2018 Jun;102(6):898-899. doi: 10.1097/TP.0000000000002203. People who receive solid organ transplants (such as hearts, lungs and kidneys) often must take drugs to suppress their immune systems and prevent rejection. Effective April 1, 2021. A number of other investigational agents and drugs that are approved by the FDA for other indications are being evaluated for the treatment of COVID-19 (e.g., antiviral therapies, COVID-19 convalescent plasma) and its associated complications (e.g., immunomodulators, antithrombotic agents). Interleukin-6 receptor antagonists in critically ill patients with COVID-19. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. When possible, treatment should be given as part of a clinical trial. Transplantation. Memo #. COVID-19 in solid organ transplant: a multi-center cohort study. Furthermore, solid organ transplantation for patients with end organ failure is a well-established and life-saving treatment. An international consensus panel recommended a consistent set of guidelines in 2003 based on American . Cytomegalovirus infection in organ transplant recipients. The American Society of Transplantation is dedicated to advancing the field of transplantation and improving patient care by promoting research, education, advocacy, organ donation, and service to the community. A transplant program is defined as a component within a transplant hospital that provides transplantation of a particular type of organ. Solid organ transplantation has increased worldwide since the first successful human kidney transplant was performed in 1954. Epub 2010 Oct 26. Available at: Centers for Disease Control and Prevention. 8600 Rockville Pike This is the first comprehensive textbook on intracranial metastases in over 20 years with an update on current methods for their management, including the use of newer technologies. 1 More than 33,000 transplantations were performed in 2016 alone. Ci��l5����o�V��>i��wb>�Bou�c�� m�l �d Alberici F, Delbarba E, Manenti C, et al. The Guidelines represent the collective opinions of a number of experts in the field and do not have the force of law. For this reason, the six-month time period following your transplant is critical. doi: 10.1111/ctr.13576. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. The Incidence and Effect of Cytomegalovirus Disease on Mortality in Transplant Recipients and General Population: Real-world Nationwide Cohort Data. For more details, see Human papillomavirus. Disclaimer, National Library of Medicine New developments in the management of cytomegalovirus infection after solid organ transplantation. Found inside – Page iiiThe book begins with an overview of infections in various modalities. This is followed by chapters on clinical disorders, etiologic agents, therapeutics, and infection prevention. 2021. After completing SARS-CoV-2 vaccination, immunocompromised persons should be advised to continue to exercise precautions to reduce their risk of SARS-CoV-2 exposure and infection (e.g., they should continue wearing a mask, maintain a distance of 6 feet from others, and avoid crowds and poorly ventilated spaces). The ASHP Guidelines on Pharmacy Services in Solid Organ Transplantation are intended to promote understanding of the evolving role of pharmacists in the care of transplant recipients and living donors.. 3 0 obj doi: 10.1111/ctr.13563 PTDM has been associated with greater mortality and increased infections in different transplant groups using different diagnostic criteria. Nocardia infections in solid organ transplantation: guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation [published online February 28, 2019]. Drugs. The prevention and management of skin cancers in organ transplant recipients will be reviewed here. This article reviews the epidemiology, and provides diagnostic and therapeutic recommendations for the management of the most relevant endemic mycoses in solid organ transplant (SOT) recipients, including histoplasmosis, coccidioidomycosis, paracoccidioidomycosis, sporotrichosis, and cryptococcosis (Cryptococcus gattii). Based on the Certified Clinical Transplant Nurse (CCTN) exam content, this is a must-have training and teaching guide for nursing educators, students, and all clinicians seeking CCTN certification or a transplant nursing practice. 