant recipients. Most reports arise from the epicenters of where the SARS‐CoV‐2 virus was first detected such as New York City1,2,5 and Europe3,4. We in UNOS Region 1 experienced COVID‐19 weeks to a month later and questioned whether our experience was different. The programs within UNOS Region 1 have had a long history of sharing information in an attempt to mitigate the effect of viruses on our patients.

Hepatitis B virus (HBV) can be transmitted from organ donor to recipient, but details of transmission events are not widely published. The Disease Transmission Advisory Committee (DTAC) evaluated 105 cases of potential donor derived transmission events of HBV between 2009-2017. Proven, probable or possible transmission of HBV occurred in 25 (23.8%) cases. Recipients of liver grafts were most commonly infected (20 of 21 exposed recipients) compared to 9 of 21 exposed non-hepatic recipients. Eleven of 25 donors were HBV core antibody (HBcAb) positive/HBV surface antigen (HBsAg) negative and infected 8/20 recipients. Of the 10 liver recipients and 1 liver-kidney recipient who received organs from these donors: six were not given antiviral prophylaxis, two developed infection after antiviral prophylaxis was discontinued, two developed HBV while on lamivudine prophylaxis, one was on antiviral prophylaxis and did not develop HBV viremia or antigenemia. One recipient of a HBcAb positive/HBsAg negative kidney developed active HBV infection. Unexpected donor-derived transmission of HBV was a rare event in reports to DTAC, but was often detected in the recipient late post-transplant. Six of 11 recipients (54.5%) of a liver from a HBcAb positive donor did not receive prophylaxis; all of these were potentially preventable with the use of anti-viral prophylaxis.

This article discusses the recommended vaccines used before and after solid organ transplant period, including data regarding vaccine safety and efficacy and travel-related vaccines. Vaccination is an important part of the preparation for solid organ transplantation, because vaccine-preventable diseases contribute to the morbidity and mortality of these patients. A pretransplantation protocol should be encouraged in every transplant center. The main goal of vaccination is to provide seroprotection before transplantation, because iatrogenically immunosuppressed patients posttransplant have a lower seroresponse to vaccines.

The availability of direct-acting antiviral agents for the treatment of hepatitis C virus (HCV) infection has resulted in a profound shift in the approach to the management of this infection. These changes have affected the practice of solid organ transplantation by altering the framework by which patients with end-stage organ disease are managed and receive organ transplants. The high level of safety and efficacy of these medications in patients with chronic HCV infection provides the opportunity to explore their use in the setting of transplanting organs from HCV-viremic patients into non-HCV-viremic recipients. Because these organs are frequently discarded and typically come from younger donors, this approach has the potential to save lives on the solid organ transplant waitlist. Therefore, an urgent need exists for prospective research protocols that study the risk versus benefit of using organs for hepatitis C-infected donors. In response to this rapidly changing practice and the need for scientific study and consensus, the American Society of Transplantation convened a meeting of experts to review current data and develop the framework for the study of using HCV viremic organs in solid organ transplantation.

Background Potential deceased organ donors are screened for human immunodeficiency virus (HIV-1), hepatitis B virus (HBV), and hepatitis C virus (HCV) with serologic tests and nucleic acid tests (NATs). The results of these tests on the utilization of donors have not been directly measured. Methods Twenty-six organ procurement organizations (OPOs) provided primary HIV, HBV, and HCV screening results and utilization information for donor referrals evaluated from 2004 to 2017. Additional information regarding donor organ utilization was obtained from the Organ Procurement and Transplantation Network database. Data were analyzed using logistic regression. Results Test results were submitted for 38 166 potential deceased organ donors; 31 (0.1%) were HIV NAT-negative but seropositive, 5.2% were HBV core antibody-positive and NAT-negative, while 1.8% were HCV antibody-positive and NAT-negative. Organ utilization of HBV and/or HCV NAT-negative organs increased over time despite positive antibody status. Conclusions Nucleic acid test detected infections in seronegative donors, especially for HCV. The use of NAT for deceased donor screening correlated with increased utilization of donor organs.

