Hi everyone, welcome to Febrile, a cultured podcast about all things infectious disease. We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management. I'm Sara Dong, your host and a MedPeds ID doc. I have three guests with me today, I'm super excited to introduce. I'll start with Dr. Chelsea Gorsline. Chelsea is a transplant ID physician and assistant professor at the University of Kansas Medical Center in Kansas City. She completed her internal medicine residency, general and transplant ID fellowship training at Vanderbilt University Medical Center in Nashville.

Hi, I'm Chelsea Gorsline.

Next, we have Dr. Courtney Harris, who is a transplant ID physician and assistant professor at the Medical University of South Carolina in Charleston, which is my alumni. She completed her residency and chief residency at Mayo Clinic in Minnesota, followed by general and transplant ID fellowship at the combined program of Brigham and Women's Hospital and Massachusetts General Hospital in Boston.

Hey, this is Courtney Harris.

And our third member today is Dr. Rebecca Kumar. She is a transplant ID physician and assistant professor at MedStar Georgetown University Hospital in the Division of Infectious Diseases and Tropical Medicine. She completed her internal medicine residency at MedStar Georgetown University Hospital in Washington, D. C., followed by fellowship in infectious diseases at Northwestern University in Chicago.

Hey, this is Rebecca.

Welcome. So as everyone's favorite cultured podcast, we like to kick off the episode by asking you to share a little piece of culture, something that you've enjoyed recently.

I can go first. Uh, I, if I wasn't in medicine, I would be in the arts. So I couldn't pick one thing, but I picked two. So, uh, my favorite band right now is Fontaines DC. They're from Ireland. They're like a proper rock band. I'm obsessed with the lead singer's voice. It's so great. The lyrics are poetry. I love the music. I got to see them last year and I'm going to see them again next month and I'm just really really excited for it. And then the second thing is, uh, totally obsessed with the TV show Severance on Apple TV right now. Cannot get enough of it. A psychological thriller, a little bit of a workplace comedy, a little bit of sci fi, just incredible. Front to back, my husband and I cannot stop reading theories about it. It's just such a great time.

Severance is so good, and I haven't had anyone to talk to about it, and it's been driving me crazy.

So good. It's amazing.

So good.

So I can go next. My sister introduced me to fantasy books as well as Chelsea on this call. Um, and so I am currently starting the seventh book of the Throne of Glass series, which has been a slog and it is amazing. It's a, like a fantasy novel series following like a teenage assassin trying to take down a corrupt kingdom with a tyrannical ruler. Like it's wonderful. So I'm very excited to like finish this series out strong.

Great series.

Um, the piece of culture that I'm really enjoying right now is White Lotus. At the time of recording, I think the third episode has just aired, I'm also obsessed with like reading fan theories online and trying to figure out what the deal with Rick is.

Yes!

So that's really what's been occupying my time off service.

Oh, this is so great. Now everyone can see why I invited you guys. We have such shared cultural interest. Uh, well, today is a fun episode. As an also, uh, young or junior transplant ID doc, I've been, uh, excited to meet you guys and have been following along with the Transplant ID Early Career Network and efforts from that. And so before we talk through the goal of the episode today and some of our consult questions, I was hoping actually you could tell people about the network in case they aren't familiar.

Yeah. So I founded the Transplant ID Early Career Network during the pandemic, was really lonely time I think for all of us. Really is a way to do virtual networking for trainees who were interested in transplant ID. And then a couple of years ago, when I transitioned to faculty at KUMC, I recruited help from Courtney and Rebecca, and really we wanted to expand the scope of what this was able to offer, not just for trainees, but also for early career faculty as well. And with Courtney's help, we really introduced a lot of new medical education activities, which a lot of this has been based on social media. And then we've subsequently formed a partnership with the Transplant ID Journal, and we've published numerous papers now, mostly with practical pragmatic tips for trainees and early career faculty that are really based off of these activities. And now we are starting to transition into doing more in person live events at conferences. So be on the lookout for those in 2025.

