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   2022| October  | Volume 16 | Issue 5  
    Online since October 18, 2022

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Preparing for transplant - Screening and prophylaxis of donor and recipients before solid organ transplantation: Expert group opinion from South Asia
Shyam Bihari Bansal, Vijay Kher, Venkatasubramanian Ramsubramanian, Narendra S Choudhary, Camille Nelson Kotton
October 2022, 16(5):2-14
Infections are major cause of morbidity and mortality after transplantation. Although many infections are common worldwide, there are differences in various geographic locations. South Asia and India, in particular, has a very active transplant program for kidney and liver transplantation, however, there are no guidelines as how to screen and provide prophylaxis to solid organ transplant (SOT) recipients and donors for both specific infections prevalent in this region along with usual infections. Keeping this in mind, a working group was created comprising transplant physicians, surgeons, and infectious disease specialists from South Asia as well as experts from other countries. This working group developed guidelines based on published evidence, unpublished data from large centers in this region, along with expert opinion. This section of the guidelines deals with pretransplant screening of donors and recipients, which should be useful in dealing with transplants performed in this region for patients belonging to these countries, for those coming for transplantation from other countries, and for programs outside of South Asia who are screening donors and recipients from this region or who have spent significant time in this region.
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Evaluation and management of tuberculosis in solid organ transplant recipients: South Asian expert group opinion
Santosh Varughese, Manisha Sahay, Dibya Singh Shah, Vasant Nagvekar, Vivekanand Jha
October 2022, 16(5):15-22
Both tubercular and non-tubercular mycobacterial infections are common in South Asia. These are important pathogens in solid organ transplant recipients and hence prevention (when possible), prompt diagnosis, and early and optimum treatment is critical to reduce morbidity and prevent mortality. This article reviews available data to portray a possible approach to evaluation and management of mycobacterial infections in South Asian solid organ transplant recipients.
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Screening, prophylaxis and management of endemic infections and travel medicine in solid organ transplant recipients and donors: Expert opinion from South Asia
Shyam Bihari Bansal, Venktasubramanian Ramsubramanian
October 2022, 16(5):1-1
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Diarrhea in solid organ transplant recipients in the South Asian Region - Expert group opinion for diagnosis and management
Srikant Mohta, Sowmya Sridharan, Ram Gopalakrishnan, Narayan Prasad, Shyam Bihari Bansal, Govind K Makharia
October 2022, 16(5):23-33
Diarrhea after solid organ transplantation is a common problem. Posttransplant diarrhea can lead to dehydration, weight loss, graft dysfunction, frequent hospitalization and increased mortality. Posttransplant diarrhea is seen in 20%–25% of patients within 2 years of transplantation and it can be both due to infections and the drugs. The most common cause of drug causing diarrhea is mycophenolate mofetil, and tacrolimus. The common infective causes of diarrhea in posttransplant recipients include viral infections (norovirus, sapovirus, cytomegalovirus [CMV]), bacterial infections (Salmonella, Clostridium difficile, Aeromonas, Campylobactor, Enterotoxigenic, and Enterohemorrhagic Escherichia coli) and parasitic infections (Cryptosporidium, Giardia lamblia, Microsporidia Cyclospora, Strongyloidiasis etc.). Because of overall poor hygienic conditions, infective diarrhea is common in South Asian region. Since most cases of acute diarrhea are infective, and many with viral etiologies, conservative management using oral rehydration solution, antidiarrheal drugs, and where appropriate, a short course of antibiotics helps in the resolution of most cases. A detailed evaluation should be performed in patients with chronic diarrhea, recurrent diarrhea, and those with graft dysfunction. The evaluation of diarrhea should include stool microscopy for ova and cysts, special stains for opportunistic parasitic infection, and molecular diagnostic tools like multiplex Polymerase chain reaction. Colonoscopic and upper gastrointestinal endoscopic examination with biopsies are required to investigate for CMV infection, malabsorption syndrome, inflammatory bowel diseases and posttransplant lymphoproliferative disorder. Although the causes of diarrhea are numerous, an algorithmic approach should be followed both for the diagnosis and the treatment of diarrhea in an organ transplant recipient.
