P2988 - Differences by Transplant Organ Type in the Evaluation of Acute Diarrhea in Solid Organ Transplant Recipients With Stool Gastrointestinal PCR Panel

Tuesday, October 26, 2021

10:30 AM – 4:00 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Presenting Author(s)

Abhishek Verma, MD

New York University School of Medicine
New York, NY, United States

Abhishek Verma, MD¹, Ashley Hine, BS², Andrew Joelson, MD³, Benjamin Lebwohl, MD⁴, Jordan Axelrad, MD, MPH¹
¹New York University School of Medicine, New York, NY; ²University of Connecticut School of Medicine, Farmington, CT; ³New York-Presbyterian/Columbia University Medical Center, New York, NY; ⁴Columbia University Medical Center, New York, NY

Introduction: Acute diarrhea is common in solid organ transplant (SOT) recipients. Although immunosuppression regimens overlap among transplant organ types, it is not known whether particular organ transplants are at higher risk for infectious diarrhea. We compared rates of enteric infection as detected by stool multiplex gastrointestinal PCR panel (GI panel) testing among multiple types of SOT recipients.

Methods: We performed a cross-sectional study at two academic institutions of inpatient and outpatient recipients of single solid organ transplantation who underwent stool testing with a FilmArray GI panel during an acute episode of diarrhea over 3 years. Patients were stratified by transplant type and the primary outcome was infectious diarrhea by GI panel.

Results: Of 300 subjects, there were 58 (19%) heart, 65 (22%) liver, 68 (23%) lung, and 109 (36%) renal single transplant recipients. Use of mTOR inhibitors was less common in lung and renal transplant patients (p< 0.001). Lung transplant patients were more likely to be on more immunosuppressive agents (p< 0.001; Table) – especially steroids (p< 0.001) – and more likely to be on antimicrobial prophylaxis for opportunistic infections (OI). A positive GI panel was identified in 118 (39%) patients, and was more common in renal transplant recipients (54% renal vs. 41% heart vs. 28% liver vs. 25% lung, p< 0.001). Bacterial infection was less common in lung transplant recipients (8.8% lung vs. 34% renal vs. 22% heart vs. 22% liver, p=0.002). Hospitalization for acute diarrhea was more common in lung transplant recipients and less common in renal transplant recipients (78% lung vs. 58% renal vs. 68% liver vs. 76% heart, p=0.019). In the multivariate analysis controlling for age, sex, race, comorbidities, prophylaxis, recent hospitalization, and transplant age, use of mTOR inhibitors (Odds Ratio [OR] 3.7, 95% Confidence Interval [CI] 1.1-15), hospitalization (OR 2.3, 95% CI 1.3-4.3), and lung transplant (OR 2.5, 95% CI 1.0-6.4) predicted negative GI panel (Figure 1).

Discussion: In SOT recipients with acute diarrhea, lung transplant patients – who receive more immunosuppression and OI prophylaxis – are more likely to be hospitalized and have a negative GI panel. Lung transplantation, hospitalization, and mTOR inhibitor use independently predict a negative GI panel. Transplant and immunosuppression type should be accounted for during the management of acute diarrhea in SOT recipients.

Figure: Figure Title: Multivariate Analysis of Factors Predictive of Positive GI Panel in Solid Organ Transplant Recipients with Acute Diarrhea

Figure Legend: Coefficient plot of the multivariate logistic regression predicting positive GI panel with 95% confidence intervals demonstrated. Use of mTOR inhibitors (Odds Ratio [OR] 3.69, 95% Confidence Interval [CI] 1.09-15.4), hospitalization (OR 2.34, 95% CI 1.30-4.26), and lung transplant (OR 2.54, 95% CI 1.04-6.37) were predictive of negative GI panel. Reference groups are as follows for the listed variables: race: white, transplant type: heart.