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of tuberculosis in the pre- and post-transplant period. The challenges of screening for both latent and active TB in the setting of transplantation are reviewed. The use of interferon gamma release assays for detection of latent tuberculosis is discussed and compared to tuberculin skin testing. Given the limitations of both testing modality, it is important to consider exposure history and chest imaging. The clinical manifestations of active tuberculosis in transplantation are covered. New recommendations for treatment of latent tuberculosis and active tuberculosis are included.

Nucleic acid testing (NAT) for hepatitis C virus (HCV) is recommended for screening of organ donors, yet not all donor infections may be detected. We describe three US clusters of HCV transmission from donors at increased risk for HCV infection. Donor's and recipients' medical records were reviewed. Newly infected recipients were interviewed. Donor-derived HCV infection was considered when infection was newly detected after transplantation in recipients of organs from increased risk donors. Stored donor sera and tissue samples were tested for HCV RNA with high-sensitivity quantitative PCR. Posttransplant and pretransplant recipient sera were tested for HCV RNA. Quasispecies analysis of hypervariable region-1 was used to establish genetic relatedness of recipient HCV variants. Each donor had evidence of injection drug use preceding death. Of 12 recipients, 8 were HCV-infected-6 were newly diagnosed posttransplant. HCV RNA was retrospectively detected in stored samples from donor immunologic tissue collected at organ procurement. Phylogenetic analysis showed two clusters of closely related HCV variants from recipients. These investigations identified the first known HCV transmissions from increased risk organ donors with negative NAT screening, indicating very recent donor infection. Recipient informed consent and posttransplant screening for blood-borne pathogens are essential when considering increased risk donors.

Background Infectious diseases (ID) specialists with experience in managing infections in transplant recipients and other immunocompromised hosts are increasingly needed as these fields expand. Methods To evaluate experiences and identify trainee-described needs in transplant infectious diseases (TID) training, the American Society of Transplantation, Infectious Diseases Community of Practice (AST IDCOP) surveyed ID fellows across the United States and TID fellows in the United States and Canada and received responses from 203 ID fellows and 13 TID fellows. Results Among ID fellows, the amount of TID training during ID fellowship was rated between less than ideal and adequate. Reasons cited included limited frequency of didactic activities and limited exposure to transplant patients during training. In particular, ID fellows at low-volume transplantation centers expressed interest in more TID training time, away training opportunities, and specific TID didactics. Educational resources of high interest among trainees were case-based interactive websites, mobile phone applications with TID guidelines, and a centralized collection of relevant articles. Pediatric ID fellows reported lower satisfaction scores with TID training, while TID fellows were overall satisfied or more than satisfied with their training experience. Conclusion Findings from this survey will inform local and national TID educational initiatives.

Organ Procurement & Transplantation Network policy requires post-transplant screening of recipients of organs from donors at increased risk for transmission of HIV, hepatitis B virus, and hepatitis C virus. Available data suggest that follow-up testing of recipients is not routinely conducted. Data on increased risk donors and recipients of their organs from 2008 to 2012 were retrospectively collected from 6 transplant centers after IRB approval. Descriptive statistics were performed. About 363 (60%) recipients were screened for transmission of HIV, HBV, and/or HCV at some time point; 257 (70.8%) within 90 days of transplant. The type of test used to screen for infection was variable with many recipients (25%-43%) screened with serology alone. Our results reveal that post-transplant screening for HIV, HBV, and HCV in recipients of increased risk donor organs did not universally occur and testing methods were variable.