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Cryptosporidium infection in solid organ transplant recipients in South Asia - Expert group opinion for diagnosis and management
Narayan Prasad, Shyam Bihari Bansal, Syed Fazal Akhtar
October 2022, 16(5):34-40
Cryptosporidium is a protozoan ubiquitous in natural water sources worldwide. It is a common intestinal pathogen that frequently causes gastroenteritis syndrome. It is mainly transmitted from person to person via the fecal-oral route, sexual transmission, and possibly through respiratory secretions. After an incubation period of a few days to 2 weeks, it presents as an asymptomatic oocyst passer to clinically evident profuse and prolonged diarrhea, associated with nausea, vomiting, abdominal pain, and fever. The extraintestinal manifestations may occur in the form of respiratory tract disease, pancreatitis, cholangitis, rarely sclerosing cholangitis, and urinary tract infection. Stool microscopy examination for identifying oocysts is the mainstay diagnostic tool. The association with cancer is new evolving paradigm with cryptosporidium infection. Nitazoxanide is the treatment of choice. However, paromomycin in combination with other antiparasitic agents, such as macrolides (azithromycin, spiramycin), and nitazoxanide may be a more effective option in case of no response.
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Expert group opinion for diagnosis and management of fungal infections in solid organ transplant recipients in South Asia
Rajeev Soman, Sujata Rege, Tarun Jeloka, Tulip A Jhaveri, Shyam B Bansal
October 2022, 16(5):41-52
Fungal infections, are common in solid organ transplant (SOT) récipients in South Asia. Invasive fungal infections (IFI) are the third-most common cause of infections in SOT recipients in South Asia after urinary tract infection and tuberculosis and are a significant cause of morbidity and mortality in this population. There are multiple factors, which lead to poor outcomes of these patients, i.e., lack of awareness, inadequate training of physicians, poor laboratory support to diagnose these infections, and sometimes nonavailability of appropriate antifungal agents to treat these infections. Among the IFI in India, invasive candidiasis is the most common followed by mucormycosis, invasive aspergillosis, and cryptococcosis. There is an increasing prevalence of azole resistance and multi-drug resistance among candida infections in South Asia. There are drug interactions of azoles with tacrolimus, cyclosporine, and everolimus and this must be kept in mind when treating various fungal infections. Another challenge is, how to screen and treat the donors and recipients before accepting them for transplant and subsequent management of transplant recipients. The most common endemic mycoses in the Asia-Pacific region are histoplasmosis caused by Histoplasma capsulatum, talaromycosis caused by Talaromyces marneffei and sporotrichosis caused by Sporothrix schenckii. The endemic fungal infections should be kept in the differential diagnosis of pyrexia of unknown origin in transplant recipients. Finally, the outcomes of these patients can be improved by increasing awareness among transplant physicians, better and wider availability of diagnostic facilities, and appropriate use of antifungal agents to treat these infections.
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Pre and posttransplant vaccination for solid organ transplant recipient and in South Asia - Expert group opinion
Shyam Bihari Bansal, Venktasubramanian Ramasubramanian, Sidharth Sethi, Narayan Prasad, Camille Nelson Kotton
October 2022, 16(5):106-111
Infections are common after solid organ transplantation (SOT) and are an important cause of significant morbidity and mortality. Many of these infections can be prevented or their severity reduced by vaccination in pre and posttransplantation period. It is better to complete the vaccination before transplantation as protection and seroconversion is better, and live vaccines are mostly contraindicated after SOT. Live vaccines should be given at least 4 weeks before transplantation but killed vaccines can be given up to 2 weeks before the planned transplantation. Vaccination for some diseases which are endemic in South Asia should be given, along with usual vaccinations. Serological monitoring is required for some vaccines to check their efficacy. Similarly, some vaccines are recommended for SOT recipients traveling to various endemic regions.
