Solid Organ Research Articles

Belatacept and regulatory T cells in transplantation: synergistic strategies for immune tolerance and graft survival.

Calcineurin inhibitors (CNIs) have been a cornerstone in solid organ transplantation for many years; however, their prolonged use is linked to significant adverse effects, most notably nephrotoxicity. Belatacept, a modified version of cytotoxic T lymphocyte antigen-4 immunoglobulin with increased binding affinity for its ligand, has emerged as a viable alternative to traditional CNIs due to its lower toxicity profile. Despite these benefits, belatacept is associated with a higher rate of acute rejection, which presents a challenge for long-term graft survival. This review reevaluates the limitations of belatacept in achieving long-term acceptance of transplants and highlights the importance of regulatory T (Treg) cells in maintaining immune tolerance and preventing graft rejection. Additionally, it discusses the potential benefits of combining therapies that boost Treg cells with belatacept to increase the effectiveness of immunosuppression and improve graft outcomes.

Relationship Between Body Weight and Leukopenia in Non-Kidney Solid Organ Transplant Recipients With Normal Renal Function Who Are Receiving Valganciclovir for CMV Prophylaxis.

Cytomegalovirus (CMV) disease causes significant morbidity among solid organ transplant (SOT) recipients. To prevent CMV disease, eligible recipients are frequently started on valganciclovir (VGC) prophylaxis post-transplant. Leukopenia has been documented as a primary adverse events of the drug (1). This study's primary aim was to determine whether a patient's weight at the start of VGC prophylaxis was associated with the development of leukopenia. This was a single center, retrospective cohort study that included adults > 18 years of age, who had received an organ transplant (heart, liver, or lung) at an academic transplant center from January 1, 2018 through December 31, 2022. A creatinine clearance of > 60mL/min was required. All 294 included patients received 900mg/day of VGC for CMV prophylaxis, without dose adjustment. Fifty-two percent of the patients developed leukopenia while receiving VGC prophylaxis. The mean weight at initiation of VGC was higher in patients who did not develop leukopenia (97.9kg) compared to those who did (90.7kg; p = 0.0112). It was found that with each 1kg increase in body weight, the likelihood of developing leukopenia decreased by 1.7% (p = 0.004, odds ratio = 0.983, 95% confidence interval [CI], 0.972-0.994). Patients with a baseline body-mass index (BMI) > 25 had a longer median freedom time from leukopenia after initiation of VGC as compared to the group with baseline BMI < 25 (log-rank p = 0.035). These data suggest that in SOT recipients with normal renal function, receiving a fixed dose of VGC resulted in a significant, inverse relationship between body weight and the development of leukopenia.

Antigen–antibody complex density and antibody-induced HLA protein unfolding influence Fc-mediated antibody effector function

Donor-specific antibodies (DSAs) targeting mismatched human leukocyte antigen (HLA) molecules are one of the principal threats to long-term graft survival in solid organ transplantation. However, many patients with long-term circulating DSAs do not manifest rejection responses, suggesting a degree of heterogeneity in their pathogenicity and related functional activity. Immunologic risk stratification of transplant recipients is complicated by challenges intrinsic to defining alloantibody responses that are potentially pathogenic versus those that are not. Thus, a comprehensive understanding of how human alloantibodies target and interact with donor HLA molecules is vital for the development and evaluation of new strategies aimed at reducing antibody-mediated rejection responses. In this study, we employ hydrogen–deuterium exchange–mass spectrometry (HDX–MS), molecular dynamics (MD) simulations, and advanced biochemical and biophysical methodologies to thoroughly characterize a panel of human monoclonal alloantibodies and define the influence of Fc-region biology, antibody binding kinetics, target antigen density, and structural characteristics on their ability to potentiate the forms of immune effector mechanisms that are strongly implicated in transplant rejection. Our findings have significant implications for our understanding of the key biological determinants that underlie the pathogenicity or lack thereof of human alloantibodies.

Vaccination for solid organ transplanted patients: Recommendations, efficacy, and safety.