2010 Apr 15;89(7):779-95. doi: 10.1097/TP.0b013e3181cee42f. Horby P, Lim WS, Emberson JR, et al. Zurich Open Access Repository and Archive. Edited by leaders at one of the acclaimed transplant institutions in the United States, this reference covers all aspects of living donor solid organ and cellular transplantation in current clinical practice, including the kidney, liver, ... Primary infection occurs in infants and young children 1 and is typically characterized by mild upper respiratory tract symptoms or is asymptomatic in an immunocompetent host. Fix OK, Hameed B, Fontana RJ, et al. An international multidisciplinary panel of experts was convened to expand and revise evidence and expert opinion-based consensus guidelines on CMV management including prevention, treatment, diagnostics, immunology, drug resistance, and pediatric issues. Acute cellular rejection should not be presumed in SOT recipients without biopsy confirmation, regardless of whether the individual has COVID-19. !���l�OA�H�����hi�x���8�"��0����?�Ff�z�_�b%�0AU�%����~�^P�H]�,2��0�����ҳ?+��= ��$Ğ�6�u��O�"�J��L�p��0PKGxn��g�d��(p���r�s�`|řO,�t�'�p��.�o�����'Y��� �������_ߧ�oV�o Horby PW, Pessoa-Amorim G, Peto L, et al. Transplant recipients who are hospitalized with mild to moderate COVID-19 may be considered for anti-SARS-CoV-2 monoclonal antibodies that are available through expanded access programs. Burbach G, Bienzle U, Stark K, et al. The medications that are used to treat COVID-19 may present different risks and benefits to transplant patients and nontransplant patients. This updated guideline from the American Society of Transplantation Infectious Diseases Community of Practice provides evidence-based and expert recommendations for screening, diagnosis, prevention, and treatment of CMV in solid organ transplant recipients. • Apply general principles and practices of disease prevention to solid organ transplant recipients. See Therapeutic Management of Nonhospitalized Adults With COVID-19 and Therapeutic Management of Hospitalized Adults With COVID-19 for more information. Tissue and blood protozoa including toxoplasmosis, Chagas disease, leishmaniasis, Babesia, Acanthamoeba, Balamuthia, and Naegleria in solid organ transplant recipients- Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Dexamethasone in hospitalized patients with COVID-19. The Panel recommends diagnostic molecular testing for SARS-CoV-2 for all potential solid organ transplant (SOT), hematopoietic cell transplant (HCT), and cell therapy candidates with signs and symptoms that suggest acute COVID-19 infection (AIII). Indications for an ultrasound examination of the solid organ transplant include, but are not limited to , the following: A. Liver transplant 1. Posting Date. Management of cytomegalovirus infection in solid organ transplantation. 2020. Despite recent advances, cytomegalovirus (CMV) infections remain one of the most common complications affecting solid organ transplant recipients, conveying higher risks of complications, graft loss, morbidity, and mortality. In addition to its user-friendly, easy-access format and consistent, reliable coverage, this Expert Consult title includes a regularly updated website with the complete contents of the book, fully searchable, downloadable images, and more, ... Int J Med Sci. Final decisions should be made on a case-by-case basis while weighing the risks of delaying or altering therapy for the underlying disease. 9 The goal suggested by transplant experts is less than. Kotton CN, Kumar D, Caliendo AM, Asberg A, Chou S, Danziger-Isakov L, Humar A; Transplantation Society International CMV Consensus Group. 2. Unable to load your collection due to an error, Unable to load your delegates due to an error, Collaborators, Research in the field and development of prior consensus guidelines supported by The Transplantation Society has allowed a more standardized approach to CMV management. SARS-CoV-2 vaccines can be offered as early as 3 months after a patient receives HCT or chimeric antigen receptor T cell (CAR-T) therapy, although the efficacy of the vaccines may be reduced compared to the efficacy observed in the general population. Vaccines and related biological products advisory committee meeting. Nutrition plays a key role in the transplant process. Ideally, SOT candidates should receive SARS-CoV-2 vaccines while they are awaiting transplant. Pathology of Transplantation provides a relatively simple but diagnostically comprehensive and practical book that the pathologist will keep