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Expert group opinion for endemic bacterial infections in South Asia in solid organ transplant recipients - Typhoid, paratyphoid, leptospirosis, scrub typhus, and melioidosis
Vikas Deswal, Venktasubramanian Ramasubramanian, Abhyudaysingh Rana, Shyam Bihari Bansal, Sandeep Mahajan
October 2022, 16(5):63-76
Typhoid, paratyphoid, leptospirosis, scrub typhus, and melioidosis are some of the common bacterial infections which are endemic in the region of South Asia. Typhoid and paratyphoid cause enteric fever which is a common cause of fever in the general population in this region. It is caused by Salmonella through contaminated food and water. Enteric fever is one of the most common causes of fever in travelers in this region. Leptospirosis is a zoonotic disease caused by Leptospira and occurs due to direct contact with animals like or through abraded skin after the monsoon in the endemic area. Fever and jaundice are the most common presentations. Scrub typhus is caused by mite Orientia tsutsugamushi and it has now emerged as one of the most common causes of pyrexia in this region. Melioidosis is an uncommon infection caused by the bacteria Burkholderia pseudomalle, which is endemic in some regions of South Asia and is usually seen in immunocompromised individuals. Melioidosis is often called great mimicker due to a variety of clinical manifestations which might confuse it with other diseases. All these infections can cause fever or other systemic complications involving various organs in transplant recipients, so they should be kept as part of differential diagnosis of pyrexia in transplant recipients. There are no recommendations to screen for these infections in transplant candidates or donors, however, transplant candidates or donors with fever should be investigated for these infections and transplant should be deferred until full recovery and for some time thereafter.
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Surgical site infections in solid organ transplant recipients: Expert group opinion for prophylaxis and management in South Asia
Abhinav Seth, Ashish Sharma, Ashwinin B Gadde, Milind Mandwar, Shyam Bihari Bansal
October 2022, 16(5):89-97
Surgical site infections (SSIs) are defined as superficial infections, deep incisional infections, and organ/organ space infections that occur within 30 days of the surgical procedure or up to 90 days if a prosthetic implant has been used. Incidence of SSI is highest in recipients of small bowel transplant, followed by liver, pancreas, and kidney transplant. These are diagnosed by the presence of at least one of the following: purulent discharge from the wound, organism identified from the specimen obtained from the site with culture/nonculture-based methods, evidence of infection on gross/histopathological examination or on imaging, or a clinical diagnosis of SSI by a physician. The spectrum of organisms implicated in SSIs in solid organ transplant recipients is more diverse due to underlying end-stage organ failure, need for immunosuppression, prolonged hospitalization, colonization or active infection in the deceased organ donor, contamination during organ transportation/preservation. SSI in solid organ transplant can be prevented leading to hospital stay and cost of transplantation. Minimizing surgical operative time, sterile and appropriate surgical technique and antimicrobial prophylaxis, management of patient comorbidities as well as glucose and temperature regulation are important for prevention of SSI. This article discusses useful preventive strategies for preventing SSI such as preoperative bathing, use of appropriate preoperative antibiotic prophylaxis, surgical site and hand preparation, use of wound protectors, drapes and gowns, incisional wound irrigation, adequate nutritional support, and use of perioperative oxygenation.
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Expert group opinion for urinary tract infection in solid organ transplant recipients in South Asia
Sishir Gang, Abhyuday Rana, Shyam Bihari Bansal
October 2022, 16(5):82-88
Urinary tract infection (UTI) is one of the common infections in solid organ transplant recipients and the most common infection in kidney transplant recipients. UTI in the early posttransplant period is associated with significant morbidity and graft dysfunction. Female gender, advanced age, presence of urinary tract abnormalities, and diabetes mellitus are some of the risk factors for UTI. The emergence of multi-drug resistant bacteria has made the treatment difficult and one needs to be aware of the local antibiotic resistance pattern when treating empirically. These patients should be treated adequately and those with recurrent UTI would need long-term prophylaxis. Asymptomatic bacteriuria should only be treated if it occurs within the first 2–3 months of transplant, otherwise, it can lead to the emergence of the resistant organism without any benefit. To reduce the risk of UTI after transplant, the Foley's catheter should be removed within 3–5 days, DJ stent should be removed within 2–3 weeks and the recipient should be kept on routine prophylaxis for 6 months.
  496 83 -
Expert group opinion for respiratory infections in solid organ transplant recipients in South Asia
P Prasannakumar, Ashwini B Gadde, Shyam B Bansal, Priscilla Rupali
October 2022, 16(5):98-105
Respiratory infections are among the most common and serious infections after solid organ transplantation (SOT). Infections within a month after transplant are usually donor-derived or bacterial infections related to surgical infections or ventilator associated. Infections between 1–6 months after SOT are mostly opportunistic due to various viruses, or fungal infections. After 6 months of transplantation usually community acquired infections predominate, however it is not uncommon to find opportunistic fungal and viral infections in this period. The signs and symptoms of these infections are often mitigated in SOT recipients, so a high index of suspicion is required along with microbiological or tissue diagnosis early in the course to timely treat these infections. Thorough screening for common infections and endemic infections is required in donor and recipients before transplantation to reduce the risk of infections in posttransplant period. Finally, a longer duration of treatment and prophylaxis is required for adequately treat these infections and prevent the relapse.
