Effect of temporary suspension of chronic immunosuppressive drugs on day-90 mortality and ICU-acquired infections among critically Ill patients with solid organ transplant: a retrospective multicenter study

Purpose: Decision-making for management of immunosuppressive drugs in solid organ transplant patients admitted to the ICU remains controversial. This study aimed to evaluate the impact of a temporary suspension strategy (interruption of immunosuppressive drugs > 24h) on day-90 mortality and ICU-acquired infections.Methods: This multicenter observational retrospective study conducted in solid organ transplant patients admitted to nine ICUs used a Bayesian approach with priors based on a belief elicitation process conducted among a panel of experts.Results: Among 591 enrolled patients, suspension strategy was used in 34% of them, during a median period of 5 days [IQR: 3-10]. This approach was more common in patients admitted for sepsis (38%) or COVID-19 (49%) than for non-septic causes (24%) (p < 0.001). Overall, day-90 mortality reached 30%, and Bayesian analysis revealed substantial uncertainty with an OR at 1.13 (95% Credible Interval (CrI): 0.74-1.70), and a 15% probability of a beneficial effect. In the subgroup of patients with sepsis, OR was at 0.90 (95% CrI: 0.55-1.55), with a 50% probability of a beneficial effect. ICU-acquired infections occurred in 26% of patients. The suspension strategy indicated a potential benefit, both in the entire cohort, with a 73% probability of a beneficial effect [OR: 0.74 (95% CrI: 0.49-1.15)], and in the subgroup of sepsis patients with a 78% probability of beneficial effect [OR 0.70 (95% CrI, 0.42-1.16)].Conclusion: Temporary suspension of immunosuppressive drugs may reduce the risk of ICU-acquired infections, with a true uncertainty on day-90 mortality. Prospective studies are warranted to confirm these results.