Solid organ transplant recipients face unique challenges in managing their immunosuppressed status, making vaccination a critical consideration. This review aimed to comprehensively analyze current recommendations, evaluate the efficacy of vaccinations in this population, and assess safety concerns. We explored the latest evidence on vaccine types, timing, and potential benefits for transplant patients, highlighting the importance of individualized approaches for routinely used vaccines as well as coronavirus disease 2019 vaccines. By synthesizing available data, this review underscored the pressing need to optimize vaccination strategies, ensuring that transplant recipients can obtain the full protection against many pathogens while minimizing risks associated with their post-transplant immunosuppression.

Severe Outcomes of Pneumocystis Pneumonia: A 10-year Retrospective Cohort Study.

A considerable knowledge gap exists in predicting severe Pneumocystis pneumonia (PCP) outcomes following PCP diagnosis. In this retrospective cohort, we studied immunocompromised patients with PCP admitted to 5 University Health Network centers in Canada (2011-2022). The study outcome included severe PCP, a composite of 21-day ICU admission or 28-day all-cause mortality. Adjusted odds ratios (aOR) estimated the association between severe PCP and comorbidities as well as clinical and laboratory variables at diagnosis. A total of 44 out of 182 (24.2%) immunocompromised patients (19 [10.4%] HIV-infected, 55 [30.2%] hematologic malignancies, 32 [17.6%] hematopoietic stem cell transplants, 32 [17.6% solid tumors, 26 solid organ transplants [14.3%], 12 (6.6%) autoimmune diseases, and 6 (3.3%) other immunosuppressive conditions) developed composite outcomes (40 ICU admissions [21.9%], 18 deaths [9.9%]). Patients with composite outcomes more often had acute-onset PCP (< 7 days) (18/34 [52.9%] vs. 38/126 [30.1%], p = 0.013), shortness of breath (39/44 [88.6%] vs. 96/136 [70.6%], p = 0.002), chronic liver disease (15/44 [34.1%] vs. 9/138 [6.5%], p < 0.001), hypoalbuminemia (median [IQR] albumin (g/L): 27 [25-31] vs. 32 [29-35], p < 0.001), elevated lactate dehydrogenase (median [IQR] LDH (U/L): 537 [324-809] vs. 340 [237-475], p < 0.001), lymphopenia (median [IQR] absolute lymphocyte count [(10*9/L),]: 0.4 [0.2-0.6] vs. 0.7 [0.3-1.2], p < 0.001), or required supplemental oxygen (39/44 [88.6%] vs. 60/136 [44.1%], p < 0.001) than those without composite outcomes. In multivariable analysis, chronic liver disease (aOR: 11.6, 95% CI: 2.2-61.3) and requiring supplemental oxygen on admission (aOR: 19.7, 95% CI: 3.0-128.5) were significantly associated with severe PCP. Alongside hypoxemia upon admission, chronic liver disease appears to significantly predict severe PCP in immunocompromised patients. This biologically plausible finding warrants further investigation.

Immunogenicity and safety of the fourth dose of quadrivalent human papillomavirus (HPV) vaccine in immunosuppressed women who did not seroconvert after three doses

IntroductionImmunocompromised persons have high risk of persistent human papillomavirus (HPV) infection and HPV-related diseases, and lower immune response to vaccines. This study evaluated the immunogenicity and safety of administering a fourth dose of quadrivalent (4v)HPV vaccine in immunosuppressed women who did not seroconvert after three doses.MethodsAn open-label, not-controlled trial included immunosuppressed women (solid organ transplant patients and women receiving treatment for SLE) who did not seroconvert to at least one of the four HPV vaccine types after three 4vHPV vaccine doses. All participants received a fourth 4vHPV vaccine dose (median 27 months after third dose). Immunogenicity was evaluated a month after the fourth dose, by measuring seroconversion rates and antibody geometric mean concentration (GMC).ResultsTwenty-three women were included. Among women who did not seroconvert for each vaccine type after three doses, 2/10 seroconverted to HPV6, 3/10 to HPV11, 3/10 to HPV16 and 6/18 to HPV18, after the fourth 4vHPV dose. There was an increase in antibody GMC for HPV 6, 16, 18, with highest increase for HPV16 (from 6.02 to 44.63 International Units). There was no increase of anti-HPV-11. Within seven days after vaccination, only three of the 23 vaccinees reported any adverse event, none of which were classified as serious.ConclusionsAlthough safe, the fourth 4vHPV vaccine dose led to seroconversion in only few immunosuppressed women who had not seroconverted after three doses.