BACKGROUND Before the 2014 policy change pertaining to infectious disease screening, many organ procurement organizations (OPOs) were supplementing serologic screening of deceased organ donors with nucleic acid testing (NAT) for human immunodeficiency virus (HIV-1), hepatitis B virus (HBV), and hepatitis C virus (HCV). The number of seronegative, NAT-positive donors has not been directly measured. METHODS HIV, HBV, and HCV screening results of 11 229 donor referrals evaluated from 2010 to 2013 were obtained from 3 OPO-affiliated laboratories, capturing 35% of all donors in the United States. Laboratories used either polymerase chain reaction assay or transcription-mediated amplification assay to test 9643 deceased donors by NAT. RESULTS The NAT results were positive in 21 (0.2%), 1 (0.02%), and 11 (0.1%) donors who were seronegative for HIV, HBV, and HCV, respectively. All discordant HIV-1 results were from one laboratory using a polymrease chain reaction assay. Thirteen of the reactive HIV NAT results in seronegative referrals were repeated and were non-reproducibly positive (NRP). Ten (0.1%), 452 (7.8%), and 197 (2.2%) of HIV-, HBV-, and HCV-seropositive donors, respectively, were negative by NAT. CONCLUSIONS This study highlights the importance of robust quality assurance to minimize NRP NAT results. NAT may allow for increased utilization of organs from HBV- and HCV-seropositive, NAT-negative donors.

A Gram-negative, rod-shaped bacterium, designated H63T, was isolated from aortic valve tissue of a patient with native valve endocarditis. 16S rRNA gene sequencing revealed that H63T belongs to the genus Legionella , with its closest neighbours being the type strains of Legionella brunensis (98.8 % similarity), L. londiniensis (97.0 %), L. jordanis (96.8 %), L. erythra (96.2 %), L. dresdenensis (96.0 %) and L. rubrilucens , L. feeleii , L. pneumophila and L. birminghamensis (95.7 %). DNA–DNA hybridization studies yielded values of T and its nearest neighbours in terms of 16S rRNA gene sequence similarity, indicating that the strain represents a novel species. Phylogenetic analysis of the 16S rRNA, macrophage infectivity potentiator (mip) and RNase P (rnpB) genes confirmed that H63T represents a distinct species, with L. brunensis being its closest sister taxon. Fatty acid composition and biochemical traits, such as the inability to ferment glucose and reduce nitrate, supported the affiliation of H63T to the genus Legionella . H63T was distinguishable from its neighbours based on it being positive for hippurate hydrolysis. H63T was further differentiated by its inability to grow on BCYE agar at 17 °C, its poor growth on low-iron medium and the absence of sliding motility. Also, H63T did not react with antisera generated from type strains of Legionella species. H63T replicated within macrophages. It also grew in mouse lungs, inducing histopathological evidence of pneumonia and dissemination to the spleen. Together, these results confirm that H63T represents a novel, pathogenic Legionella species, for which the name Legionella cardiaca sp. nov. is proposed. The type strain is H63T ( = ATCC BAA-2315T = DSM 25049T = JCM 17854T).

N. Theodoropoulos, F. Lanternier, J. Rassiwala, G. McNatt, L. Preczewski, E. DeMayo, V. Stosor, M.G. Ison. Use of the QuantiFERON-TB Gold interferon-gamma release assay for screening transplant candidates: a single-center retrospective study. Transpl Infect Dis 2011. All rights reserved Background. Tuberculosis (TB) reactivation is a rare but significant complication of organ transplantation, and screening of all transplant candidates for latent infection is recommended with either an interferon-γ release assay (IGRA) or tuberculin skin test (TST). Methods. After institutional review board approval, we retrospectively collected data to describe the yield of transplant candidate screening using the QuantiFERON-TB Gold (QFT) and QuantiFERON-TB Gold In-Tube (QFT-IT) assays since the institution of TB screening in 2008 and the epidemiology of all cases of post-transplant TB in our institution since 2004. Results. A total of 2392 patients were screened with either the QFT or QFT-IT assay through October 2009; 245 (10.2%) tested positive and 206 (8.6%) were indeterminate. Of those with positive results, 107 (43.7%) were foreign born and most of the remainder had prior TB exposures. Of the tests performed at a reference lab, 29% were indeterminate, whereas 14% were indeterminate using our in-house lab. The majority of indeterminate results were seen in liver transplant candidates (40.6% vs. 11.8% in non-liver candidates). Three of 694 (0.43%) screened patients who underwent transplantation developed TB post transplant. Conclusions. Post-transplant TB occurs at a low rate with universal IGRA-based candidate screening, which is comparable to studies using TST screening.

