Changing trends in infectious disease in heart transplantation.
BACKGROUND
During the past 25 years, advances in immunosuppression and the use of selective anti-microbial prophylaxis have progressively reduced the risk of infection after heart transplantation. This study presents a historical perspective of the changing trends of infectious disease after heart transplantation.


METHODS
Infectious complications in 4 representative eras of immunosuppression and anti-microbial prophylaxis were analyzed: (1) 38 in the pre-cyclosporine era (1978-1980), (2) 72 in the early cyclosporine era (1982-1984), where maintenance immunosuppression included high-dose cyclosporine and corticosteroid therapy; (3) 395 in the cyclosporine era (1988-1997), where maintenance immunosuppression included cyclosporine, azathioprine, and lower corticosteroid doses; and (4) 167 in the more recent era (2002-2005), where maintenance immunosuppression included cyclosporine and mycophenolate mofetil.


RESULTS
The overall incidence of infections decreased in the 4 cohorts from 3.35 episodes/patient to 2.03, 1.35, and 0.60 in the more recent cohorts (p < 0.001). Gram-positive bacteria are emerging as the predominant cause of bacterial infections (28.6%, 31.4%, 51.0%, 67.6%, p = 0.001). Cytomegalovirus infections have significantly decreased in incidence and occur later after transplantation (88 +/- 77 days, pre-cyclosporine era; 304 +/- 238 days, recent cohort; p < 0.001). Fungal infections also decreased, from an incidence of 0.29/patient in the pre-cyclosporine era to 0.08 in the most recent era. A major decrease in Pneumocystis jiroveci and Nocardia infections has also occurred.


CONCLUSIONS
The overall incidence and mortality associated with infections continues to decrease in heart transplantation and coincides with advances in immunosuppression, the use of selective anti-microbial prophylaxis, and more effective treatment regimens.
Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University, Stanford, California 94305, USA. fhaddad@stanford.edu
François
F
Haddad
Tobias
T
Deuse
Michael
M
Pham
Prateeti
P
Khazanie
Fernando
F
Rosso
Helen
H
Luikart
Hannah
H
Valantine
Sebastian
S
Leon
Thu A
TA
Vu
Sharon A
SA
Hunt
Philip
P
Oyer
Jose G
JG
Montoya
D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000998:Antiviral Agents / Q000627:therapeutic use; D001424:Bacterial Infections / Q000453:epidemiology / Q000517:prevention & control; D015331:Cohort Studies; D003141:Communicable Diseases / Q000453:epidemiology*; D005260:Female; D006331:Heart Diseases / Q000601:surgery*; D016027:Heart Transplantation / Q000276:immunology / Q000401:mortality; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000453:epidemiology / Q000517:prevention & control; D009894:Opportunistic Infections / Q000453:epidemiology* / Q000276:immunology; D011183:Postoperative Complications / Q000453:epidemiology* / Q000382:microbiology / Q000821:virology; D012189:Retrospective Studies; D014777:Virus Diseases / Q000453:epidemiology / Q000517:prevention & control
D000900:Anti-Bacterial Agents; D000998:Antiviral Agents; D007166:Immunosuppressive Agents