A Comprehensive Review on Mucormycosis as co infection of Immunodeficiency Diseases

Mucormycosis is a fatal, life-threatening fungal infection occurring in humans that is associated with considerable morbidity and mortality. It is caused by a group of ubiquitous saprophytic molds, which typically affect patients with weak immune defences such as diabetes mellitus, diabetic ketoacidosis, malignant hematological diseases, post-hematopoietic stem cell or solid organ transplants, as well as those with neutropenia. Mucormycosis is mostly related to the current COVID-19 epidemic and the overuse of steroids but can also be caused by haemato-oncological conditions and other health conditions, such as unbalanced diabetes or caustic injuries. It mostly impacts the nose and sinuses, affecting the eyes and other parts of the body. Immediate treatment of mucormycosis is required, consisting of reversal of underlying risk factors, prompt antifungal therapy (preferably as lipid formulations of amphotericin B or isavuconazole), and early surgical debridement. However, the stringent neutropenic and metabolic status of these patients prevents early diagnosis and withholds aggressive antifungal and surgical treatments. The ability of mucormycosis to invade blood vessels and cause angioinvasion, thrombosis, tissue infarction, and the formation of fungal emboli, increases mortality among patients. New surveillance strategies, novel preventive strategies, new applicative detection techniques, novel antifungal agents, or screening for effective agent repurposing are immediately needed to pave the way to enhance the survival of these high-risk patient populations from this deadly infection and reduce the global burden. The present review aimed to provide an exhaustive overview of mucormycosis, including basic information, etiology, epidemiology and incidence, pathogenesis, risk factors, clinical manifestations, diagnosis modalities, and treatment.

A Half-Century of Heterotopic Heart Transplantation in Mice: The Spearhead of Immunology Research

Since the success of solid organ transplants, such as human kidneys, livers and hearts, from the 50s to the 60s in the last century, the field of organ transplantation has progressed rapidly. Mainly due to modifications in surgical operation techniques and improvements in immunosuppressive therapy regimes, organ survival time can now be greatly prolonged. This progress has also been dependent upon the availability of appropriate animal models for organ transplantation. Therefore, the mouse heart transplantation model has developed into an irreplaceable research model for solid organ transplantation, providing indelible contributions to the field. In this review, we will provide an overview of the technical developments in murine heart transplantation, as well as its historical and current role for alloimmune research. Further, we will describe its current fields of application and its scientific achievements before we discuss potential future applications.

Gut Microbial Dysbiosis and Implications in Solid Organ Transplantation

The gut microbiome has been shown to play a significant role in solid organ transplantation, potentially influencing graft function and patient outcomes. Dysbiosis, characterized by reduced microbial diversity and an increase in pathogenic taxa, has been linked to higher incidences of allograft rejection, graft dysfunction, and post-transplant mortality. Several studies suggest that the gut microbiome might be able to serve as both a biomarker and a therapeutic target, potentially guiding personalized immunosuppressive therapies and other interventions to improve outcomes after solid organ transplantation. As summarized in this review, clinical studies have shown that specific microbial shifts correlate with adverse outcomes, including acute rejection and chronic allograft dysfunction. As research surrounding the relationship between the gut microbiome and solid organ transplant progresses, the integration of microbial analysis into clinical practice has the potential to revolutionize post-transplant care, offering new avenues to improve graft survival and patient quality of life. This review aims to provide a comprehensive overview of the relationship between gut microbial dysbiosis and transplantation outcomes, emphasizing the impact on kidney, liver, lung, and heart transplant recipients.

Patch Testing in Solid Organ Transplant Recipients: Experience From a Tertiary Medical Center Over 13 Years (2010-2022).

Background: It is generally recommended that patients not be on immunosuppressive medications for patch testing, as these medications may suppress delayed-type hypersensitivity and lead to false negative results. There is a paucity of literature describing organ transplant recipients who underwent patch testing. Objective: The aim of this study is to examine patch testing results in solid organ transplant recipients over a 13-year period at our institution. Methods: We performed a retrospective analysis of patch test data from adult transplant recipients at our institution. Transplant patients who underwent patch testing were identified from a clinical patch test database, and a chart review was conducted. Results: Eighteen patients were included in the study. Patients had received kidney, liver, or heart transplants. Seven patients (38.9%) had at least one positive reaction. The highest reaction rates were seen with methylisothiazolinone (12.5%), methyldibromo glutaronitrile (12.5%), and benzalkonium chloride (10.0%). Limitations included small sample size, data from a tertiary referral center, and retrospective analysis. Conclusions: Liver and kidney transplant recipients displayed allergic reactions during patch testing. Patients may benefit from patch testing even if receiving immunosuppressive therapy, but some reactions may be falsely negative because of immunosuppression.

