Delphipanel on Antimicrobial Stewardship and Management of Clinical Syndromes in Thoracic Organ Transplants and Mechanical Circulatory Device Recipients

Abstract

<h3>Purpose</h3> Antimicrobial overuse contributes to antimicrobial resistance in lung transplant recipients (LTRs). Guidance on assessment of the quantity and appropriateness of antimicrobial prescribing is required in LTRs for standardized management. This study aims to define the expected appropriate antibiotic prescribing of clinical scenarios in LTRs using a modified Delphi method. <h3>Methods</h3> We developed an online questionnaire to solicit from ISHLT membership and Delphi Panel members regarding the appropriate treatment of 21 common clinical scenarios treated with systemic antimicrobials. Consensus was predefined as 80% agreement on the importance of each metric. The metrics that did not achieve the consensus on questionnaire were presented to an online multidisciplinary Delphi panel consisting of 25 experts from various disciplines (infectious diseases (6), pediatric infectious diseases (1), respirology (8), cardiology (2), cardiothoracic surgery (5), immunology (1) and pharmacy (1)) within ISHLT. An independent non-content expert conducted the panel. <h3>Results</h3> Following the initial online survey, 69 responses were received. Consensus on the antimicrobial management was reached on 20% (20/ 98) of questions related to 21 clinical scenarios. The survey was modified and shortened (based on relevancy, controversy of topic and consensus) to 38 questions in 10 clinical scenarios. Eleven further questions were removed due to redundancy. In total, 27 questions related to 10 clinical scenarios were discussed on-line among the Delphi Panel. Consensus was reached among 77% (21/ 27) of questions. Consensus was not reached regarding the antimicrobial management of the following 6 clinical syndromes: 1) CMV (duration of secondary prophylaxis); 2) <i>Burkholderia cepacia</i> pneumonia (duration of therapy); 3) RSV (duration of therapy); 4) <i>Mycobacterium abscessus</i> (intra operative antimicrobials); 5) <i>Aspergillus</i> (treatment of culture negative BAL but galactomannan BAL +) and 6) LVAD deep infection (initial empirical antimicrobial coverage). <h3>Conclusion</h3> This study resulted in expert consensus for defined levels of appropriate antibiotic prescribing in majority of clinical scenarios assessed in LTRs. These results can be aid in antimicrobial stewardship adjudications in LTRs.