© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Transplant Infectious Disease, ISSN 1398-2273
Immunization after renal transplantation: current clinical practice G.H. Struijk, A.J.J. Lammers, R.J. Brinkman, M.J.M.H. Lombarts, M. van Vugt, K.A.M.I. van der Pant, I.J.M. ten Berge, F.J. Bemelman. Immunization after renal transplantation: current clinical practice. Transpl Infect Dis 2015: 17: 192–200. All rights reserved Abstract: Background. The use of potent immunosuppressive drugs and increased travel by renal transplant recipients (RTR) has augmented the risk for infectious complications. Immunizations and changes in lifestyle are protective. The Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group has developed guidelines on vaccination following solid organ transplantation. The degree of adherence to these guidelines is unknown, as is which barriers must be overcome to improve adherence. Methods. We performed a cross-sectional national survey among Dutch nephrologists to assess vaccination policy and adherence to the KDIGO guidelines. In addition, to investigate awareness and attitude of RTR regarding their risk of infection, we performed a cross-sectional survey of RTR in our outpatient clinic. Results. A total of 132 (63%) nephrologists completed the survey. Reported immunization rates were 90.8% for influenza and 27.3% for hepatitis B. However, pneumococcal, tetanus toxoid, and meningococcal immunization rates were low. Twenty-seven percent of respondents were familiar with the guideline contents. The most frequent perceived barrier to guideline adherence was expectation of low effectiveness. A total of 403 RTR (62%) completed the survey. Sixty-eight percent perceived more risk for complicated infection. A significant correlation was found between education level and variables concerning awareness and attitude toward risk of infection. Conclusions. Our results show that nephrologists’ knowledge of and adherence to the recommendations regarding immunization after renal transplantation is suboptimal. Most Dutch RTR are aware of their increased risk and the possible seriousness of infectious complications. However, their behavior does not match their awareness. This disparity points to an important role for nephrologists in providing adequate counseling. Infectious complications are among the leading causes of morbidity and death in renal transplant recipients (RTR) (1). The development of more potent immunosuppressive drugs has enabled successful transplantation across higher immunological barriers, but is at the cost of a more profound immunosuppressed state, putting RTR at risk for nosocomial infections and endogenous reactivation of latent infections. In addition, the age of patients on the renal transplant waiting list has increased. Elderly patients are more susceptible to infections because of decreased immunocompetence and, in some reports, infections are the number one cause of death in RTR
192
G.H. Struijk1, A.J.J. Lammers2, R.J. Brinkman1, M.J.M.H. Lombarts3, M. van Vugt2, K.A.M.I. van der Pant1, I.J.M. ten Berge1, F.J. Bemelman1 1
Renal Transplant Unit, Department of Nephrology, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, 2 Department of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, 3Professional Performance Research Group, Center of Evidence-Based Education, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Key words: barriers; guideline adherence; immunization; infection; renal transplantation Correspondence to: F.J. Bemelman, Renal Transplant Unit, Dept. of Nephrology, Div. of Internal Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Room F4-110, 1105 AZ Amsterdam, The Netherlands Tel: + 31205663365 Fax: + 31206914904 E-mail: [email protected]
Received 21 May 2014, revised 30 November 2014, 6 January 2015, accepted for publication 1 February 2015 DOI: 10.1111/tid.12368 Transpl Infect Dis 2015: 17: 192–200
older than 65 years (2). Another factor contributing to the rising incidence of infections after solid organ transplantation is increased globalization, migration, and transplant tourism. More RTR travel internationally, thereby increasing the incidence of travel-related diseases (3, 4). This risk of infectious complications can be reduced by protective measures such as immunizations. Although most data concerning the efficacy and safety of vaccinations in solid organ transplant recipients are derived from small and heterogeneous trials, most experts agree that the benefits of vaccination with inactivated vaccines outweigh the risks (5–8).