Association Between Obesity and Intra-Abdominal Solid Organ Damage in Patients with Blunt Abdominal Trauma: A Cross-Sectional Study.

Background/Objectives: The global prevalence of obesity continues to rise. However, whether obesity affects the degree of intra-abdominal solid organ damage following blunt trauma remains unclear. This study aimed to investigate the correlation between obesity and intra-abdominal solid organ damage. Methods: This cross-sectional study was conducted at a regional trauma center in the Republic of Korea from January 2018 to December 2022 and included 582 patients aged 18-98 years with blunt abdominal trauma. Patients were categorized into four groups-underweight, normal weight, overweight, and obesity-based on their body mass index (BMI). Odds ratios (ORs), beta coefficients, and 95% confidence intervals (CIs) for intra-abdominal organ damage were calculated across BMI categories using multiple logistic regression analysis after adjusting for the confounding variables. Results: The obesity group exhibited a significant decrease in the prevalence of liver injury (OR: 0.553, CI: 0.316 to 0.966) and a reduction in liver injury severity (β: -0.214, CI: -0.391 to -0.037) compared with the normal-weight group after adjusting for the confounding factors. However, no significant association was observed between the BMI and injuries to other solid organs, such as the spleen, pancreas, and kidneys. Additionally, the younger obesity group (participants aged < 45 years) exhibited a significant negative association with both liver injury and injury grade. However, the older obesity group (participants aged > 65 years) exhibited a statistically significant association only with the liver injury grade compared with the normal-weight group. Conclusions: Obesity can serve as a predictive factor for the presence and severity of liver damage caused by blunt abdominal trauma.

Real-World Comparison of Maribavir to Foscarnet for the Treatment of Cytomegalovirus in Solid Organ and Hematopoietic Stem Cell Transplant Recipients

Cytomegalovirus (CMV) infection in solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients may increase the risk of rejection or allograft dysfunction, other infection(s), and morbidity and mortality. Treatment can be challenging due to medication-associated toxicities. Maribavir (MBV) is a promising option for the treatment of resistant or refractory (R/R) CMV infection in lieu of foscarnet (FOS), which has long been the recommended therapy for (val)ganciclovir-resistant infection. This was a single-center retrospective study of clinical outcomes of patients who received MBV compared to a control group who received FOS for an episode of CMV infection. Each cohort consisted of 27 episodes of CMV infection. Twenty patients in the MBV cohort and from the FOS cohort cleared the infection, with five and three patients developing MBV or FOS resistance, respectively. There were no statistically significant differences in failure of therapy as evidenced by persistent DNAemia (p = 0.56) or development of antiviral resistance (p = 0.24). In conclusion, MBV was as effective as FOS for the treatment of R/R CMV infection and was better tolerated without increased risk of antiviral resistance.

Bridging the Gap: A Review of Pediatric to Adult Transition of Care in Liver Transplantation.

With improvements in long-term graft function and survival, an increasing population of pediatric liver transplant (LT) recipients now require adult care. A process to successfully transition young adults to adult LT centers is supported in the literature with discussions on the rationale for health care transition (HCT), barriers to transition, stakeholder perspectives, and transfer readiness (TR). Results of outcomes studies are difficult to generalize and there remains no standard of care for HCT in LT. Of concern is that the youth's increasing independence occurs during a period of developmental vulnerability, with a threat to graft function due to risk-taking behaviors, specifically nonadherence, that may lead to rejection, graft loss, and death. The purpose of this comprehensive literature review is to discuss current knowledge, practices, and outcomes of HCT for LT recipients with additional support from literature in solid organ transplant (SOT) and pediatric-onset chronic conditions literature. Recent position statements in LT and SOT express a greater awareness of the importance of HCT with broad agreement that reflects a similarity in approach in endorsing HCT as an essential process that should be initiated in early adolescence with TR as a primary determinant of transfer; however, standardization with consistent outcomes measurement is lacking. The literature supports transition as an esential component of care that should be initated in early adolescence with programs that address knowlege, skill-development, and advocacy. The engagement of all stakeholders in LT is essential to program development. There is increasing awareness among the multidisciplinary team of the importance and role of the adult provider in extending transitional care into the adult setting as executive functioning skills mature. Outcome measures need to be clearly defined and standardized. Regulatory agency involvement to validate and support the need for TOC programs is crucial and should promote outcomes research for best practice program standardization.