on hand and pick up to rapidly find answers in daily practice of transplantation pathology. Clin Transplant. Certain therapeutics (e.g., remdesivir, tocilizumab) are associated with elevated levels of transaminases. %���� • Background on Organ Transplant Outcomes Standards: Medicare Conditions of Participation (CoPs) require that each solid organ transplant program maintain patient and graft survival rates that are . Clinical characteristics and outcomes of COVID-19 in haematopoietic stem-cell transplantation recipients: an observational cohort study. The text features detailed instructions on the various procedures as well as an overview of the area. Post-transplant prophylaxis protocol for Pneumocystis jirovecii for solid organ transplant recipients.. Pneumocystis jirovecii is a ubiquitous fungus that causes PCP pneumonia. *I��3ZoP��͍2X�3��0���M�~�g�����>��,f Kates OS, Haydel BM, Florman SS, et al. Studies of Pediatric Liver Transplantation. Shah GL, DeWolf S, Lee YJ, et al. eCollection 2021. COVID-19 in solid organ transplant recipients: initial report from the US epicenter. Draft ASHP Guidelines on Pharmacy Services in Solid Organ Transplantation 5 . Posting Date. Infect Dis Clin North Am. At this time, reducing the dose of immunosuppressants and holding immunosuppressants prior to SARS-CoV-2 vaccination. COVID-19 ACIP vaccine recommendations. Available at: Khawaja F, Chemaly R, Dadwal S, et al. The American Association for the Study of Liver Diseases (AASLD),1 the International Society for Heart and Lung Transplantation, the American Society of Transplantation, the American Society for Transplantation and Cellular Therapy (ASTCT), the European Society for Blood and Marrow Transplantation (EBMT), and the Association of Organ Procurement Organizations provide guidance for clinicians who are caring for transplant recipients with COVID-19, as well as guidance for screening potential donors and transplant or cell therapy candidates. 2021. Danziger-Isakov L, Kumar D. Vaccination of solid organ transplant candidates and recipients: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice [published online April 19, 2019]. The epidemiology and risk factors for skin cancers in organ transplant recipients, as well as a summary of other malignancies that develop with increased frequency after solid organ transplantation, are discussed separately. Nutrition Guidelines After Solid Organ Transplant. . Affiliations. �N�a�/; -:�I�v#!؟ �(�SJ�� gcgT��Lh��gq���T�I@`�]u@�9 ��k{��J6Y�7i Z,�]��c�Ѿ�v҂��>�NK�t�3FBFK8���m���s��n�0�ܵ�Ƨ'-�~`��E����Ib[�������O� A multidisciplinary approach with inclusion of a pharmacist in the care of transplant recipients is highly desired and may necessitate the addition of transplant pharmacy resources to existing teams to meet these growing needs. Vaccination of solid organ transplant candidates and recipients: guidelines from the American Society of Transplantation Infectious Disease Community of Practice. Kotton CN, Kumar D, Caliendo AM, Asberg A, Chou S, Snydman DR, Allen U, Humar A; Transplantation Society International CMV Consensus Group. Clinicians should consider performing diagnostic testing for SARS-CoV-2 in all HCT and cellular therapy candidates who exhibit symptoms. Solid organ transplantation from hepatitis B virus-positive donors: Consensus guidelines for recipient management An official website of the United States government. The Veterans Health Administration has offered solid organ transplant services since 1962 and bone marrow transplant services since 1982. A single center observational study of the clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-CoV2 pneumonia. 2Integrated Solid Organ Transplant Program, Cincinnati Childrens Hospital . Found insideThis book is addressed to researchers, practicing physicians, and surgeons in the field of organ transplantation, as well as the medical students, residents, and fellows. Clin Transplant 2019; 33:e13563. Research in the field and development of prior consensus guidelines suppor … %����ٜ` S^��j���K ���"F�����o��U��]��*p�� ���U�$��@�t�l��o�^y�ؗm��V�e�yw����AUg�\$�_1����'��,j? Danziger-Isakov L, Kumar D. Vaccination of solid organ transplant candidates and recipients: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice [published online April 19, 2019]. Outside of a clinical study, antibody testing is not recommended to assess immunity to SARS-CoV-2 following COVID-19 