Pneumonia In Solid Organ Transplantation
Publication Date: April 1, 2019
Last Updated: March 14, 2022
Recommendations
DIAGNOSTIC TESTING
The diagnostic evaluation of SOT recipients with suspected or confirmed pneumonia should be performed using a tiered approach with the pace and extent of evaluation informed by the severity and acuity of presentation, the degree of immunosup pression, and the patient's risk factor/exposure history. (Low, Strong)
317067
We recommend against using current pneumonia severity score in SOT recipients with pneumonia. (Very Low, Strong)
Pneumonia severity scores have been evaluated in non‐transplant patients with community‐acquired pneumonia and have variable ability to stratify for severity and clinical outcome. No studies of pneumonia severity scoring systems have been performed in SOT recipients though the PSI and CURB‐65 scores had poor performance characteristics in cancer patients presenting with pneumonia.
317067
Practitioners evaluating SOT recipients with symptoms or signs of pneumonia should assess the following at initial evaluation:
- Key features of the patient's medical, transplant, immunization, and social histories.
317067
- Current and prior microbial colonization and current and prior antimicrobial prophylaxis regimens.
317067
- Social history for exposure(s) which would suggest risk of un‐treated latent infection such as latent TB infection, coccidioidomycosis, and strongyloidiasis.
317067
- The acuity of the patient's clinical presentation and use of this information in guiding the differential diagnosis, diagnostic evaluation, and empiric antimicrobial therapy.
317067
The need for contact or respiratory isolation should be assessed and acted upon early in the patient evaluation to avoid exposure of other SOT recipients, patients, and/or staff to potentially contagious pathogens. (High, Strong)
317067
Local epidemiology of respiratory viruses, and in particular influenza virus, should be reviewed and considered in the evaluation. (High, Strong)
317067
The initial evaluation of a SOT recipient with pneumonia should include both blood and radiologic testing with consideration given to viral detection from the nasopharynx.
Clinicians should obtain complete blood count with differential, electrolyte chemistries, and liver function testing as part of the initial laboratory evaluation both for aiding in diagnosis and determining risk of toxicity associated with empiric or directed antimicrobia treatment. (Low, Strong)
317067
Blood cultures should be obtained at presentation of pneumonia and prior to initiation of antibiotic therapy, especially if the patient is febrile or requiring hospitalization. (Low, Strong)
While blood culture yields for etiologic organisms are low in both healthy and SOT recipients with pneumonia, a positive blood culture significantly impacts clinical care.
317067
A chest X‐ray should be performed in all SOT patients with suspected pneumonia. (Moderate, Strong)
317067
Performance of a chest CT scan in the initial evaluation for pneumonia is recommended in settings of high acuity or high net state of immunosuppression. (Low, Weak)
317067
Risk for illness attributable to CMV should be assessed by considering CMV donor‐recipient serostatus, status of CMV‐active prophylaxis, duration of time post‐transplant, and depth of immunosuppression in all SOT patients presenting with symptoms indicative of pneumonia. (Low, Strong)
317067
Testing of urine for Legionella antigens is recommended. (Very Low, Weak)
Though sensitivity is low and urine testing does not detect non‐Legionella pneumophila species, diagnosis of Legionella through this non‐invasive test can accelerate diagnosis and institution of appropriate antimicrobial therapy.
317067
Testing of the nasopharynx for influenza virus by PCR in seasonally appropriate times is recommended to clarify the need for antiviral treatment. (High, Strong)
317067
Multiplex molecular respiratory virus testing is recommended in the evaluation of pneumonia in SOT recipients in seasons of high respiratory virus incidence. (Moderate, Weak)
Identifying a respiratory viral etiology can impact clinical decisions regarding further evaluation as well as the need for antimicrobial therapy though the impact has not been specifically evaluated in SOT recipients.
