Tackling infectious threats post transplantation dash a retrospective cohort study of opportunistic infections in the first year post renal transplant semicolon determinants of infectious risk and impact of pharmacist-led intervention

Introduction: Opportunistic infections are a major cause of morbidity following kidney transplantation, particularly within the first year. Many studies rely on composite infection outcomes, potentially masking pathogen-specific risk factors. The contribution of multidisciplinary care - especially clinical pharmacists, also remains underexplored. We aimed to define pathogen-specific determinants of infection risk and evaluate how immunosuppressant exposure and pharmacist-led interventions influence infection burden in a contemporary transplant cohort.
Methods: We conducted a mixed-methods study at Westmead Hospital, a major Australian transplant centre, combining a retrospective cohort analysis of 159 adult kidney transplant recipients with 12-month follow-up and qualitative interviews of healthcare professionals (n=10). Opportunistic infections were classified as bacterial, viral or fungal. Clinical variables, including tacrolimus trough concentrations, were analysed using multivariable logistic regression to identify pathogen-specific risk factors. Pharmacist-led interventions were extracted from electronic records and categorised, while thematic analysis explored their clinical role within the multidisciplinary team.
Results: Overall, 78% of recipients experienced at least one opportunistic infection, with 342 infection episodes recorded; 66% had multiple infections. Viral infections predominated (53.5%), followed by bacterial (42.4%) and fungal (4.1%), with median time to first infection of 42 days.
Bacterial infection risk was independently associated with female sex, deceased donor transplantation, and tacrolimus trough concentrations ≥9 ng/mL. Viral infections were associated with thymoglobulin induction therapy. These relationships were not apparent when infections were analysed as a composite endpoint.
Infection burden was also associated with maintenance therapy instability, increasing age, female sex, and deceased donor grafts. Pharmacists performed 521 interventions (mean 3.3 per patient), primarily involving patient education and medication management. Qualitative analysis identified the pharmacist as a “prescribing safety net”, mitigating over-immunosuppression, preventing prescribing errors, and addressing cognitive vulnerability and care transitions.
Conclusion: Opportunistic infection risk after kidney transplantation is both pathogen-specific and shaped by clinical instability and care delivery factors. Tacrolimus exposure is a key modifiable determinant of bacterial risk, while viral risk is driven by induction therapy. Clinical pharmacists play a critical role in mitigating these risks by optimising immunosuppression, improving medication safety, and supporting patient understanding. Integrating pathogen-specific risk stratification with proactive, pharmacist-led care and model-informed dosing may improve infection prevention and overall transplant outcomes.