Impact of the Duration of Trimethoprim-Sulfamethoxazole Prophylaxis on the Incidence of Infection After Kidney Transplantation: A Target Trial Emulation Study Within the Swiss Transplant Cohort Study (STCS)-The QUID-PRO-QUO Study (QUIDney Transplantation and Duration of PROphylaxis With QUO-Trimoxazole).
Aline Munting, Frédérique Chammartin, Isabelle Binet, Katia Boggian, Michael Dickenmann, Marc Froissart, Christian Garzoni, Dela Golshayan, Fadi Haidar, Cédric Hirzel, Kerstin Hübel, Uyen Huynh-Do, Nina Khanna, Michael Koller, Nicolas Mueller, Daniel Sidler, Christian van Delden, Oriol Manuel
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Abstract
Background: Trimethoprim-sulfamethoxazole prophylaxis effectively prevents opportunistic and non-opportunistic infections in kidney transplantation, but optimal duration remains uncertain. This study investigated whether extending TMP-SMX prophylaxis is associated with lower infection rates.
Methods: This target trial emulation using observational data from the Swiss Transplant Cohort Study compared short (< 7 months) versus long (≥ 7 months) TMP-SMX prophylaxis. The primary outcome was bacterial infection potentially susceptible to TMP-SMX up to 12-months post-transplant. Inverse probability weighting (IPW) adjusted for confounders including age, living donation, lymphocyte counts, use of antithymocyte globulin, acute rejection, CMV infection, and transplant center. All bacterial and opportunistic infections, kidney function, and patient and allograft survival were summarized descriptively.
Results: A total of 1700 KTRs fulfilled inclusion criteria; 1325 (78%) participants received a short prophylaxis and 375 (22%) received a long prophylaxis. Median TMP-SMX duration was 179 days in the short group and 280 days in the long group. At 12-month post-transplant, the primary outcome was observed in 120/1325 (9.1%) in the short group and 43/375 (11.5%) in the long group. IPW analysis estimated an adjusted risk difference of 2.11% (95% CI -0.47% to 5.27%). Center, rejection, and use of ATG were associated with longer TMP-SMX duration, but risk difference was similar before and after weighting. Urinary tract infection was the most common bacterial infection. Opportunistic and overall infection rates, kidney function, and patient and graft survival were similar among groups.
Conclusions: In this target trial emulation, no differences in bacterial infection rates at 12-month post-transplant was observed between short and long TMP-SMX prophylaxis.
背景：甲氧苄啶-磺胺甲恶唑预防可有效预防肾移植术后的机会性和非机会性感染，但最佳持续时间尚不确定。这项研究调查了延长TMP-SMX预防是否与降低感染率有关。方法：该目标试验模拟使用来自瑞士移植队列研究的观察数据，比较了短期(结果：总共1700名ktr符合纳入标准；1325名（78%）参与者接受了短期预防，375名（22%）参与者接受了长期预防。中位TMP-SMX持续时间短组为179天，长组为280天。移植后12个月，短组的主要预后为120/1325(9.1%)，长组的主要预后为43/375（11.5%）。IPW分析估计调整后的风险差异为2.11% （95% CI -0.47%至5.27%）。中心、排斥和ATG的使用与更长的TMP-SMX持续时间相关，但加权前后的风险差异相似。泌尿道感染是最常见的细菌感染。各组间机会性感染率和总体感染率、肾功能、患者和移植物存活率相似。结论：在这个目标试验模拟中，移植后12个月的细菌感染率在短期和长期TMP-SMX预防之间没有差异。
期刊介绍：
Transplant Infectious Disease has been established as a forum for presenting the most current information on the prevention and treatment of infection complicating organ and bone marrow transplantation. The point of view of the journal is that infection and allograft rejection (or graft-versus-host disease) are closely intertwined, and that advances in one area will have immediate consequences on the other. The interaction of the transplant recipient with potential microbial invaders, the impact of immunosuppressive strategies on this interaction, and the effects of cytokines, growth factors, and chemokines liberated during the course of infections, rejection, or graft-versus-host disease are central to the interests and mission of this journal.
Transplant Infectious Disease is aimed at disseminating the latest information relevant to the infectious disease complications of transplantation to clinicians and scientists involved in bone marrow, kidney, liver, heart, lung, intestinal, and pancreatic transplantation. The infectious disease consequences and concerns regarding innovative transplant strategies, from novel immunosuppressive agents to xenotransplantation, are very much a concern of this journal. In addition, this journal feels a particular responsibility to inform primary care practitioners in the community, who increasingly are sharing the responsibility for the care of these patients, of the special considerations regarding the prevention and treatment of infection in transplant recipients. As exemplified by the international editorial board, articles are sought throughout the world that address both general issues and those of a more restricted geographic import.
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