Background It is estimated that 30–50% of antimicrobial agents prescribed inpatient are not optimal. Historically, antimicrobial evaluation has been based primarily upon expert opinion of ID trained individuals. Spivak and colleagues proposed standard terminology and definitions to assess antimicrobial prescribing practices. At UMass Memorial Medical Center we utilized Spivak’s criteria to measure antimicrobial use within point prevalence studies (PPS) and assessed the ability of Spivak’s criteria to provide consistent results between different evaluators. Methods A PPS was conducted in September 2017 (SEPT) by infectious disease (ID) attendings and ID trained pharmacists. A follow-up PPS was completed in November 2017 (NOV) by a pharmacy practice resident (PGY-1) and first year ID fellow. Patients were included if they were prescribed antibiotics at the time of review, greater than 18 years of age, and admitted to an inpatient unit. Patients only receiving antiretroviral therapy or antifungal prophylaxis were excluded from the study. Antibiotics, indications, days of therapy, and appropriateness or reason for inappropriateness, as defined by Spivak’s criteria, were collected. Results Four hundred five patients in SEPT and 475 patients in NOV were reviewed. Baseline characteristics between SEPT and NOV, including sex, age, average length of hospital stay (LOS) at time of review were similar between groups, (SEPT vs. NOV: male sex: 53.2% vs. 51.1%; age: 60.4 vs. 61.7; LOS:8.55 vs. 8.36 days). Number of antibiotics per patient was different between PPS (SEPT 1.69 vs. NOV 1.28). For non-intensive care unit (ICU) patients, 64.9% of use was considered appropriate in SEPT vs. 69.3% in NOV. The top reasons for inappropriate use in non-ICU patients in both PPS were no indication and excess length of therapy. Within the ICU, 89.4% of use was considered appropriate in SEPT, with 75% of use considered appropriate in NOV. The top reason for inappropriate use in ICU patients in both PPS was overly broad therapy. Conclusion Application of standard antibiotic evaluation criteria can assist healthcare professionals with different levels of ID training to assess antibiotic use in non-ICU patients. Further evaluation should be considered for critically ill patients. Disclosures All authors: No reported disclosures.

Organ donors reflect the diverse US population, and there are an increasing number of donors born in, who have resided in, or who have traveled to underdeveloped areas of the world or areas with geographically restricted infections. As such, these donors are exposed to pathogens that can potentially be transmitted to recipients of the donor’s organs. Additionally, there are newer techniques to identify many pathogens that may be transmitted from the donor to the transplant recipients. Finally, high-profile reports of several donor-derived infections have heightened awareness of donor-derived infections and have likely contributed to increased recognition. In this chapter, the incidence, methods of identification and prevention, and management of unexpected donor-derived infections will be reviewed.

