The discipline of Transplant Infectious Diseases (ID) has matured significantly over the past two decades. We are grateful to the founders of the discipline, notably Robert Rubin and his outstanding mentees who have continued the tradition of excellence. Their contributions continue to be a source of inspiration to us all. As coeditors of this version of the guidelines, we are honored to have had the opportunity to continue in a path that was created by Jutta Preiksaitis, Robyn Avery and Michael Green with the production of guideline #1 in 2004. As Avery and Green noted in 2004, our gratitude to the Editor-in-Chief of these guidelines, Jutta Preiksaitis, cannot be adequately expressed. She inspired and motivated the authors and did a monumental amount of organizational work, without fanfare and with her characteristic graciousness and modesty. Without her vision and dedication, these guidelines would not have come into being. This effort could not have gotten underway without the leadership and guidance of Robert Rubin and Jay Fishman. Jay Fishman's election and subsequent service as President of the American Society of Transplantation (AST) from 2004 to 2005, in addition to reflecting his outstanding qualities, is also a recognition of the field of transplant ID as a legitimate entity.'
The vision for the creation of guideline #2 was born during Michael Green's tenure as chair of the AST ID Community of Practice. Indeed, in the foreword to guideline #1, Avery and Green noted that ‘In recognition of the ever-changing nature of this field, we are already planning work on an updated version’. Following Michael Green as chair of the AST ID Community of Practice, Emily Blumberg further assisted in moving this charge forward. The first step in the creation of guideline #2 was the evaluation of guideline #1 using a survey instrument. This allowed us to identify the most important topics from the perspective of health care providers involved in transplantation. This information was instrumental in the development of topics for guideline #2. We assembled an editorial team consisting of Upton Allen, Atul Humar, Ajit Limaye, Marian Michaels and Rachel Miller and set about to identify authors and peer-reviewers based on their expertise in their respective fields. We were overwhelmed with the response from the AST ID Community of Practice. We are extremely grateful to everyone for there outstanding contributions. The final stages in the preparation of these guidelines occurred in the midst of the 2009 H1N1 influenza pandemic. Consequently, ID clinicians have been very busy refining and implementing pandemic preparedness initiatives as well as taking care of patients, while pursuing professional and family obligations. We sincerely appreciate the time that they have taken out from their busy schedules and thus their contributions to this document are even more appreciated.
We are particularly grateful for the support from the administrative staff at the AST, including Susan Nelson, Executive Director of the AST, Anna Shnayder and Courtney Wright. The publication of these guidelines was facilitated in part by support from the Canadian Society of Transplantation. We are grateful for their support.
The various sections of these guidelines mention the use of medications outside of approved indications. This reflects current clinical practice and expert opinion against a background of varying strengths of evidence from the literature. Areas of controversy are acknowledged. In addition, wherever appropriate, areas in need of additional research are highlighted. The field of pediatric antimicrobial therapy is challenged by the fact that several medications that are used in adults have not been fully evaluated in children. This limits the extent to which extrapolations can be made from adult to pediatric settings. Wherever appropriate, we have highlighted these differences (e.g. the current status of CMV prophylaxis in adults versus infants and young children).
Besides the updating and refining of guidelines, what is new in guideline #2? A comprehensive summary of what is new is outside the scope of this foreword. However, some areas deserve special mention for varying reasons, including their relative ranking in terms of relevance based on the result of the evaluation of guideline #1. In this regard, with respect to CMV, there have been recent advances in molecular diagnostics and antiviral agents in the setting of evolving immunosuppressive regimens. The impact of these advances is captured. The ongoing challenge of the consequences of Epstein-Barr virus infection is addressed. The section on respiratory-viral infections includes information on the antiviral agents for use in the treatment of influenza A, notably the pandemic strain of H1N1. Of note is the current status of the treatment of infants less than 1-year of age, for whom prior to 2009, there were no antiviral agents approved for treatment or prophylaxis. The sections of immunizations and strategies for safe living remain popular, as with the increasing longevity of transplant recipients, more and more recipients are returning to active lives, to work and to recreational activities that expose them to different infection risks.
In closing, we sincerely hope that you will find these guidelines useful. We welcome feedback from readers and we do look forward to interacting with users of the guidelines through different fora over the upcoming months.