vaccination in transplant patients. doi: 10.1111/ctr.13563 <> • Patients with acute leukaemia - from diagnosis (unless/until decision Cross-posted from HHS NewsroomUpdate Improves Transplant Safety and Access to Lifesaving Organs[On Thursday, June 25, 2020], the U.S. Department of Health and Human Services and the U.S. Public Health Service (USPHS) published an updated solid organ transplant guideline to assess donors and monitor recipients for human immunodeficiency virus (HIV), hepatitis B virus, and Food and Drug Administration. This book focuses on the care of adult solid organ transplant recipients, and is targeted at the level of the primary care provider. It begins with an introduction and overviews of solid organ transplantation and anti-rejection medications. 1 Year after year, this trend is . The aim of this guideline is to provide guidance on the clinical development of compounds for the prevention and treatment of allograft rejection in solid organ transplantation. Summary. Outline unique patient populations that require additional disease screening. Recommendations that have changed since the 2013 PHS guideline include updated criteria for Available at: Elens L, Langman LJ, Hesselink DA, et al. Found insideFocusing on must-know clinical information needed to provide optimal patient care, this expertly written guide helps you gain the knowledge and expertise you need in this complex area. Transplantation guidelines recommend universal statin therapy in kidney and heart recipients. American Society of Transplantation. Recommendations for screening are outlined in the ASTCT and EBMT guidelines. Dose modifications may be necessary for drugs that are used to treat COVID-19 in transplant recipients with pre-existing organ dysfunction. 2019 Sep;33(9):e13576. Older age (≥50 years), male sex, and receipt of a COVID-19 diagnosis within 12 months of transplantation were associated with a higher risk of mortality among allogeneic recipients. Akalin E, Azzi Y, Bartash R, et al. 2016. Available at: Centers for Disease Control and Prevention. In contrast, immunocompromised patients are at risk for hyperinfection syndrome and disseminated disease . Prolonged viral shedding has been described in SOT and HCT recipients; this can have implications for infection prevention and for the timing of potential therapeutic interventions.21. In general, ABO considerations are important in most solid organ transplants (even above HLA) and most transplants are ABO compatible; this is in contrast to PBSC transplants (HLA above ABO considerations). It provides a ready source of reference, to both the basic science and organ specific surgical technique and after care. This second edition has been extensively updated in light of recent developments in this rapidly advancing area. No current testing strategy is sensitive enough or specific enough to totally exclude active infection. Early impact of COVID-19 on transplant center practices and policies in the United States. Living solid organ donors should be counseled on strategies to prevent infection and monitored for exposures and symptoms in the 14 days prior to a scheduled transplant.10 HCT donors should practice good hygiene and avoid crowded places and large group gatherings during the 28 days prior to donation.11. x��[[s��~��> ���f�I�N.n��>�y�@�DC� �u~}�e� b�����8{.߹�����=5�(������ش��Z����x���×��Շf���;^�oono^}�8O�7����X�yƢ(�����3���ϥ��7��⏿�������៷7��!|PrqP&��s>������}F�_���jQ���������ۛ3:���B�H���f��#��(�u{#�����>�ݿ�����+�s�eiXK�~8�A��;�x���j�]���Q{ԫ��$Y���juޏ���>Y��Z���m�⡇��0����x�l�kٔ�4��6}_Eћ��t�ť�����>NV���Xm��~���b�m��Ϟ�������Ė|l����ܗ�/H��e��� Influenza vaccination in liver transplant recipients. At this time, the procedures for evaluating and managing COVID-19 in transplant recipients are the same as those for nontransplant patients (AIII). In response to this clinical knowledge gap, ICU Care of Abdominal Organ Transplant Patients provides a concise at the bedside resource fo intensivists, surgeons, and nurses caring for abdominal organ transplant patients before and after ... This study found that the number of comorbidities, the presence of infiltrates on initial chest imaging, and neutropenia were predictors for increased disease severity.20 Additional factors that have been used to determine the clinical severity of other respiratory viral infections include the degree of cytopenia, the intensity of the conditioning