Neutropenic enterocolitis (NE) is a deadly ileocecal-based disease seen in patients with a recent history of chemotherapy. As histology is not included in the current diagnostic criteria, the pathologic features of NE are poorly understood. We undertook a multi-institutional study of NE, and report helpful clinical clues, such as immunosuppression (n=20/20), recent chemotherapy (n=17/18), neutropenia (n=16/18) gastrointestinal symptoms (n=19/19), abnormal imaging studies of the cecum/right colon (n=11/14), and positive microbiological studies (n=13/15). Fever (n=9/15) and sepsis (n=8/16) were also common. Pathologically, the cecum/right colon was always involved (n=17/17), but findings were identified in other bowel segments as well. NE lesions consisted of patchy necrosis (n=18/20), infiltrating organisms (n=17/20), hemorrhage (n=15/20), ulcer (n=15/19), edema (n=15/20), and depletion of inflammatory cells (n=15/20). Seventy-nine percent (n=15/19) of patients with histologically confirmed NE died: 47% (n=7/15) of these deaths were attributed to NE and the remainder to the patients' underlying conditions. Importantly, we observed a clinical diagnostic discordancy rate of 35% (n=9/26): 15% (n=3/20) of histologically confirmed NE were clinically unsuspected, and 26% (n=6/23) of clinically suspected NE represented a different disease process. Alternative diagnoses included unspecified colitis, infection, graft-versus-host disease, relapsed malignancy, mycophenolate injury, appendicitis, and ischemia. The causes of death in patients with NE mimics included unrecognized appendicitis and unrecognized graft-versus-host disease. To improve diagnostic accuracy, we propose that histology be required for a diagnosis of "definitive NE," with other clinically suspicious cases reported as "suspicious for NE" until all other possible diagnoses have been reasonably excluded.

Legionellae are Gram-negative bacteria which are capable of causing disease, most commonly in the form of pneumonia. We describe a case of native valve endocarditis caused by a Legionella strain which by genotypic (16S rRNA and mip gene sequencing) and phenotypic analyses is unlike previously described strains of Legionella .

Background Current U.S. policy requires screening of all deceased organ donors for syphilis infection. To date, information on syphilis test performance in this population is limited. Methods All donors with a positive rapid plasma reagin (RPR) and matched donors with negative RPR who were evaluated by one organ procurement organization from January 1, 2000, to September 30, 2012, were retrospectively tested, using retained, residual serum, with two alternate RPR tests and four treponemal-specific tests: A fluorescent treponemal antibody absorption test, a microhemagglutination test, a chemiluminescence immunoassay (CLIA), and a Treponema pallidum particle agglutination (TP-PA) test. Results Thirty-two of 3,555 (0.9%) potential deceased organ donors screened during the study period showed a positive RPR; 61 RPR-negative matched donor samples were studied as well. Thirteen (40.6%) of the RPR-positive donors were found to be false-positive based on confirmatory TP-PA. As compared to TP-PA, the sensitivity of the fluorescent treponemal antibody absorption, microhemagglutination, and CLIA was 87.5%, 91.7% and 100%, respectively. The CLIA and TP-PA results were 100% concordant. Only 17 (53.1%) of the RPR-positive donors had a total of 46 organs recovered for transplantation. Conclusion Current screening of deceased organ donors by RPR yields a significant number of false-positive results. Use of alternative tests or the routine use of confirmatory tests may reduce the frequency of false-positive results in deceased organ donors.

Data are limited regarding the use of direct-acting antivirals for treatment of hepatitis C infection post lung transplant, especially in a donor-derived infection. We present a case of a lung transplant recipient with donor-derived hepatitis C that was successfully treated with a 12-week regimen of simeprevir and sofosbuvir. This case reiterates the importance of screening recipients of increased-risk donor organs for disease transmission and the value of early therapy.

Although Organ Procurement and Transplantation Network (OPTN) policy requires that all potential deceased organ donors are screened for human immunodeficiency (HIV), hepatitis B (HBV) and hepatitis C (HCV) viruses by serology, no current policy requires the use of nucleic acid testing (NAT) for organ donor screening. An electronic survey was sent to 58 organ procurement organizations (OPO) in the United States to assess current screening practices of potential deceased organ donors. Fifty-seven responses were collected for data analysis; not all respondents answered all questions. All OPOs performed required HIV, HBV and HCV serology screening and 48 (84%) performed confirmatory testing for seropositive donors. Ninety-eight percent, 75% and 97% of OPOs performed prospective HIV, HBV and HCV NAT, respectively. Fifty-two percent and 47% used a transcription-mediated amplification assay for HIV and HCV NAT, respectively. Of the 56 respondents that performed HIV NAT and 55 respondents that performed HCV NAT, 39 tested all donors. Seventeen (32%) OPOs performed confirmatory testing for all HIV-positive NAT results, and 15 (27%) OPOs performed confirmatory testing for all HCV-positive NAT results. Since 2008, the number of OPOs performing NAT has increased and more OPOs are testing all donors.