Love it. And we're going to put links to those papers. So a large portion of our job in Transplant ID is giving advice on risk of infection related to organ transplantation, and one part of that is something that most people call donor call. So when a surgeon or a transplant coordinator or someone from the transplant team calls and asks about the suitability of an organ for transplant. I want to highlight one of those articles that you mentioned that has come out through the Early Career Network, and we're going to walk through some scenarios today to give examples of the thought process. Maybe before we give a clinical example, you can talk a little bit about donor call in general for those who maybe aren't used to participating.

Yeah, so this is when a surgeon or a transplant coordinator will call and ask about the suitability of an organ for transplant. So when I was a transplant fellow, I would occasionally field these calls and then sometimes would discuss them when my attending would receive them, but I never received formal training on how to approach these. And actually my colleague, Rachel Sigler, she worked pretty hard to develop a mock donor call educational activity while she was a fellow. And we loved this idea. We really wanted to collaborate with her and build on what she started so that others could actually use this as a template if they're also trying to teach this in a structured setting.

So what we ended up doing from the Early Career Network is we created a series then of five donor call examples and posted one example, like donor call scenario to social media in the morning at that time we were using X or Twitter, and then over the course of the day, let the transplant ID community kind of comment on what they would do, and then in the evening posted the resolution to the case with some teaching points, so we saw a lot of engagement with this approach, and many followers commented daily, like, and it was nice to see kind of that wide variety of approaches and how people approaching so differently. Things that are standard, you know, dosing is different, how long you treat is different. So it was really nice to kind of see, you know, some of the really great leaders in our field have different approaches to donor calls, which I think really shows the variability which is why it's always good to discuss these with our trainees.

Yeah, and something that we felt really strongly about when we wrote the paper was that we really wanted to develop a framework to help trainees and early career faculty think about how to prepare for these calls. And so this would include what are the appropriate follow up questions to ask and what are the important non infectious considerations that you should be thinking about when you accept a donor?

And I think key among them is just this idea that there's a risk to the recipients if we keep them on the waitlist for longer, waiting for that perfect, absolutely perfect organ. So I think weighing that risk of a possible donor derived infection with the risk associated with mortality on the waitlist is really what's a key driving principle in donor call.

I think one of the other things about donor calls, too, is it's very easy to get flustered when you're on the phone, like answering questions, so it's good to have a really stepwise approach, especially when they may be giving you really minimal information, but you want to think about it the same way every time you approach it. So if you check out our paper, Table 1, there's really good steps to how to consider these offers in a, you know, stepwise manner. So you ask donor specific questions like their medical, social history, any recent micro, their hospital course for the donor, then recipient specific questions like, you know, what kind of immunity do they have? What vaccines have they received? What kind of underlying medical conditions do they have? And then, you know, what is the transmissibility? So in, for example, a donor has a urinary tract infection. Is the transplanted organ the kidneys or the heart? Cause that matters. Um, and then has the donor been treated? So what's the treatment of the donor and then can you treat the recipient? And then finally, what is the likelihood of future offers and the mortality? So, is the recipient going to be a heart transplant who's on temporary mechanical support and has a high mortality in the coming days and has a low likelihood of receiving another offer, then, you know, maybe there is a risk, but maybe that risk is much lower than them having a fatality on the waitlist waiting for another offer. So I think that's kind of our stepwise way to approach them.

Perfect. All right. Well, you guys, we have the pager or the cell phone, whatever people are using. I'm going to go through a couple of donor calls today. So I'll start with call number one. You receive an offer for a liver transplant from a donor in Georgia. The donor is a 35 year old previously healthy woman who was hospitalized after injuries related to trauma from a car accident. Encephalopathy was noted during the hospitalization, and she was subsequently declared brain dead. There were some varying reports from family on the preceding symptoms before this happened. So maybe fever, maybe she'd been more tired and fatigued recently. There was no fever documented during the hospitalization and the labs on admission were not suggestive of infection. So what questions do you have?