Struijk et al: Immunization after renal transplantation
The Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group published a clinical practice guideline for the care of RTR in 2009 (9). This guideline, as well as the guidelines for immunizations in RTR established by the American Society of Transplantation, contain specific recommendations regarding immunizations in RTR (7). Despite these guidelines, several reports suggest a gap between clinical practice and guidelines (10, 11). Many factors have been identified as possible barriers to the implementation of guidelines in practice. Cabana et al. (12) reviewed studies on barriers to physician guideline adherence and identified 7 general types of barriers. They developed a framework in which these barriers are classified into 3 main categories: barriers related to physicians’ knowledge, barriers that affect physicians’ attitudes, and external barriers. Lifestyle after transplantation is also in many ways of vital importance for transplant outcome: non-adherence to drug regimens is associated with a high risk of acute rejection and allograft loss, and may occur early and/or late after transplantation (13, 14). Promoting lifestyle changes after transplantation may help to limit exposure to potential pathogens, thereby reducing the risk of infections. Dietary advice might include avoidance of potentially contaminated foods like undercooked meat, shellfish, unwashed fruits and vegetables, and unpasteurized dairy products to prevent infection with Listeria monocytogenes or Toxoplasma (15). In addition, RTR should avoid close contact with people suffering from respiratory illnesses. However, the awareness and attitude of RTR regarding their risk of infections is unknown. It is known that the percentage of RTR seeking pre-travel health advice when travelling to the tropics is suboptimal, ranging from 22% to 66% (16). The aim of this study was 2-fold. First, we analyzed clinical practice and barriers to adherence to the recommendations of the KDIGO, regarding immunizations in RTR, among Dutch nephrologists. Second, we assessed the awareness and attitude of RTR regarding their risk of infectious complications.
Patients and methods Part I: Survey of nephrologists Study design and population We performed a cross-sectional survey to assess Dutch nephrologists’ perceived barriers to adherence with best practice in the management of RTR according to the KDIGO guidelines (9). All Dutch nephrologists
were invited to participate in the study. We used the database of the Dutch Federation of Nephrology to obtain contact details. The anonymous printed paper questionnaire, accompanied by a return envelope and informative letter, was sent by mail. A reminder card was sent to non-responders after 2 weeks, requesting them to complete and return the questionnaire. Nephrologists received a second copy of the questionnaire, if they did not return the first questionnaire within 6 weeks. Owing to the anonymous nature of the questionnaire, it was not necessary to obtain approval from the medical ethical committee of our institute.
Questionnaire design and content A focus group study was performed to explore potential barriers for guideline adherence. A semistructured focus group discussion among nephrologists of different gender, age, length of time in practice, and practice setting was held in the Academic Medical Center in Amsterdam, the Netherlands. A nephrologist moderated this discussion using a topic guide with open-ended questions. This topic guide was based on possible barriers in adhering to guideline recommendations in practice identified by Cabana et al. (12) and Lammers et al. (17). These authors classify barriers into 3 main categories: barriers related to physicians’ knowledge (i.e., lack of awareness and familiarity with the guideline); physicians’ attitudes (i.e., lack of agreement, outcome expectancy, or motivation); and external barriers (i.e., patient-, organization-, and guideline-related factors). The barriers identified in the focus group were classified in accordance to this framework and used to develop our questionnaire. The questionnaire consisted of 4 parts. The first part of the questionnaire contained 15 questions concerning current practice of participating nephrologists. Respondents were asked to rate their responses using a 4-point Likert scale: 1 (never), 2 (sometimes [in 50% of cases]), and 4 (always). The second part contained 22 statements regarding potential barriers to best-practice management for RTR, according to the recommendations by the KDIGO Transplant Work Group. A 5-point Likert scale was used to rate the extent of agreement with the statements: 1 (strongly disagree), 2 (disagree), 3 (agree nor disagree), 4 (agree), and 5 (strongly agree). In the third part, suggestions for additional guideline recommendations, suggestions for improving guideline adherence, and respondents’ demographics and professional characteristics were assessed.
Transplant Infectious Disease 2015: 17: 192–200
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Struijk et al: Immunization after renal transplantation
The questionnaires were pilot-tested before mailing them to the study sample.