regimen, the graft source, the degree of mismatch, and the need for further immunosuppression to manage graft-versus-host disease. In general, the considerations for treating COVID-19 are the same for transplant recipients as for the general population. transplant-specific, and higher rates of all types of infection, graft loss, morbidity, and mortality.2,3 A panel of experts on CMVand solid organ transplantation (SOT) was previously convened in 2008 and 2012 by The Infectious Diseases Sec-tion of The Transplantation Society to develop consensus guidelines on CMV management, subsequently published Solid Organ Transplantation . The optimal management and therapeutic approach to COVID-19 in these populations is unknown. Fiscal Year. 116. medication education, and discharge planning though each transition of . Kumru Sahin G, Eyupoglu S, Eren Sadioglu R, Cinar G, Ates K, Erturk S, Nergizoglu G, Sengul S, Kutlay S, Keven K. Int Urol Nephrol. Adenovirus is an important cause of infectious complications in both stem cell transplant and SOT patients, causing a . 2021 Aug 4;9(8):1666. doi: 10.3390/microorganisms9081666. ��=D�� �~�'� ݍ�42�uwe�}��H�w$˟��m��[�����$K�*vhX�x�(f>��q���:GsGE�!y]���)�aD��I�߾� ��;��M ��@����G|�֛�J,J��?$��.W�F��Џ垂���?��C��� ����}���^ ��.ؙE ?�ˇE�f/�4�����|^��2�? Highlights of the Third Edition include a chapter on new immunosuppressive agents and expanded coverage of tropical infections and West Nile virus. �&s���u���7��#�Fwh&ٵ�7X�dEn6t���N����*��wJ�5܌B5�@��F��c ��`�h�fk��62�]��~�SUl|��Ч��vhʖ �����#������@45Jd���[� ��fJ��w��$X>�]�;E�|���/����Hɨ���|�'�&�|�[EaYM�R0����r�=���Lu"�aW����r�)�"�����w1���Vʵ�m��y�]�;鰋�S�.4���k쵥 �u���r�J��]����곹z`�Nx����3,�����ǚ�Oql����O�v�a���[��E\1[eXks�E�!��N�|J�x����n�tt�F�;��]ɭѡ��: 3�,�U�F����tb�ᷜ���ќ. For liver transplant recipients, the AASLD does not consider abnormal liver biochemistries a contraindication to using remdesivir.25 Close monitoring of liver biochemistries is warranted in patients with COVID-19, especially when they are receiving agents with a known risk of hepatotoxicity. COVID-19 is an emerging, rapidly evolving situation. Prevention and treatment information (HHS). • Patients who have had SOT - for as long as the patient is taking immunosuppressants. Clin Transplant. Clinicians should pay special attention to the potential for drug-drug interactions and overlapping toxicities with concomitant medications, such as immunosuppressants that are used to prevent allograft rejection (e.g., corticosteroids, mycophenolate, and calcineurin inhibitors such as tacrolimus and cyclosporine), antimicrobials that are used to prevent opportunistic infections, and other medications. An official publication of the International Transplant Nurses Association, the updated Second Edition provides a guide to safe and effective care for solid organ transplant recipients worldwide. Transplant pharmacists work with healthcare professionals in all settings of care115 to ensure a seamless medication-use process, provision of transplantation . FOIA Influenza vaccination in liver transplant recipients. 2021 Aug 16. doi: 10.1007/s11255-021-02973-w. Online ahead of print. Cytomegalovirus in solid organ transplant recipients-Guidelines of the American Society of Transplantation Infectious Diseases Community of Practice Cytomegalovirus (CMV) is one of the most common opportunistic infections that affect the outcome of solid organ transplantation. The clinical trials that have evaluated the SARS-CoV-2 vaccines that have received Emergency Use Authorizations from the Food and Drug Administration have excluded severely immunocompromised patients.2-4 The Advisory Committee on Immunization Practices notes that the currently authorized COVID-19 vaccines are not live vaccines; therefore, they can be safely administered to immunocompromised people.5 The efficacy rates for the available vaccines may be lower in immunocompromised patients than in the general population, and the relative efficacy of the different vaccines for transplant candidates or recipients is currently unknown. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated.html. for these infections among solid organ donors, implementation of laboratory screening of solid organ donors, and monitoring of solid organ transplant recipients. This site needs JavaScript to work properly. ASTCT interim patient guidelines April 20, 2020. 