I think one of the hard things about donor call is just the fact that in, in essence, it is essentially a game of telephone where you get the information from somebody else who's gotten it secondhand from a family member who may or may not know everything about what's going on with the donor. So one of the key things that I'm thinking about when I hear the coordinator call and mention that there's encephalopathy is what, what's the underlying cause of this altered mental status. And anytime there's an unknown etiology, I think one of the big things that we almost always recommend is a lumbar puncture. And really, in a patient who's presenting with fever and altered mental status, you want that lumbar puncture before you accept the organ because we really don't know if there's possibly some sort of viral, um, meningitis or something else that could be easily transmitted from the donor to the recipient. Um, and so, and I didn't quite catch, sorry, what time of year did this happen?

It's summertime.

It's summertime. So I think one of the big things that we'd be worried about would be something like West Nile. Um, and then the other things that you need to consider when you're assessing the donor is where's the donor from? So are there any outbreaks ongoing in Georgia at this time, at this particular time of year? One of the things that we talk about in our paper is related to the Fusarium meningitis outbreak that happened in 2023 related to patients going to Mexico to get plastic surgery. Um, and another thing to consider at time of recording is this big measles outbreak that's going on in the U. S. So all of these things are considerations when we're assessing the suitability of this of this donor. So that's sort of the things that I'm thinking about right now. So I would ask for this lumbar puncture. I would make sure because it's summertime that we check for West Nile and get the cell count everything else with it. And based on the results, we would make our decision. Because of the time of year, if the lumbar puncture, if it cannot be done, I think that this would be an organ that I would recommend declining because we don't know why the patient's encephalopathic with a fever.

That's a take home that I try and reinforce with fellows about unknown encephalopathy is, is quite worrisome when you get a donor call. All right. Okay, perfect. And everyone should know that these are sort of cases created for education, so they're not, um, fully fleshed out. We kind of just want to go through the thought process of getting donor calls. So, all right, your pager goes off again and you call them back and they say, we've received an offer for a kidney transplant donor who we just found out has Enterobacter cloacae in the urine. The donor had a Foley catheter in place and urine was collected from the Foley and is now growing drug resistant Enterobacter. The sensitivities that we have so far are cefepime MIC32, which is resistant, our pip-tazo is resistant, the meropenem is susceptible the MIC is less than 0. 5, ertapenem was intermediate with an MIC of 1, and ceftazidime avibactam is sensitive with an MIC of 4. The donor has decreasing pressure requirements and improving white blood cell count and creatinine, and all vitals are within normal limits. They also have information that the blood cultures from two days ago are negative to date, and the patient is now on day two of meropenem for the isolate. So just wondering, what do you think? Are you worried about accepting?

Yeah, so this is a pretty common scenario that we run into with our kidney transplant recipients. Because patients can have bacteria in the urine, it's not necessarily a reason we should decline an organ, but there are a few things that we would want to make sure that the donor has been set up with and then appropriately treat the recipient as well. Um, so for the most part, we would want patients or donors to have received at least 24 to 48 hours of appropriate antibiotic therapy prior to procurement. And then looking at the recipient, we would want to treat them with at least, you know, seven or so days of targeted therapy. I think this can also vary depending on what institution you work at and how long you will treat the patient. And also things like whether there was bacteremia present can impact that duration as well. But I think this case is nice too because it also highlights that you have to be familiar with resistance patterns, not just the principles of how to treat a recipient. So for instance, in this case, the Enterobacter is meropenem susceptible, but it's ertapenem intermediate. So in some cases that might give you pause, but then if you Enterobacter species can actually have a low level ertapenem monoresistance, and this doesn't necessarily preclude the use of meropenem. That makes this case a little bit more approachable and easier to say, okay, we're going to go ahead and give the recipient meropenem to treat them. And then we'll call out that the IDSA has published some updates to their MDR gram negative treatment recommendations in the past couple of years, so those can always be a great resource when you're looking at tough cases like this. And then I know, at least at my institution, we also have developed our own, uh, internal guidelines on how to approach these organisms, so those can be helpful as well.

Excellent. All right. Well, we're getting another, another call. You get the message that our patient who received a lung transplant last week is doing great, but we were just informed that the donor had a positive Strongyloides antibody so, do we need to do anything about this?