Part II: Survey of RTR Study design and population A second cross-sectional survey was performed at the renal transplant outpatient clinic of the Academic Medical Center. RTR visiting the outpatient clinic were asked to fill out an anonymous printed paper questionnaire assessing their awareness of and attitudes about infections. Recently transplanted patients (50% of cases) into “positive,” and 1 (never) and 2 (sometimes or in
Immunization after renal transplantation: current clinical practice G.H. Struijk, A.J.J. Lammers, R.J. Brinkman, M.J.M.H. Lombarts, M. van Vugt, K.A.M.I. van der Pant, I.J.M. ten Berge, F.J. Bemelman. Immunization after renal transplantation: current clinical practice. Transpl Infect Dis 2015: 17: 192–200. All rights reserved Abstract: Background. The use of potent immunosuppressive drugs and increased travel by renal transplant recipients (RTR) has augmented the risk for infectious complications. Immunizations and changes in lifestyle are protective. The Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group has developed guidelines on vaccination following solid organ transplantation. The degree of adherence to these guidelines is unknown, as is which barriers must be overcome to improve adherence. Methods. We performed a cross-sectional national survey among Dutch nephrologists to assess vaccination policy and adherence to the KDIGO guidelines. In addition, to investigate awareness and attitude of RTR regarding their risk of infection, we performed a cross-sectional survey of RTR in our outpatient clinic. Results. A total of 132 (63%) nephrologists completed the survey. Reported immunization rates were 90.8% for influenza and 27.3% for hepatitis B. However, pneumococcal, tetanus toxoid, and meningococcal immunization rates were low. Twenty-seven percent of respondents were familiar with the guideline contents. The most frequent perceived barrier to guideline adherence was expectation of low effectiveness. A total of 403 RTR (62%) completed the survey. Sixty-eight percent perceived more risk for complicated infection. A significant correlation was found between education level and variables concerning awareness and attitude toward risk of infection. Conclusions. Our results show that nephrologists’ knowledge of and adherence to the recommendations regarding immunization after renal transplantation is suboptimal. Most Dutch RTR are aware of their increased risk and the possible seriousness of infectious complications. However, their behavior does not match their awareness. This disparity points to an important role for nephrologists in providing adequate counseling. Infectious complications are among the leading causes of morbidity and death in renal transplant recipients (RTR) (1). The development of more potent immunosuppressive drugs has enabled successful transplantation across higher immunological barriers, but is at the cost of a more profound immunosuppressed state, putting RTR at risk for nosocomial infections and endogenous reactivation of latent infections. In addition, the age of patients on the renal transplant waiting list has increased. Elderly patients are more susceptible to infections because of decreased immunocompetence and, in some reports, infections are the number one cause of death in RTR
192
G.H. Struijk1, A.J.J. Lammers2, R.J. Brinkman1, M.J.M.H. Lombarts3, M. van Vugt2, K.A.M.I. van der Pant1, I.J.M. ten Berge1, F.J. Bemelman1 1
Renal Transplant Unit, Department of Nephrology, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, 2 Department of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, 3Professional Performance Research Group, Center of Evidence-Based Education, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Key words: barriers; guideline adherence; immunization; infection; renal transplantation Correspondence to: F.J. Bemelman, Renal Transplant Unit, Dept. of Nephrology, Div. of Internal Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Room F4-110, 1105 AZ Amsterdam, The Netherlands Tel: + 31205663365 Fax: + 31206914904 E-mail: [email protected]
Received 21 May 2014, revised 30 November 2014, 6 January 2015, accepted for publication 1 February 2015 DOI: 10.1111/tid.12368 Transpl Infect Dis 2015: 17: 192–200
older than 65 years (2). Another factor contributing to the rising incidence of infections after solid organ transplantation is increased globalization, migration, and transplant tourism. More RTR travel internationally, thereby increasing the incidence of travel-related diseases (3, 4). This risk of infectious complications can be reduced by protective measures such as immunizations. Although most data concerning the efficacy and safety of vaccinations in solid organ transplant recipients are derived from small and heterogeneous trials, most experts agree that the benefits of vaccination with inactivated vaccines outweigh the risks (5–8).