			Heart Transplant (n=58)	Liver Transplant (n=65)	Lung Transplant (n=68)	Renal Transplant (n=109)	P-Value
Age, median (IQR)			59.7 (40.1-68.0)	61.0 (39.0-66.3)	61.7 (53.7-69.0)	53.9 (42.0-65.0)	0.161
Female, n (%)			22 (37.9)	22 (33.8)	37 (54.4)	50 (45.9)	0.081
Race, n (%)							< 0.001
		White	31 (53.4)	37 (56.9)	52 (76.5)	27 (24.8)
		Black	9 (15.5)	7 (10.8)	8 (11.8)	32 (29.4)
		Asian	6 (10.3)	2 (3.1)	1 (1.5)	13 (11.9)
		Other/Mixed	2 (3.4)	4 (6.2)	3 (4.4)	16 (14.7)
		Unknown	10 (17.2)	15 (23.1)	4 (5.9)	21 (19.3)
Ethnicity, n (%)							0.097
		Non-Hispanic	36 (62.1)	42 (64.6)	56 (82.4)	67 (61.5)
		Hispanic	11 (19.0)	10 (15.4)	8 (11.8)	21 (19.3)
		Other/Declined/Unknown	11 (19.0)	13 (0.20)	4 (5.9)	21 (19.3)
Human Immunodeficiency Virus (HIV), n (%)			0 (0)	3 (4.6)	0 (0)	3 (2.8)	0.161
Charlson’s Comorbidity Index, median (IQR)			4 (3-5)	4 (3-6)	3 (2.75-5)	4 (3-6)	0.007
Symptoms at Test, n (%)
		Hematochezia	0 (0)	0 (0)	1 (1.5)	3 (2.8)	0.342
		Abdominal Pain	13 (22.4)	20 (30.8)	14 (20.6)	24 (22.0)	0.496
		Fever	11 (19.0)	15 (23.1)	14 (20.6)	26 (23.9)	0.884
		Nausea/Vomiting	11 (19.0)	10 (15.4)	12 (17.6)	31 (28.4)	0.145
		Other/Unknown	1 (1.7)	2 (3.1)	8 (11.8)	0 (0)	< 0.001
Travel 30 Days Prior to Test, n (%)			4 (6.9)	3 (4.6)	1 (1.5)	5 (4.6)	0.514
Sexual Exposure, n (%)			0 (0)	10 (15.4)	0 (0)	2 (1.8)	0.526
Recent Antibiotics or Hospitalization, n (%)			30 (51.7)	33 (50.8)	50 (73.5)	53 (48.6)	0.009
On Opportunistic Infection Prophylaxis, n (%)			18 (31.0)	20 (30.8)	54 (79.4)	51 (46.8)	< 0.001
Place of Test, n (%)							0.012
		Outpatient	15 (25.9)	16 (24.6)	14 (20.6)	37 (33.9)
		Inpatient	43 (74.1)	46 (70.8)	54 (79.4)	63 (57.8)
		ED	0 (0)	3 (4.6)	0 (0)	9 (8.3)
Hospitalized, n (%)			44 (75.9)	44 (67.7)	53 (77.9)	63 (57.8)	0.019
Length of Stay, median (IQR)			6 (2-11)	9 (4-18)	8.5 (6-24.3)	6 (4-10)	0.006
Duration of Transplant, median (IQR)			2392 (612-5270)	1280 (245-2806)	643 (120-2404)	711 (162-2364)	0.004
Transplant Age > 1 Year, n (%)			47 (81.0)	42 (64.6)	40 (58.8)	69 (63.3)	0.05
Immunosuppression, n (%)
	None		1 (1.7)	1 (1.5)	0 (0)	4 (3.7)	0.387
	Calcineurin Inhibitor		56 (96.6)	56 (86.2)	66 (97.1)	97 (89.0)	0.046
	Mycophenolate Mofetil/Azathioprine		34 (58.6)	37 (56.9)	56 (82.4)	91 (83.5)	< 0.001
	Steroids		45 (77.6)	31 (47.7)	67 (98.5)	78 (71.6)	< 0.001
	mTOR Inhibitor		9 (15.6)	9 (13.8)	1 (1.5)	2 (1.8)	< 0.001
	Other		0 (0)	3 (4.6)	4 (5.9)	5 (4.6)	0.361
Immunosuppression Held, n (%)			13 (23.2)	6 (9.2)	8 (11.8)	21 (19.3)	0.124
Number of Immunosuppressive Agents, n (%)							< 0.001
	1		3 (5.2)	19 (29.2)	0 (0)	10 (9.2)
	2		25 (43.1)	21 (32.3)	13 (19.1)	32 (29.4)
	3		28 (48.3)	24 (36.9)	52 (76.5)	65 (59.6)
	4		2 (3.4)	1 (1.5)	3 (4.4)	2 (1.8)
Positive GI Panel, n (%)			24 (41.4)	18 (27.7)	17 (25.0)	59 (54.1)	< 0.001
Viral infection, n (%)			12 (20.7)	6 (9.2)	11 (16.2)	26 (23.9)	0.100
Bacterial Infection, n (%)			13 (22.4)	14 (21.5)	6 (8.8)	37 (33.9)	0.002