Renal transplant ultrasound: assessment of complications and advanced applications.

Renal transplantation is the most commonly performed solid organ transplant procedure. Monitoring renal transplants with ultrasound is a critical component in the management of transplant patients both in the immediate aftermath of surgery and longitudinally. Many complications are detectable via ultrasound evaluation with relative prevalence dependent on the time since surgery. It is critical for the practicing radiologist to recognize these complications to help guide appropriate treatment. Fundamental understanding of the procedure, including various surgical techniques is of great importance. In this article, the sonographic findings of the most common postoperative and long-term complications of renal transplantation are reviewed. As complications are highly related to surgical technique, the most common surgical techniques are presented first. Comprehensive ultrasound evaluation of the allograft is discussed next, followed by extensive review of the ultrasound findings of common complications. Finally, select recent advances in ultrasound are presented with their current and potential applications to renal transplant evaluation.

Recurrent Outbreak of Carbapenem-Resistant IMP-1-Producing Pseudomonas aeruginosa in Kidney Transplant Recipients: The Impact of Prolonged Patient Colonization.

Infections by carbapenem-resistant Pseudomonas aeruginosa (CRPA) have been associated with high morbidity and mortality among solid organ recipients. To delineate the epidemiological and molecular characteristics of a recurrent outbreak of imipenem (IMP)-producing P. aeruginosa (CRPA) among kidney transplant (KT) recipient METHODS: We described a recurring CRPA outbreak in a KT ward, divided into two periods: before unit closure (Feb 2019-2020) and after reopening (Aug 2020-Dec 2023). Routine surveillance cultures (SCs) were performed using axillary-perineum-rectal swabs with immunochromatographic tests. A case-control study identified risk factors for CRPA acquisition. Pulsed-field gel electrophoresis and whole genome sequencing characterized the strains. After reopening, new cases arose from patients previously colonized, peaking 18 months later. A total of 67 KT recipients with CRPA-IMP-producing strains were identified. All except one sequenced strain belonged to the ST446 clone, differing by a maximum of 110 single nucleotide polymorphisms. Forty-five (67.2%) cases were identified through SC, with 45.7% showing intermittent SC positivity. Patients remained colonized for up to 623 days. Twenty-four (35.8%) patients had infections, with the most common site being the urinary tract. Identified risk factors included older age, deceased donor, re-transplantation, reoperation, carbapenem or quinolone use, lymphopenia, hospital stay >10 days, and the first 60 days post-KT. KT recipients can harbor CRPA for extended periods, and detecting CRPA-colonized patients is challenging. These characteristics highlight the patient as the major source and a critical point in outbreak control.

Extracorporeal Photopheresis for the prevention of rejection after lung transplantation - a prospective randomized controlled trial.

Lung transplant recipients have the worst long-term outcomes of all solid organs due to acute rejection and chronic lung allograft dysfunction (CLAD). To investigate the efficacy of ECP as a prophylactic treatment to prevent acute cellular rejection (ACR), CMV infections and reduce the risk of CLAD. Single-center prospective randomized controlled trial conducted at Medical University of Vienna between 2018 and 2020. It included 31 COPD recipients per group. Treatment group underwent extracorporeal photopheresis in addition to standard triple-drug immunosuppression protocol after lung transplantation. Control group received standard triple-drug immunosuppressive therapy. The primary outcome was a composite outcome defined as incidence of high-grade ACR, CMV infection or CLAD within 24 months after lung transplantation. In the control group, 19 patients (61.3%) achieved the primary combined endpoint, compared with only 6 patients (19.4%) in the treatment group (p<0.001). Freedom from high-grade ACR was significantly greater in the ECP group (p=0.045). Cumulative A scores were significantly lower in the ECP group than in the control group at 3 months (0.18±0.44 versus 0.56±0.94, p<0.05) and at 12 months (0.25±0.48 versus 1.0±1.45, p=0.002). The rate of infections was lower in the ECP group with 5 cases and 67 cumulative hospital days compared to 22 cases and 309 days in the control group (p=0.002). Freedom from CLAD at three years was significantly greater in the ECP group (p=0.015). Adding ECP to standard triple immunosuppression resulted in a significant reduction of the number of ACR episodes and significantly lower incidence of CLAD.