Struijk et al: Immunization after renal transplantation
The Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group published a clinical practice guideline for the care of RTR in 2009 (9). This guideline, as well as the guidelines for immunizations in RTR established by the American Society of Transplantation, contain specific recommendations regarding immunizations in RTR (7). Despite these guidelines, several reports suggest a gap between clinical practice and guidelines (10, 11). Many factors have been identified as possible barriers to the implementation of guidelines in practice. Cabana et al. (12) reviewed studies on barriers to physician guideline adherence and identified 7 general types of barriers. They developed a framework in which these barriers are classified into 3 main categories: barriers related to physicians’ knowledge, barriers that affect physicians’ attitudes, and external barriers. Lifestyle after transplantation is also in many ways of vital importance for transplant outcome: non-adherence to drug regimens is associated with a high risk of acute rejection and allograft loss, and may occur early and/or late after transplantation (13, 14). Promoting lifestyle changes after transplantation may help to limit exposure to potential pathogens, thereby reducing the risk of infections. Dietary advice might include avoidance of potentially contaminated foods like undercooked meat, shellfish, unwashed fruits and vegetables, and unpasteurized dairy products to prevent infection with Listeria monocytogenes or Toxoplasma (15). In addition, RTR should avoid close contact with people suffering from respiratory illnesses. However, the awareness and attitude of RTR regarding their risk of infections is unknown. It is known that the percentage of RTR seeking pre-travel health advice when travelling to the tropics is suboptimal, ranging from 22% to 66% (16). The aim of this study was 2-fold. First, we analyzed clinical practice and barriers to adherence to the recommendations of the KDIGO, regarding immunizations in RTR, among Dutch nephrologists. Second, we assessed the awareness and attitude of RTR regarding their risk of infectious complications.
Patients and methods Part I: Survey of nephrologists Study design and population We performed a cross-sectional survey to assess Dutch nephrologists’ perceived barriers to adherence with best practice in the management of RTR according to the KDIGO guidelines (9). All Dutch nephrologists
were invited to participate in the study. We used the database of the Dutch Federation of Nephrology to obtain contact details. The anonymous printed paper questionnaire, accompanied by a return envelope and informative letter, was sent by mail. A reminder card was sent to non-responders after 2 weeks, requesting them to complete and return the questionnaire. Nephrologists received a second copy of the questionnaire, if they did not return the first questionnaire within 6 weeks. Owing to the anonymous nature of the questionnaire, it was not necessary to obtain approval from the medical ethical committee of our institute.
Questionnaire design and content A focus group study was performed to explore potential barriers for guideline adherence. A semistructured focus group discussion among nephrologists of different gender, age, length of time in practice, and practice setting was held in the Academic Medical Center in Amsterdam, the Netherlands. A nephrologist moderated this discussion using a topic guide with open-ended questions. This topic guide was based on possible barriers in adhering to guideline recommendations in practice identified by Cabana et al. (12) and Lammers et al. (17). These authors classify barriers into 3 main categories: barriers related to physicians’ knowledge (i.e., lack of awareness and familiarity with the guideline); physicians’ attitudes (i.e., lack of agreement, outcome expectancy, or motivation); and external barriers (i.e., patient-, organization-, and guideline-related factors). The barriers identified in the focus group were classified in accordance to this framework and used to develop our questionnaire. The questionnaire consisted of 4 parts. The first part of the questionnaire contained 15 questions concerning current practice of participating nephrologists. Respondents were asked to rate their responses using a 4-point Likert scale: 1 (never), 2 (sometimes [in 50% of cases]), and 4 (always). The second part contained 22 statements regarding potential barriers to best-practice management for RTR, according to the recommendations by the KDIGO Transplant Work Group. A 5-point Likert scale was used to rate the extent of agreement with the statements: 1 (strongly disagree), 2 (disagree), 3 (agree nor disagree), 4 (agree), and 5 (strongly agree). In the third part, suggestions for additional guideline recommendations, suggestions for improving guideline adherence, and respondents’ demographics and professional characteristics were assessed.
Transplant Infectious Disease 2015: 17: 192–200
193
Struijk et al: Immunization after renal transplantation
The questionnaires were pilot-tested before mailing them to the study sample.
Part II: Survey of RTR Study design and population A second cross-sectional survey was performed at the renal transplant outpatient clinic of the Academic Medical Center. RTR visiting the outpatient clinic were asked to fill out an anonymous printed paper questionnaire assessing their awareness of and attitudes about infections. Recently transplanted patients (50% of cases) into “positive,” and 1 (never) and 2 (sometimes or in
