Post COVID Pulmonary Necrosis and Polymicrobial Empyema Managed with Bilateral Lung Transplantation and Post-Transplant Local and Parenteral Antibiotics

COVID associated end-stage lung disease requiring lung transplantation can be complicated by opportunistic infection. We describe a case of extensive pleural and pulmonary infection managed with lung transplantation followed by local and systemic antibiotics. A 37-year-old unvaccinated pregnant female was admitted to her local hospital for planned caesarean section. Three days post-operatively, SARS-CoV-2 testing was positive. Respiratory failure followed and she received dexamethasone and tocilizumab. Course was further complicated by bacterial pneumonia, pneumothoraces requiring chest tubes, and left empyema requiring thoracotomy and decortication. Bronchoalveolar lavage (BAL) and pleural fluid cultures grew Pseudomonas aeruginosa, Staphylococcus aureus and Acinetobacter baumannii , treated with vancomycin and meropenem. Veno-venous extracorporeal membrane oxygenation was initiated, and she was transferred for lung transplant evaluation. Due to development of carbapenem-resistant P. aeruginosa (CRPA), meropenem was changed to cefepime and ciprofloxacin. Pleural and respiratory cultures remained persistently positive. Seventy-eight days from COVID diagnosis and after fifty-five days of antibiotics, bilateral lung transplantation was performed. Diffuse adhesions and visible empyema were seen intraoperatively and her pleural cavities were washed with colistin and vancomycin solution. Intraoperative cultures grew CRPA and pathology revealed significant pulmonary injury with diffuse microabscesses. Post-operatively she received 7 days of intrapleural colistin and vancomycin via chest tube and continued prior parenteral regimen. CT Chest obtained one month after transplant was without evidence of ongoing infection and antibiotics were stopped. Five days later, tracheal aspirate obtained due to purulent secretions and grew CRPA for which she received cefepime and inhaled colistin. In the six months since there have been no further significant infectious issues. Extensive bacterial infection preceding lung transplant can be successfully managed with careful review of prior microbiology data, development of an antimicrobial regimen and aggressive intraoperative and post-operative local and systemic antibiotic therapy. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Heart Transplantation with Covid 19 Positive Donor Hearts

Coronavirus disease 2019 (COVID-19) causes a profound systemic inflammatory response and the transmissibility was unknown early in the pandemic;consequently, transplant centers were hesitant to utilize organs from COVID-19+ donors. This study aims to analyze short and medium-term outcomes in recipients of hearts from COVID-19+ donors. The Organ Procurement and Transplantation Network database was queried for all heart transplant recipients between January 1, 2020 and December 31, 2021. Recipients of COVID-19+ donor hearts were compared to recipients of COVID-19- donor hearts. Pediatric recipients, multiorgan transplants, donors without COVID-19 testing, and recipients allocated under the old heart allocation system were excluded. One to three propensity score matching was used to match COVID+ donor heart recipients to COVID- donor heart recipients. Over the study period, 4,621 heart transplant recipients met inclusion-exclusion criteria, including 62 recipients of COVID+ donor hearts. After matching on pre-transplant recipient and donor characteristics, the 59 COVID+ donor heart recipients were matched to 177 COVID- donor heart recipients. Baseline characteristics were similar following matching. Thirty-day survival was similar between groups (COVID- 95.5% vs. COVID+ 100.0%, log rank p=0.10) as was six-month survival (COVID- 93.2% vs. COVID+ 98.3%, log rank p=0.15;Figure 1). National COVID+ donor heart usage varied by region, with region 11 transplanting the largest proportion of COVID+ hearts [11/62 (17.7%)] and region 10 transplanting the least [1/62 (1.64%)]. COVID+ heart utilization per region was greatest in region 1 [7/249 (2.8%)] and least in region 10 [1/384 (0.26%)]. Thirty-day and six-month survival in recipients of COVID+ donor hearts is similar to that of COVID- donor hearts. These data should encourage increased utilization of COVID+ donor hearts. Further analyses are needed to determine if long-term outcomes are equivalent between groups. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Infection with Covid Variants of Concern in a Lung Transplant Population

The COVID pandemic has evolved as the SARS-2 Coronavirus (CoV-2) mutated into unique variants of concern (VOC). The clinical approach to COVID has evolved as new therapeutics have become available. Previous reports demonstrate differences in patient outcomes based on VOC, however outcomes in a lung transplant population have not been described. Our lung transplant program follows over 300 transplant recipients. Relevant information including date of first positive test, hospital admission, monoclonal antibody (mAb) or oral anti-viral treatment, CoV-2 vaccination history, tixagevimab/cilgavimab (T/C) and COVID attributed mortality have been tracked for quality improvement purposes. Outcomes were stratified by predominant US VOC at time of positive testing: wild strain 02/2020-02/2021, alpha strain 02/2021-05/2021, delta strain 06/2021-12/2021, omicron strain 01/2022- 09/25/2022. From 03/20/2020 through 09/25/2022, 142 recipients were diagnosed with COVID 152 times, including 9 recipients infected twice and 1 recipient infected 3 times. Most infected recipients tested positive with CoV-2 during the omicron wave. All recurrent infections occurred during the omicron wave. 8 deaths (5.6%) were attributed to COVID: 6 due to COVID respiratory failure, 1 stroke and 1 new restrictive-chronic lung allograft dysfunction. Therapies directed against CoV-2 were more likely administered in delta and omicron waves. Recipients were more likely to require hospital admission in wild type and alpha waves of CoV-2. Most deaths occurred in the wild type and delta waves. Deceased recipients, and those requiring hospital admission received less vaccinations and were less likely to have received T/C. (Table) This analysis shows changing trends in management and outcomes over the COVID pandemic. Future research should focus on transplant specific outcomes, including post-infection changes in allograft function and risk of developing chronic lung allograft dysfunction based on likely infecting VOC. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)