Tuberculosis (TB) is a possible complication of solid organ and hematopoietic stem cell transplantation. The identification of candidates for preventive chemotherapy is an effective intervention to protect transplant recipients with latent infection with Mycobacterium tuberculosis from progressing to active disease. The best available proxy for diagnosing latent infection with M. tuberculosis is the identification of an adaptive immune response by the tuberculin skin test or an interferon-γ based ex vivo assay. Risk assessment in transplant recipients for the development of TB depends on, among other factors, the locally expected underlying prevalence of infection with M. tuberculosis in the target population. In areas of high prevalence, preventive chemotherapy for all transplant recipients may be justified without immunodiagnostic testing while in areas of medium and low prevalence, preventive chemotherapy should only be offered to candidates with positive M. tuberculosis-specific immune responses. The diagnosis of TB in transplant recipients can be challenging. Treatment of TB is often difficult due to substantial interactions between anti-TB drugs and immunosuppressive medications. This management guideline summarises current knowledge on the prevention, diagnosis and treatment of TB related to solid organ and hematopoietic stem cell transplantation and provides an expert consensus on questions where scientific evidence is still lacking.

Organ procurement organizations have the task of evaluating potential deceased organs donors for both active and latent infections in order to protect the potential recipients. We discuss deceased donor evaluation and infectious disease screening, as well as donor-derived infections in organ transplant recipients, both expected and unexpected.

N. Theodoropoulos, D.P. Ladner, M.G. Ison. Screening recipients ofincreased-risk donor organs: a survey of transplant infectiousdiseases physician practices.Transpl Infect Dis 2013. All rights reservedAbstract: Background. In 1994, the Public Health Servicepublished guidelines to minimize the risk of humanimmunodeficiency virus (HIV) transmission and to monitorrecipients following the transplantation of organs from increased-risk donors. A 2007 survey revealed the post-transplant surveillanceof recipients of organs from increased-risk donors (ROIRD) isvariable.Methods. An electronic survey was sent to transplant infectiousdiseases physicians at US solid organ transplant centers.Results. A total of 126 surveys were sent to infectious diseasesphysicians, and we received 51 (40%) responses. We found that 22%of respondents obtain only verbal, 69% verbal and written, and 8% donot obtain any special consent from ROIRD, despite an OrganProcurement and Transplantation Network policy requiring suchconsent. Post-solid organ transplantation serologies for HIV,hepatitis B virus (HBV), and hepatitis C virus (HCV) are performedby 6–8% of respondents in all recipients, by 69% of respondents inROIRD only, and 25% of respondents do not perform them at all.Post-transplant nucleic acid testing is carried out by 55–64% ofrespondents in ROIRD, by 0–2% in all recipients, and not performedby 35–43% of respondents.Conclusion. Screening RIORD for HIV, HBV, and HCV hasincreased since 2007, but remains less than optimal and isincomplete when screening for disease transmission at manycenters.N. Theodoropoulos

BK virus nephropathy (BKVN) is a recognized cause of graft failure in kidney transplant recipients. There are limited data on the epidemiology of BK virus (BKV) infection after alemtuzumab induction. By clinical protocol, the kidney transplant recipients at our center were screened with BKV plasma PCR monthly for the first 4 months posttransplant then every 2-3 months for 2 years. A single center retrospective cohort study of all kidney transplant recipients from January 2008 to August 2010 was conducted to determine incidence and outcomes of BKV infection. Descriptive statistics and Kaplan-Meier analysis was performed. Of 666 recipients, 250 (37.5%) developed viruria, 80 (12%) developed viremia and 31 (4.7%) developed BKVN at a median of 17, 21 and 30 weeks, respectively. Induction with alemtuzumab did not significantly affect incidence of BKVN. Increased recipient age, African American race, acute graft rejection and CMV infection were significantly associated with the development of BKVN in multivariate analysis. The incidence of BK viruria, viremia and nephropathy was not significantly different among kidney transplant recipients who received alemtuzumab induction compared to patients receiving less potent induction.

