583 - Successful prevention of Strongyloides reactivation in liver transplant recipients with individualized screening and treatment: 10 year experience at a large transplant center in New York City

Background: Strongyloides stercoralis is an intestinal nematode that can establish chronic, asymptomatic infection in human hosts. Following solid organ transplantation, subclinical infection may progress to  hyperinfection syndrome, which is associated with high morbidity and mortality. However, the optimal approach for screening and treatment of strongyloidiasis in liver transplant candidates in non-endemic areas is unknown.

Methods: We performed a retrospective chart review of all liver transplant (LT) recipients from 2010-2019. All patients were evaluated by an infectious diseases physician prior to transplant, and screening for Strongyloides exposure (with Strongyloides IgG antibody) was typically limited to those with risk factors for strongyloidiasis. Only patients with positive serologic testing or other evidence of strongyloidiasis were treated with ivermectin.

Results: One thousand and seventy-two LT cases (including 15 retransplants) were reviewed. Serologic testing was perfomed in 664 cases, of which 36 (5.4% of those tested, 3.4% of total) were positive.  Of the 36 cases with positive serologic testing, 31 had identifiable risk factors including birth place, travel or eosinophilia. Eosinophilia (defined as peripheral eosinophila greater than 5%) was noted in 3 of the 36 recipients who had positive serology.
 Of the total 36 cases with positive serology, 18 were treated both pre- and post-transplant, 7  were treated only pre-transplant and 9 were treated only post-transplant. One patient died prior to initiating treatment, and one did not have documented treatment. One patient with negative serologic testing was empirically treated due to persistent eosinophilia. There was one case of Strongyloides  hyperinfection due to likely donor-derived infection. There were no cases of Strongyloides reactivation in the study cohort.

Conclusion: This study demonstrates that an individualized screening and treatment protocol can effectively prevent Strongyloides reactivation in LT recipients. Given the high mortality rate of Strongyloides hyperinfection, especially in solid organ transplant recipients, a methodical assessment of epidemiologic risk is essential for appropriate risk stratification and management of Strongyloides in LT candidates.