So this case is a little bit different since the patient has already received their transplant, but donor derived infection with Strongyloides typically occurs, um, within 90 days after transplant when immunosuppression is the highest. So here we're going to worry about hyperinfection syndrome, which can impact the lungs and the GI tract and can be devastating to recipients, the rapid larval migration and risk for ARDS, GI bleeding can be severe and the mortality rate's up to 35 percent. So despite this, we can safely accept organs from donors who have positive Strongy exposures as effective treatment exists. It really isn't going to interact with a lot of the other medications. So if a donor or recipient is positive for Strongyloides, we can just go ahead and treat. Treatment, there's a little bit of a debate about how many doses you need to give. You can either give two doses over two days and whether that's enough or whether secondary dosing in two weeks and repeating those two doses is necessary, but regardless, it's recommended to give the recipient ivermectin, which again is well tolerated with minimal drug interactions. And it's notable to that a positive Strongy IgG in a pretransplant recipient doesn't give them any protective immunity. So even if they were treated pre transplant for their positive Strongy, if their donor is positive, I would go ahead and retreat then. Um, and while strongy is kind of prevalent in Africa, Asia, Latin America is kind of the teaching. There are pockets of endeminicity in the U. S., um, especially in the Eastern U. S. So where I practice at MUSC in South Carolina, a lot of our patients are living in rural South Carolina, and we've actually like looked, there was a prior team that looked at this, um, Ruth Adekunle from MUSC here, her and our prior team studied universal screening in our heart transplants over a shorter period of time and found that our heart transplants had near 11 percent Strongy positive. And a good percentage of our donors have not had travel outside the United States. Um, so, you know, we're now actually studying over a five year period of universal screening in heart transplant, whether or not the rate is really this high, but I suspect that it is. And so because of this, we've started screening all of our solid organ transplants for Strongy. So I think having an increasing vigilance for this infection transmission in the U. S. is really important.

I love hearing what other, other centers are doing and comparing and contrasting. That's awesome. Okay, well we have another call. Our fourth case here, the Lung Transplant Coordinator calls to let you know that the OPO just notified us that the donor we want to take has "fungus" in the sputum. The donor is a 45 year old incarcerated man from California. He has a hemoglobin A1c of 14 but no smoking history. Cause of death was suicide. So, can we take this organ? The procurement team is present and the recipient has just arrived at the hospital. And for additional information on the recipient, it is a 24 year old patient with cystic fibrosis.

I think this case is super fun. It's like doing a consult just with a donor call. So this case really presses you to know what the differential for fungus on a sputum culture is, and really what other information do you need to obtain from the OPO to help you decide if you should accept this organ or not. And so differential for fungus is going to be broad, right? So there's endemic mycoses, there's molds, there's yeast, but we would only want to accept this organ if we know what the fungus is, and there's a good treatment option for it. So in this case, we asked the OPO, Hey, can you identify what the fungus is? And they were not able to identify it. And so this organ would be declined because we really just don't know what we're dealing with. Um, the setup for this case is that the donor had Coccidioides, um, with risk factors being uncontrolled diabetes, residence in California. And I think this is important because Coccidioides, we do not have universal recommendations for donor screening. And so as someone who is getting these donor calls, you really have to be mindful of where is the donor located? What are their radiographic findings, which is available in the U. S. through UNET, and also other things like ventilator settings or respiratory status of the donor which that OPO can provide to you if you ask. And the reason that we care about this so much is because donor derived infections with Coccidioides can also be very devastating, um, disseminated disease. And so, if we knew that the donor had Coccidioides, we really wouldn't want to be taking organs from them unless we know that the infection is under control or hopefully cleared. But if we also knew that the donor had a prior history of it, we could actually also give preemptive azole therapy to the recipients to then prevent that risk of transmission and harm to the recipient. And then also if we do detect a case of donor derived infection, then we would want all of the other recipients to be treated for Coccidioides as well, just because this fungus is quite transmissible and associated with high mortality.

And I realize I may have said OPO earlier and never defined it otherwise, so, um, just to explain, OPO stands for organ procurement organization. And so the last thing I want to do is for us to have a transplant ID episode using acronyms and not explaining them, especially because we're trying to shed some light on the behind the scene aspects of transplant. So these are just a few example calls, and it's a really big topic, but I hope at least people have a starting framework on approaching donor call, and I wanted to see if you guys have any other take home points that you'd like to share, whether that's about taking donor call or donor derived infections.