317067
In older children or adults in whom sputum production is present, sputum culture is recommended for gram stain and bacterial culture. (Very Low, Weak)
317067
Laboratory tests not obtained as part of the initial evaluation should be performed. (Low, Weak)
317067
If not done yet, a CT scan of the chest should be performed to better delineate the radiologic pattern and location of infiltrate and to identity potential opportunity for invasive diagnostic procedures. (High, Strong)
317067
Additional blood testing guided by radiographic pattern, exposures, and degree of immunosuppression should include antigen and/or serologic evaluation for endemic mycoses. (High, Strong)
(see Endemic Fungi section of 4th edition of AST ID Guidelines)
317067
Fungal biomarkers measured in the blood/serum, such as galactomannan and 1,3β‐d‐glucan, have poor performance characteristics in SOT recipients as compared with HSCT recipients. (Very Low, Strong)
No studies have evaluated whether performance characteristics vary depending on post‐transplant timing of infection. Given the paucity of data evaluating utility of 1,3β‐d‐glucan, we do not recommend the use of this test currently in SOT recipients.
(see Aspergillus, Candida, and Pneumocystis sections of 4th edition of AST ID Guidelines)
317067
Physicians caring for an SOT recipient with pneumonia should have a low threshold for procedural evaluation especially in set tings in which patients are not improving, are highly immunocom promised, or the diagnosis remains uncertain. (Moderate, Strong)
317067
We recommend the performance of BAL in the setting of diffuse or focal pulmonary infiltrate in patients with failure to improve on empiric antibacterial therapy in whom diagnosis has not been reached by non.invasive testing. (Moderate, Strong)
The decision to proceed with BAL versus lung biopsy for initial invasive testing must be highly individualized for each patient and is dependent on the clinician's risk/benefit analysis.
317067
We recommend the following studies as a complete BAL fluid evaluation with modifications as needed depending on an individual patient's clinical presentation, radiographic findings, and clinical course:
- Traditional bacterial, fungal, viral, and mycobacterial culture.
(see Aspergillus, Cryptococcus, Endemic Fungi, Emerging Fungi, CMV, HSV, VZV, Respiratory Viruses, Non‐tuberculous Mycobacterial, Tuberculosis, and Nocardia sections of 4th edition of AST ID Guidelines)
317067
- Diagnostic testing including Pneumocystis jirovecii (PJP)‐directed stains or nucleic acid‐based testing for PJP from BAL fluid.
in particular in patients either no longer receiving prophylaxis or on non‐TMP‐SMX prophylaxis.
(see Pneumocystis section of 4th edition of AST ID Guidelines)
317067
- Fungal‐directed stains in patients with radiographic findings suggestive of invasive fungal infection.
317067
- Galactomannan in patients with radiographic findings suggestive of invasive fungal infection.
317067
- Antigen‐based testing for endemic fungal infections such as Histoplasma, Blastomyces, Coccidioides, and Paracoccidioides for patients with a compatible clinical history and geographic exposure risk.
317067
- Nucleic acid‐based testing (PCR, QNAT, Film array) testing for the following pathogens depending on test availability and on the patient's clinical history, exposure risk, and radiographic findings:
- Respiratory viruses
- CMV
- Mycoplasma spp, Ureaplasma spp, and/or Legionella spp
- Nocardia spp
- Invasive mold species
- Mycobacterium tuberculosis.
317067
We recommend lung biopsy (Open, VATS, or CT-guided) in the setting of diffuse or focal pulmonary infiltrate in patients with failure to improve on empiric antibacterial therapy and in whom diagnosis has not been reached by non.invasive testing or BAL. (Moderate, Strong)
317067
We recommend lung biopsy (transbronchial, Open, VATS, or CT-guided) for patients with focal pulmonary nodule(s) where diagnosis has not already been established by other means due to the risk for malignancy (including PTLD) or invasive fungal infection. (Low, Weak)
Consideration can be given to close follow‐up with serial imaging prior to performance of invasive diagnostic procedures for cases in which the risk for malignancy and/or invasive fungal infection is felt to be low.