Parasitic Infection, n (%)			0 (0)	0 (0)	2 (2.9)	4 (3.7)	0.224
Multiple Pathogens, n (%)			6 (10.3)	5 (7.7)	2 (2.9)	10 (9.2)	0.588
Viral Infection, n (%)
	Adenovirus		1 (1.7)	0 (0)	0 (0)	0 (0)	0.242
	Astrovirus		0 (0)	0 (0)	0 (0)	1 (0.92)	0.624
	Norovirus		8 (13.8)	5 (7.7)	8 (11.8)	20 (18.3)	0.241
	Rotavirus		1 (1.7)	1 (1.5)	2 (2.9)	0 (0)	0.408
	Sapovirus		2 (3.4)	1 (1.5)	2 (2.9)	4 (3.7)	0.877
Bacterial Infection, n (%)
	Campylobacter		2 (3.4)	0 (0)	0 (0)	4 (3.7)	0.180
	Clostridioides difficile		10 (17.2)	8 (12.3)	10 (14.7)	20 (18.3)	0.739
	Plesiomonas shigelloides		NA	NA	NA	NA	NA
	Salmonella spp.		NA	NA	NA	NA	NA
	Yersinia enterocolitica		0 (0)	2 (3.1)	0 (0)	0 (0)	0.064
	Vibrio parahaemolyticus		0 (0)	0 (0)	1 (1.5)	1 (0.92)	0.661
	Vibrio vulnificus		NA	NA	NA	NA	NA
	Vibrio cholerae		NA	NA	NA	NA	NA
	Enteroaggregative E. coli (EAEC)		2 (3.4)	4 (6.2)	1 (1.5)	5 (4.6)	0.560
	Enteropathogenic E. coli (EPEC)		8 (13.8)	7 (10.8)	0 (0)	17 (15.6)	0.009
	Enterotoxigenic E. coli (ETEC)		2 (3.4)	0 (0)	0 (0)	1 (0.92)	0.182
	Shiga-like toxin-producing E. coli (STEC)		0 (0)	1 (1.5)	0 (0)	2 (1.8)	0.526
	E. coli O157		NA	NA	NA	NA	NA
	Shigella/Enteroinvasive E. coli (EIEC)		0 (0)	1 (1.5)	0 (0)	0 (0)	0.305
Parasitic Infection, n (%)
	Cryptosporidium		0 (0)	1 (1.5)	0 (0)	2 (1.8)	0.526
	Cyclospora cayetanensis		NA	NA	NA	NA	NA
	Entamoeba histolytica		NA	NA	NA	NA	NA
	Giardia lamblia		0 (0)	0 (0)	3 (4.4)	2 (1.8)	0.156
Antibiotics Prescribed, n (%)			40 (69.0)	39 (60.0)	44 (64.7)	69 (63.3)	0.775
	Empiric Antibiotic Therapy		25 (36.8)	31 (47.7)	37 (54.4)	40 (36.7)	0.010
	Directed Antibiotic Therapy		16 (27.6)	9 (13.8)	8 (11.8)	41 (37.6)	< 0.001
Hospitalization Within 30 Days of PCR, n (%)			8 (13.8)	10 (15.4)	10 (14.7)	21 (19.3)	0.769
ER Visit Within 30 Days of PCR, n (%)			2 (3.4)	3 (4.6)	1 (1.5)	4 (3.7)	0.776
Surgery Within 30 Days of PCR, n (%)			1 (1.7)	3 (4.6)	7 (10.3)	7 (6.4)	0.225
Death Within 30 Days of PCR, n (%)			9 (15.5)	9 (13.8)	12 (17.6)	8 (7.3)	0.185
Endoscopy Within 30 Days of PCR, n (%)			4 (6.9)	15 (23.1)	2 (2.9)	11 (10.1)	0.001

Table: Table 1: Characteristics and Outcomes of Patients with Diarrhea by Transplant Type

Disclosures:
Abhishek Verma indicated no relevant financial relationships.
Ashley Hine indicated no relevant financial relationships.
Andrew Joelson indicated no relevant financial relationships.
Benjamin Lebwohl indicated no relevant financial relationships.
Jordan Axelrad: BioFire Diagnostics – Grant/Research Support. Crohns & Colitis Foundation – Grant/Research Support. Janssen – Consultant. National Institute of Diabetes and Digestive and Kidney Diseases – Grant/Research Support.

Abhishek Verma, MD¹, Ashley Hine, BS², Andrew Joelson, MD³, Benjamin Lebwohl, MD⁴, Jordan Axelrad, MD, MPH¹. P2988 - Differences by Transplant Organ Type in the Evaluation of Acute Diarrhea in Solid Organ Transplant Recipients With Stool Gastrointestinal PCR Panel, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.