Even if after you take donor call, everything seems fine that you should keep an eye out for possible donor derived infections after transplant. This can happen, you know, the classic teaching is anywhere from like in that first 30 days after transplant, but we have seen issues with donor derived infections months after. We recently had a case of Bartonella quintana endocarditis in our recipient who was completely asymptomatic, but got it from his donor. And the only reason we found out was because the other recipient was ill and the OPO was notified. And then we were able to screen our donor.

And then I think another key takeaway would be that, it's really important for anyone you're seeing that's infected in the early or even like mid to late post transplant period, kind of the first few months, to go on DonorNet, you know, you should have access to DonorNet at your institution if you're a transplant ID provider, or if you're taking care of transplant patients to be able to look in the chart, be able to review the imaging, the labs, and all the findings from the donor. And you can see a lot of the social history there to kind of think about what things the donor may have put your recipient at risk for.

Yeah, agree. I think anytime we get a consult on someone who's within the first few months of transplant and there's something unusual going on, I think the first step should really be going back to the donor and reviewing that in more detail to make sure nothing was missed because yeah, there are some later onset donor derived infections that can still be pretty bad. And interestingly, you know, where I practice in the Midwest, there was a few years ago a cluster of Ehrlichia donor derived infection, which was pretty wicked and wild, um, and so I, I think being aware of what region you're practicing in and what hyperspecific regional things might be at risk is also important too.

Yeah, and the other thing to keep in mind is also for any of these donor calls, it's okay to talk to other people, like within your division, or even outside of your division. You're always welcome to reach out to myself, Courtney, or Chelsea, or Sara, if you have questions, because, you know, we take these calls and we're happy to help.

And there's a lot of nuance, and so we have a group thread that we are always asking each other at other institutions about our cases, like Rebecca and Chelsea and many of our other friends. Alan Koff has helped us with lots of these donor calls, but it's nice to have a group and a big network to ask, which makes me feel better about my decisions. So thank you guys. And I love you.

And I think that's a really nice way for us to sort of start the conclusions, which is reaching out to your colleagues, because these questions are not easy. And there's often a lot of nuance and center specific things that it helps to bounce ideas off of someone else. But yeah, so maybe the last thing I'll close with is just asking you guys, for those people who are interested in transplant ID or maybe hearing more from the Early Career Network, is there anything that you would direct people to, to get started or get involved?

Yeah, so if you want to check out more interesting content from our group, the Transplant ID Early Career Network, you can find us active now on Blue Sky. And we also have several other papers, as Sara mentioned earlier, that you may find of interest. Most of these are targeted at trainees and young faculty to kind of figure out how to help you navigate the field of transplant ID. So, this includes like securing your first transplant ID job and helping negotiate for that position. Um, how to perform a transplant ID pre transplant evaluation. Uh, how to write and collaborate on a transplant ID protocol, which is a lot of what we do in our non clinical time with the transplant teams. How to understand the nuances of transplant ID training, whether this is tracks or formal years, there's formal third year fellowships that you could do in transplant ID, or you could do a track within your program. So there's a lot of differences between those, um, how to become your best transplant ID steward. AKA being an MVP like Chelsea. And then also how to incorporate and be involved in social media and transplant ID interacting with our group and others. We have a paper on that as well. So we really aim to create this content to make the field of transplant ID accessible to all because while it's been around a while, it's evolving, it's growing. And I think there are a lot of us who are in our early careers who are so interested in helping develop the field. And I think reaching out to our group, if you want to be involved, help host something with us or have an idea for an event, we'd, we'd love to have more people involved and create great events and content for you all going forward.

Thanks again to Rebecca, Courtney, and Chelsea for joining Febrile today. Don't forget to check out the website, febrilepodcast. com, where you'll find the consult notes, which are written supplements to the episodes with links to references, including the papers that we've mentioned. Our library of ID infographics and a link to our merch store. Febrile is produced with support from the Infectious Diseases Society of America, IDSA. Please reach out if you have any suggestions for future shows or want to be more involved with Febrile. Thanks for listening, stay safe, and I'll see you next time.