Martin, Max J

Background. Invasive fungal infections are associated with high morbidity in solid organ transplant recipients. Risk factor modification may help with preventative efforts. The objective of this study was to identify risk factors for the development of fungal infections within the first year following solid organ transplant. Methods. We searched for eligible articles through February 3, 2023. Studies published after January 1, 2001, that pertained to risk factors for development of invasive fungal infections in solid organ transplant were reviewed for inclusion. Of 3087 articles screened, 58 were included. Meta-analysis was conducted using a random-effects model to evaluate individual risk factors for the primary outcome of any invasive fungal infections and invasive candidiasis or invasive aspergillosis (when possible) within 1 y posttransplant. Results. We found 3 variables with a high certainty of evidence and strong associations (relative effect estimate ≥ 2) to any early invasive fungal infections across all solid organ transplant groups: reoperation (odds ratio [OR], 2.92; confidence interval [CI], 1.79-4.75), posttransplant renal replacement therapy (OR, 2.91; CI, 1.87-4.51), and cytomegalovirus disease (OR, 2.97; CI, 1.78-4.94). Both posttransplant renal replacement therapy (OR, 3.36; CI, 1.78-6.34) and posttransplant cytomegalovirus disease (OR, 2.81; CI, 1.47-5.36) increased the odds of early posttransplant invasive aspergillosis. No individual variables could be pooled across groups for invasive candidiasis. Conclusions. Several common risk factors exist for the development of any invasive fungal infections in solid organ transplant recipients. Additional risk factors for invasive candidiasis and aspergillosis may be unique to the pathogen, transplanted organ, or both.

Objectives: Prior studies report significant mortality in fibrotic interstitial lung disease patients undergoing mechanical ventilation. Little is known about baseline characteristics or ventilator strategies that might improve outcomes. We analyzed the ventilator characteristics of a large cohort of fibrotic interstitial lung disease patients from the perspective of an acute respiratory distress syndrome paradigm to see if any specific mechanical ventilation strategies might improve in-hospital mortality. Design: Retrospective cohort study. Setting: Single-center, multihospital medical ICUs. Patients: Consecutive fibrotic interstitial lung disease patients who experienced mechanical ventilation for acute respiratory failure. Interventions: Interstitial lung disease characteristics, demographics, and ventilator variables were analyzed for univariable and multivariable predictors of in-hospital mortality, adjusted for confounding with an a priori causation model. Measurements and Main Results: A total of 111 patients accounted for 114 admissions. Idiopathic pulmonary fibrosis comprised 34% with idiopathic acute exacerbation (65%) being the most common admission type. Ninety-five percent were initiated on mandatory volume-control ventilation with only 50% achieving a low tidal volume strategy (plateau pressure ≤ 30 cm H2O) within 3 hours of intubation. Unadjusted clinical predictors of in-hospital mortality included age (unit odds ratio, 1.05; 1.01–1.10; p = 0.015), time from admission to intubation (hr) (unit odds ratio, 1.01; 1.01–1.03; p = 0.017), and use of paralytics (relative risk, 1.54; 1.26–1.90, p < 0.001). Adjusted mechanical ventilation-related predictors of in-hospital mortality included achieving early targeted plateau pressures (odds ratio, 0.23; 0.07–0.76; p = 0.016), Pao 2/Fio 2 ratio at 3 (unit odds ratio, 0.98; 0.96–0.99, p = 0.002) and 48 hours (unit odds ratio, 0.98; 0.97–0.99, p = 0.018), initial mean airway pressure (unit odds ratio, 1.13; 1.02–1.28, p = 0.019), and total net fluid status (mL) (unit odds ratio, 1.01; 1.001–1.02, p = 0.0001). Conclusions: Several factors predict in-hospital mortality in fibrotic interstitial lung disease-associated mechanical ventilation when viewed through an acute respiratory distress syndrome model. Further research is needed to refine strategies that may perhaps improve survival if mechanical ventilation is pursued in this set of patients.