8.5.2: Haemolysis after ABO-incompatible solid organ transplantation Transplanted organs may contain donor B-lymphocytes capable of producing ABO antibodies. Latest public health information from CDC, Statement on the Prioritization of Anti-SARS-CoV-2 Monoclonal Antibodies, Statement on Casirivimab Plus Imdevimab as PEP, Therapeutic Management of Nonhospitalized Adults With COVID-19, Therapeutic Management of Hospitalized Adults With COVID-19, International Society for Heart and Lung Transplantation, American Society for Transplantation and Cellular Therapy (ASTCT), European Society for Blood and Marrow Transplantation (EBMT), Association of Organ Procurement Organizations, https://www.ncbi.nlm.nih.gov/pubmed/32298473, https://www.ncbi.nlm.nih.gov/pubmed/33378609, https://www.ncbi.nlm.nih.gov/pubmed/33301246, https://www.fda.gov/media/146217/download, https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html, https://www.myast.org/sites/default/files/2021%2003%2018%20COVID19%20VACCINE%20FAQS_update.pdf, https://www.hematology.org/covid-19/ash-astct-covid-19-vaccination-for-hct-and-car-t-cell-recipients, https://www.ncbi.nlm.nih.gov/pubmed/18724396, https://www.myast.org/covid-19-information, https://www.astct.org/viewdocument/astct-interim-patient-guidelines-ap?CommunityKey=d3949d84-3440-45f4-8142-90ea05adb0e5&tab=librarydocuments, https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html, https://www.ncbi.nlm.nih.gov/pubmed/32282982, https://www.ncbi.nlm.nih.gov/pubmed/32329975, https://www.ncbi.nlm.nih.gov/pubmed/32330343, https://www.ncbi.nlm.nih.gov/pubmed/32354634, https://www.ncbi.nlm.nih.gov/pubmed/32368838, https://www.ncbi.nlm.nih.gov/pubmed/32766815, https://www.ncbi.nlm.nih.gov/pubmed/33482113, https://www.ncbi.nlm.nih.gov/pubmed/32897885, https://www.ncbi.nlm.nih.gov/pubmed/33259154, https://www.ncbi.nlm.nih.gov/pubmed/32678530, https://www.medrxiv.org/content/10.1101/2021.02.11.21249258v1, https://www.ncbi.nlm.nih.gov/pubmed/33631065, https://www.aasld.org/sites/default/files/2021-03/AASLD-COVID19-ExpertPanelConsensusStatement-March92021.pdf, https://www.ncbi.nlm.nih.gov/pubmed/32304488, Nonhospitalized Patients: General Management, Nonhospitalized Adults: Therapeutic Management, Hospitalized Adults: Therapeutic Management, Chloroquine or Hydroxychloroquine and/or Azithromycin, Lopinavir/Ritonavir and Other HIV Protease Inhibitors, Table: Characteristics of Antiviral Agents, Table: Characteristics of Anti-SARS-CoV-2 Antibody Products, Table: Characteristics of Immunomodulators, Given the effectiveness of SARS-CoV-2 vaccines in the general population and the increased risk of worse clinical outcomes of COVID-19 in transplant and cellular therapy recipients, the COVID-19 Treatment Guidelines Panel (the Panel) recommends SARS-CoV-2 vaccination for potential transplant and cellular therapy candidates, potential donors, and recipients, The Panel recommends diagnostic molecular testing for SARS-CoV-2 for all potential solid organ transplant (SOT), hematopoietic cell transplant (HCT), and cell therapy candidates with signs and symptoms that suggest acute COVID-19 infection, The Panel recommends following the guidance from medical professional organizations that specialize in providing care for SOT, HCT, or cell therapy recipients when performing diagnostic molecular testing for SARS-CoV-2 in these patients, If SARS-CoV-2 is detected or if infection is strongly suspected, transplantation should be deferred, if possible, The Panel recommends assessing all potential SOT and HCT donors for signs and symptoms that are associated with COVID-19 according to guidance from medical professional organizations, The Panel recommends performing diagnostic molecular testing for SARS-CoV-2 if symptoms are present, If SARS-CoV-2 is detected or if infection is strongly suspected, donation should be deferred, Clinicians should follow the guidelines for evaluating and managing COVID-19 in nontransplant patients when treating transplant and cellular therapy recipients, The Panel recommends that clinicians who are treating COVID-19 in transplant and cellular therapy patients consult with a transplant specialist before adjusting immunosuppressive medications, When treating COVID-19, clinicians should pay careful attention to potential drug-drug interactions and overlapping toxicities with immunosuppressants, prophylactic antimicrobials, and other medications. 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