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Endemic parasitic disease - Expert group opinion for South Asia for solid-organ transplantation − Leishmaniasis, malaria, toxoplasmosis, filariasis, and strongyloidiasis
Venkatasubramanian Ramasubramanian, Rajendran Surendran, Nitin Bansal, Sowmya Sridharan, Natarajan Gopalakrishnan, Suba Guru Prasad, Muhibur Rahman, Shyam Bihri Bansal
October 2022, 16(5):57-62
Although parasitic infections including malaria, leishmania, and toxoplasmosis contribute to a significant burden of the morbidity and mortality of global populations, they remain woefully understudied in solid-organ transplantation with recommendations mainly based on expert opinions. This paradox is due to the fact that the geographic prevalence of most of these infections is restricted to the developing world where priorities of care are different due to economic constraints. Limited availability of transplant programs where parasitic infections are endemic, challenges in diagnosis, re-activation or recrudescence of latent infections which may present at a later date, the lesser impact of these infections in the immune-suppressed host and limited availability of drugs used in the treatment of some of these infections may influence therapeutic interventions. In the Indian sub-continent, malaria, visceral leishmaniasis (VL), filariasis, strongyloidiasis, and toxoplasmosis are endemic. India contributes to 4% of the total global burden of cases of malaria and has the highest number of cases among the South Asian countries. VL is restricted to Bihar and West Bengal in India and liposomal amphotericin, the drug of choice is still prohibitively expensive. The impact of toxoplasmosis, filariasis, and strongyloidiasis in solid-organ transplant is still limited compared to other infections. Challenges are mainly related to donor screening and exclusion as applying western recommendations to these endemic infections may not be practical. Early diagnosis and appropriate therapy improve outcomes.
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Expert group opinion for diagnosis and management viral hepatitis in solid organ transplant recipients in South Asia
Neeraj Saraf, Swapnil Dhampalwar, Vivek Kute, Shyam Bihari Bansal
October 2022, 16(5):77-81
Viral hepatitis is endemic in the South Asia region and is mainly caused by four hepatotropic viruses: hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), and hepatitis E virus (HEV). South Asia region consists of developing countries and HAV and HEV infections are common because of poor sanitary conditions and hygiene practices. HAV and HEV are transmitted person-to-person by fecal‒oral route. HBV and HCV are transmitted via permucosal or percutaneous exposure. It is important to know the impact of these viral infections in the setting of transplantation including evaluation and management in pre, peri, and posttransplant periods. This review summarizes the epidemiology, preventive practices, and advisory for travelers to these endemic regions. Furthermore, recommendations for screening donors and recipients in transplant settings are discussed.
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Endemic viral disease - Expert group opinion for solid organ transplant recipients in South Asia – Dengue, chikungunya, Zika, rabies, Japanese encephalitis, and Nipah virus
Venktasubramanian Ramsubramanian, Suba Guruprasad, P Krishna Prabha, Sowmya Sridharan, Harbir Singh Kohli, A W M Wazil, Shyam Bihari Bansal
October 2022, 16(5):53-56
South Asia is endemic to many virus infections such as arboviruses such as dengue virus, chikungunya virus, Zika virus, Japanese encephalitis (JE) virus, and rabies virus. Arbovirus infections present as fever, rash, arthralgia, myalgia, etc., Although transmission of these viruses has rarely been reported in organ transplants, in the endemic season, there is a possibility as the donor might be in an incubation period. Donor deferral for at least 30 days is advised in any donor with confirmed or suspected cases of arboviral infection. Rabies and JE can cause encephalitis and remain undiagnosed many times, so donors with unknown etiology of encephalitis should be excluded from donation. Nipah virus is an emerging virus, which is reported mainly from Bangladesh, Siliguri, and Kerala in India, however, no case of donor-derived infection has been reported yet.
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