CHAPTER 117 INFECTIONS IN
TRANSPLANT RECEPIENTS
A. BONE MARROW TRANSPLANT
INFECTIONS: 1st month of bone marrow
transplant
LEVOFLOXACIN: decreases bacteremia
maong bone marrow transplant px
1st few days: common org: aerobic( E coli,
klebsiella, Pseudomonas and thru skin or
catheter ( Staph coag -/+)
beyond 1st few days; Filamentous bacteria
( Nocardia/ Actininomyctes)
Late posttransplant: encapsualted org (>6
months after BM reconstitution)
beyond 1st week: fungal (candida)
TMP-SMX- prophylactic for Pneumocystis; 1
month after engrafment and continiung for at
least 1 year
- prophylactic also for Toxoplasma,
Listeria, Nocardia, Strep and haemophilus
ACYCLOVIR: prophylactic for seropositve
BMT/SCT; reduce mucositis and prevent HSV
pneumonia
: 2 wks after BMT excretion of virus of
seropositve HSV 1
_ also good for Varicella- Zoster virus
(low dose for the entire year)
CMV: 30- 90 days after transplant: great
concern on the 2nd month
-assoc w/ used of alpha CD52
antibody among GVHD px
-Ganciclovir- delay the devt of normal
immune rsponse to CMV, not really protective
- IVIg and Ganciclovir: tx for CMV
pneumonia
HHV-6 / Roseola- 2-4 wks after surgery: ?
foscarnet
EBV- fatal to transplant recepients
-lymphopriliferative disease (LPD) - 1-
3 months after engrfment
- tx: ? EBV specific T cells; Rituximab ,
ganciclovir; zidovudine
HHV -8 - Kaposi' s Sarcoma, primary effusion
sarcoma, castle man
RSV and Parainfluena- fatal pneumonia on
BMT
- tx: aerosolized Ribavirirn, RSV Ig
,Palivizumab
Influenza- Oseltamivir and Zanamivir
Rotavirus- gastoenteritis
Polyomavirus BK- hemorrhagic cystitis
B. SOLID ORGAN TRANSPLANT
Early period( <1 month)- extracellular
( Staph, strep, e coli,)
- origin : surgical wound or
anostomotic sites
CMV- 1st 6 months; sever systemic disease
HHV 6 reactivation- w/in 1st 2 to 4 wks; fever
and granulocytopenia
CMV rejection related syndromes:
- glomerulopathy- kidney
-bronchilitis obliterans- lung
transplant
-vanishing bile duct syndrome- liver
transplant
Beyond 6 months: defects on CMI ( listeria ,
nocardia, fungi other intracellular org)
EBV_LPD- 2 months to many years after
transplant; heart and lung transplants
1) KIDNEY TRANSPLANTS
-Early: due ti skin and wound
infections; Tx: Cephalosporins
-UTI- due to anatomical alterations
from surgery (pyelonephritis)-longer duration
of tx
appear after 6 mos: shorter duration
of tx
 -Prophylaxis: TMP-SMX
-Middle period- lung infections w/ T-
celldef( ICbacteria, nocardia, fungi, virus,
parasite)
-Legionella pnuemophilia- high
mortality
- CMV- 1 to 4 months -fever,
glomerulopathy; tx: administer Ig w/
antibodies w/ CMV
-EBV reactivation- extranodal prolif of
B cells; invade CNS, nasopharynx, liver, small
bowel heart and transplanted kidney
-PAPOVAVIRUS:BK-nepropathy; JC
virus- progressive multifocal
leukoencephalopathy
- L. monocytogenes- most common
cause of bacteremia >= 1 month after renal
transplantation
-NOCARDIA- skin, bones, lungs and
CNS, multiple abscess
-Late infection (>6 months) - CMV
retinitis, transplant ebow?, invasive fungal
2) HEART TRANSPLANTS
-early: sternal wound infxn and
mediastinitis
-dx: sternal instability and failure to
heal
-middle: toxoplasmosis, CMV ,CNS
infxn
- late: EBV-lymphoma like
3) LUNG TRANSPLANTS
-eearly: ischemia and mucosal
damage, denervtion and lack of lymph
drainage
- prophylactic broad spectrum 1st 3
to 4 days antibiotics
4) LIVER TRANSPLANTS
- infection on early; systemic broad
spectrum antibiotic for the 1st 5 days
- operation >12 hrs - inc incidence of
infection
-PERITONITIS and Intraabdominal
Abscess- Common complication
-Peritonitis- from biliary leak and
primary or 2ndary infx,polymicrobil
-Abscess- w/in 1st month, spleen,
liver, pericolic and pelvis,Tx: antibiotic and
drainage
-middle: Cholangitis- devt postsurgical
stricture on biliary- fever abdominla paina nd
jaundice
-Viral hepatitis- lamiduvine and
adefovir for hepa B
5) Pancreas
-infection prevented by draining
pancreas to urinary tract or bladder
INdwelling cathter- S. aureus- bloodstream
infxn w/in a week
Tuberculosis- w/in 12 months
VACCINATION:
For autologous and allogenic BMT recepients-
(1 year and 2 years after)
1) pneumococcal
-repeated every 5 years for px on
immunosuppresants
-every 3 years w/ significant exposure
risk
2) H. Influenza type b conjugate vaccines
Add: (12-14and 16 months after)
3) N. meningitides polysaccharide disease
4) diphtheia vaccines
5) tetanus vaccine
6) inactivated polio vaccine
OTHERS:
7) Live virus MMR- BMT recepients 24 mos
after transplant