Ensuring equity in psychosocial risk assessment for solid organ transplantation: a review.

This review summarizes the different instruments for evaluating the psychosocial health of transplant candidates, the evidence demonstrating how these instruments relate to probability of transplant waitlisting and transplant outcomes, and the critical knowledge gaps that exist in the causal pathway between psychosocial health and clinical transplant trajectory. The current literature reveals that psychosocial assessments are a common reason for racial and ethnic minorities to be denied access to the transplant list. Given evidence that a lack of clinician consensus exists regarding the definition of, importance of, and reproducibility of psychosocial support evaluations, this facet of the holistic evaluation process may create a unique challenge for already vulnerable patient populations. Though recent evidence shows that psychosocial evaluation scores predict select transplant outcomes, these findings remain inconsistent. Multiple instruments for psychosocial transplant evaluation exist, though the utility of these instruments remains uncertain. As equity becomes an increasingly urgent priority for the transplant system, rigorous interrogation of the causal pathway between psychosocial health and transplant longevity is still needed.

Evaluating the use of glucagon‐like peptide‐1 receptor agonists in a matched cohort of kidney and liver transplant recipients

AbstractBackgroundDiabetes mellitus (DM) and obesity are common among solid organ transplant recipients, but are associated with an increased risk of graft failure.AimAlthough glucagon‐like peptide‐1 receptor agonists (GLP‐1 RAs) are effective for managing both conditions in the general population, there is limited evidence regarding their use among transplant recipients.MethodThe effect of GLP‐1 RAs on post‐transplant glucose control (defined as haemoglobin A1c [HbA1c]) among 37 liver and kidney transplant patients was compared to a control cohort. Secondary outcomes included change in total daily insulin requirements and oral DM agents, estimated glomerular filtration rate (eGFR), weight, and body mass index (BMI). Adverse events attributed to GLP‐1 RAs, hypoglycaemia, incidence of pancreatitis, biopsy‐proven acute rejection, graft loss, and death were assessed. Ethical approval was granted by the Henry Ford Health Institutional Review Board (Reference no: 15959) and the study conforms with the US Federal Policy for the Protection of Human Subjects.ResultsWe observed that patients receiving GLP‐1 RAs had a median reduction in HbA1c of 0.5% and reduction in insulin and oral anti‐DM agents compared to the control group without GLP‐1 RAs. There were statistically significant reductions in both weight and BMI in the GLP‐1 RA group. Our observed incidence of adverse events was similar to previous literature. Unlike other smaller studies, a decline in eGFR was observed in the GLP‐1 RA group. There were no differences in incidence of biopsy‐proven acute rejection, graft loss, or death.ConclusionWhen compared to patients without GLP‐1 RA therapy, GLP‐1 RAs modestly reduced HbA1c and insulin requirements and statistically reduced weight/BMI review at 6 months. GLP‐1 RAs, even if initiated early post‐transplant, were seemingly safe and effective. Larger, prospective studies are warranted to evaluate the safety and efficacy of GLP‐1 RAs in this population.

Evaluation of the CMV RNA elite MGB kit for monitoring CMV infections in pediatric solid organ transplant

Not available.

Antibiotic Stewardship Based on Colonization with Multi-Drug-Resistant Bacteria in Liver Transplantation: A Narrative Review

In solid organs post-transplant, bacterial infections can complicate the course of recovery with devastating consequences, such as graft loss and death. We provide an expert review on early post-liver transplant bacterial infections, with a focus on infections with multi-drug-resistant organism (MDRO) etiologies. Best practice recommendations are derived from a combination of available evidence and expert consensus. The main challenge in managing antibiotic therapy arises in patients with severe clinical conditions but negative MDRO screening results, as well as in those with positive MDRO screening results but uncomplicated infections. With the aim of shedding light on these “gray areas”, we propose an algorithm where the patient is stratified as being at low risk or high risk of developing an MDRO infection.