317067
In patients who live in geographic areas that impart risk for endemic fungal infection and who have exposure history suggestive of a moderate to high risk for endemic fungal infection, we recommend deferral of lung biopsy until after antigen/serologic assessment for endemic fungal infection is complete. (Low, Weak)
317067
EMPIRIC INITIAL TREATMENT
Empiric treatment regimens for pneumonia in the SOT recipient should take into account each individual patient's known microbial colonization as well as prior antimicrobial resistance patterns of specific colonizing or pathogenic organisms with special emphasis on multi-drug resistant bacteria colonizing the airway in lung transplant recipients. (Low, Strong)
317067
During influenza season, empiric administration of an antiviral drug active against influenza is recommended in SOT recipients with influenza-like illness, including pneumonia, while awaiting results of influenza.specific testing unless there is access to PCR based detection methods with rapid turnaround time. (Moderate, Strong)
(See RNA Respiratory Viruses section of 4th editionof AST ID Guidelines)
317067
In a stable patient considered suitable for outpatient therapy who is at lower risk for opportunistic or hospital-acquired infection and in whom no specific pathogen is suspected, empiric therapy should cover community.acquired pneumonia and should follow national/international guidelines influenced by local resistance and prevalence patterns. (Low, Strong)
317067
Beta lactams or fluoroquinolones (FQ) with coverage of respiratory pathogens may be considered for empiric therapy in this setting. (Low, Strong)
Practitioners should consider the role of drug interactions, adverse reactions, and increasing antimicro‐ bial resistance when considering risks and benefits for the FQ use in SOT recipients.
317067
Consideration should be given to empiric coverage of intracellular pathogens (such as Mycoplasma pneumoniae, Chlamydia pneumonia, and Legionella spp) in SOT recipients with community‐ac‐ quired pneumonia (Low, Weak)
317067
with greater consideration given to empiric intracellular pathogen treatment of pediatric SOT recipients with community‐acquired pneumonia (Moderate, Strong)
317067
One important consideration is the selection and use of empiric therapy in this setting in which drug‐drug interactions are present between macrolides and immunosuppressive agents. Respiratory fluoroquinolones may be considered in settings with a high incidence of macrolide resistance for Mycoplasma spp with consideration given to the above‐noted issues in considering risk and benefit of FQ use (Low, Weak)
317067
With outpatient regimens discussed above, the inclusion of antibiotic therapy against methicillin‐resistant Staphylococcus aureus (MRSA) or Pseudomonas spp is dependent on local resistance patterns, prevalence, the individual patient's infection, and bacterial colonization history, as well as the features of the presenting illness (eg, radiographic evidence of lung abscess). (Low, Strong)
(see MRSA and MDR GNR sections of 4th edition of AST ID Guidelines)
317067
In SOT recipients who require hospitalization for pneumonia, combination therapy with a beta‐lactam agent (±MRSA and ±antipseudomonal activity) and an agent active against intracellular organisms (Mycoplasma spp in children and Legionella spp in adults) is recommended. (Low, Strong)
317067
The breadth of coverage of the penicillin‐based agent used depends on local resistance patterns (especially for S. pneumoniae) and whether a nosocomial approach is warranted to cover hospital‐acquired gram‐negative pathogens (eg, recent hospitalization, underlying chronic or bronchiectatic lung disease, or the presence prosthetic material). Fluoroquinolones are an alternative in this setting. (Low, Strong)
317067
For hospitalized patients with nosocomial or ventilator‐associated pneumonia, international/national guidelines apply with attention to local guidelines, prevalence, and epidemiology. (Moderate, Strong)
317067
Recommendation Grading
Overview
Title
Pneumonia In Solid Organ Transplantation
Authoring Organization
American Society of Transplantation
Publication Month/Year
April 1, 2019
Last Updated Month/Year
January 30, 2024
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
These guidelines from the AST Infectious Diseases Community of Practice review the diagnosis and management of pneumonia in the post‐transplant period.
Target Patient Population
Post solid organ transplant patients
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D011014 - Pneumonia, D019072 - Antibiotic Prophylaxis, D014180 - Transplantation, D019737 - Transplants, D016377 - Organ Transplantation
Keywords
community-acquired pneumonia, pneumonia, infection prevention, infection, hospital-acquired pneumonia, solid organ transplant
Source Citation
Dulek, DE, Mueller, NJ; on behalf of the AST Infectious Diseases Community of Practice. Pneumonia in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019; 33:e13545.