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Infectious Diseases Consultants and the Pre-transplant Evaluation:
Investing in the Future

Stanley I. Martin, MD
Ohio State University

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"Where is the knowledge we have lost in information?" —T.S. Eliot


stanley martinThe specialty input of infectious diseases (ID) consultants has become a widely embraced feature of contemporary medical care. When a patient spikes a temperature or presents a possible infection, many caregivers do not hesitate to contact those with the expertise to suggest effective diagnostic approaches and therapeutic options. After all, studies have shown that having expert ID consultant care in cases of severe infections can reduce cost, duration of hospitalization, mortality, and increase a patient's overall chance of cure.1-4

But what about the patient who has no known active infection? What role can an ID expert have in this clinical scenario? For a patient being evaluated for cardiothoracic transplantation, the work-up can be detailed, involving multiple procedures to see if the patient even qualifies as having sufficient end-organ disease. Other procedures such as cancer screening, extensive laboratory testing, and psychosocial evaluations may all be part of the process to ensure the patient can benefit from and handle a life-altering procedure with such a scarce and precious resource. Ensuring value over the long term, of course, is the goal. This is where your friendly neighborhood ID consultant can come in handy.

Screening assays for exposure to or infection with many agents have become more complicated with the advent of different molecular and cell-based assays. A case in point is the use of interferon-gamma release assays (IGRAs) for the detection of latent tuberculosis infection. These assays have different iterations with different degrees of clinical evidence to support their use compared to the classic tuberculin skin test approach. ID consultants' familiarity with their sensitivity and overlap in detecting, or not detecting, other mycobacteria exposures can have a significant effect on patients about to undergo immunosuppression.

Delving into a patient's past ID history allows an opportunity to uncover active infections, latent viruses, exposure to and colonization with drug-resistant pathogens, and to evaluate the role for decolonization or effective prophylaxis and monitoring in the post-transplant period. It can also allow clinicians the opportunity to predict what pathogens might be troublesome after the transplant process. Nowhere is this more important than in the patient presenting with severe infection. Empiric antibiotic therapy for septic transplant patients, when chosen incorrectly, can result in an increased risk of death.5

The other opportunity an ID evaluation pre-transplant can offer is the chance to administer needed vaccinations. Post-transplant, immune responses to routine vaccines may be diminished, and in the case of live viral vaccines, may be contraindicated altogether. In particular, updating influenza, tetanus, acellular pertussis, pneumococcal, hepatitis A and B, as well as many others, may all be indicated depending on the patient and region of the world in which he or she lives.

In today's world, information abounds. For the modern-day cardiothoracic transplant recipient, the same can easily be said. Making sense of this information, and transforming it into the knowledge needed to treat and prevent infections, is a great investment in your patient's future.

Disclosure Statement: The author has no conflicts of interest to disclose.

References:

  1. Fowler VG, Sanders LL, Sexton DJ, et al. Clin Infect Dis 1998; 27: 478-86.
  2. Byl B, Clevenbergh P, Jacobs F, et al. Clin Infect Dis 1999; 29: 60-6.
  3. Gums JG, Yancey RW, Hamilton CA, et al. Pharmacotherapy 1999; 19: 1369-77.
  4. Bouza E, Sousa D, Muñoz P, et al. Clin Infect Dis 2004; 39: 1161-9.
  5. Hamandi B, Holbrook AM, Humar A, et al. Am J Transplant 2009; 9: 1657-65.