The Organ Procurement and Transplantation Network (OPTN) mandates that organ recipients provide "specific informed consent" before accepting organs that the OPTN defines as "increased risk". However, the OPTN does not provide specific guidelines for what information should be disclosed to potential recipients. Such vagueness opens the door to inadequate informed consent. This paper examines the ethical dimensions of informed consent when the prospective living donor has self-reported behaviors associated with increased risk for infection transmission. Donor privacy is a primary ethical concern that conflicts with recipients' informed consent for use of increased risk organs. We propose that both the increased risk status and the specific behavior be disclosed to the recipient. Because the actual risk posed is linked to the type of risk behavior, disclosure is therefore needed to make an informed decision. The donor's risk behavior is material to recipients' decision making because it may impact the donor-recipient relationship. This relationship is the foundation of the donation and acceptance transaction, and thus comprises a critical feature of the recipient's informed consent. Optimizing a recipient's informed consent is essential to protecting patient safety and autonomy.

Solid organ transplantation (SOT) represents a significant ad-vance in medicine and currently represents the preferred treat-mentformostpatientswithend-stageorganfailure.SOTresultsin improved quality and quantity of life for more than 25,000patientseachyearintheUnitedStates[ 1].Significantadvancesin the potency of immunosuppressive agents, improvement insurgicaltechniques,andexpandeduseofantimicrobialprophy-laxis have resulted in greater patient and graft survival ratesover time [2]. Despite these advances, infections remain aleading cause of morbidity and mortality among transplantrecipients [2–4]. Likewise, hematopoietic stem cell transplan-tation(HSCT)hasmadegreatstridesincuringmanypreviouslyincurable malignancies. Although improvements to the trans-plantation process, use of prophylaxis and screening measures,and employment of supportive care have decreased the infec-tious complications of HSCT, they remain a serious threat togood patient outcomes [5].To address these significant challenges to successful trans-plantation,thefieldoftransplantinfectiousdiseases(TID)hasgrowntobeanintegralpartofallmajortransplantprogramsinthe developed world. TID experts have advanced transplanta-tion by defining the epidemiology of the infectious complica-tions of both SOT and HSCT. BK virus nephropathy andnovovirus gastroenteritis, for example, have recently beenrecognizedtobesignificantcausesofgraftfailureandchronicdiarrhea, respectively. Most significant, the knowledge ofposttransplant infections is being applied to develop and im-plementnovelantimicrobialsforthepreventionandtreatmentof these complications. These advances are having a mean-ingful impact in reducing the frequency and severity ofposttransplant infections and improving outcomes associatedwith SOTand HSCT.For this issue, we invited leaders in the field of TID tosummarize the advances in recent research that have resultedin improved understanding of the epidemiology, prevention,and management of the specific infections.Multidrug-resistant organisms (MDROs) are an emergingthreat in SOT. While it has long been recognized that trans-plantpatientsareamongthehighestriskgroupsforbecomingcolonized and developing serious infections, the frequencywith which MDROs cause infection in transplant recipientshas increased significantly in the past several years. GopiPatel, Meenakshi M. Rana, and Shirish Huprikar from theIcahn School of Medicine at Mount Sinai have detailed ourunderstanding of the mechanism of resistance, the riskfactors for acquiring MDRO infections, and the optimalstrategies for preventing acquisition of and treating thesechallenging infections.Immunomodulatory agents are increasingly used in trans-plant and other specialties to minimize inflammation andimprove graft survival and to minimize the symptoms andimpact of a number of immune-mediated diseases, includingpsoriasis, inflammatory bowel diseases, and multiple sclero-sis.These agentscause specificdefects in theimmunesystemthat result in enhanced risk of infectious complications, par-ticularly the reactivation of latent infections in the host.