Minimizing infection risks after paediatric organ transplants: Advice for practitioners

Question 1

What infections to expect in the first month post-transplant?

Answer 1

> 95% are similar to infections in non-immunosuppressed patients

Question 2

What infections to expect in one-to-six months post-transplant?

Answer 2

1. Viral pathogens associated with latent or persistent infections incld. CMV, EBV, HHV6, HBV, HCV
2. Opportunistic bacterial infections i.e. Listeria monocytogenes, Aspergillus fumigatus, Pneumocystis jiroveci

Question 3

What infections to expect >6m post transplant?

Answer 3

1. Maintenance patients with good function get normal community acquired infections
2. Poor function get recurrent infections related to uncorrected mechanical or anatomical problems
3. Opportunistic infections i.e. P jiroveci, L monocytogenes, Cryptococcus neoformans, Nocardia asteroides

Question 4

What is the recommended evaluation in febrile transplant patient when examination is abnormal and the focus of infection is defined?

Answer 4

1. May require hospital admission
2. CBC, diff, blood culture
3. Additional Ix depend on clinical focus and timing of presentation after transplantation

Question 5

What is the recommended evaluation in febrile transplant patient when examination is normal and no focus of infection is defined?

Answer 5

1. Usu. needs hospital admission
2. CBC+diff, blood culture, urine culture
3. Further investigation depends on clinical status

Question 6

What vaccines are recommended before transplantation in transplant recipients?

Answer 6

1. Diphtheria
2. Pertussis
3. Tetanus
4. Polio
5. Hib
6. Streptococcus pneumoniae (PCV13/23-valent polysaccharide)
7. Neisseria meningitidis (conjugate serogroup C and conjugate quadrivalent)
8. Influenza
9. Hepatitis A
10. Hepatitis B
11. Measles
12. Mumps
13. Rubella
14. Varicella
15. Rotavirus
16. HPV
17. BCG if indicated
18. Rabies if indicated

Question 7

What vaccines are recommended after transplantation in transplant recipients?

Answer 7

1. Diphtheria
2. Pertussis
3. Tetanus
4. Polio
5. Hib
6. Streptococcus pneumoniae (PCV13/23-valent polysaccharide)
7. Neisseria meningitidis (conjugate serogroup C and conjugate quadrivalent)
8. Influenza
9. Hepatitis A
10. Hepatitis B
11. HPV
12. Rabies if indicated

Question 8

What vaccines are contraindicated after transplantation in transplant recipients?

Answer 8

All live vaccines

1. Measles
2. Mumps
3. Rubella
4. Varicella
5. Rotavirus
6. BCG

Question 9

What are screening tests for transplant candidates?

Answer 9

1. HIV-1 and 2 serology and antigen detection
2. HTLV-1 and 2 serology
3. Hepatitis A serology
4. Hepatitis B serology
5. Hepatitis C serology
6. Hepatitis D serology
7. CMV serology
8. EBV serology
9. HSV serology
10. VZV serology
11. Toxoplasma gondii serology
12. Measles serology if vaccinated
13. Mumps serology if vaccinated
14. Rubella serology if vaccinated
15. Mycobacterium tuberculosis
16. Strongyloides stercoralis
17. Respiratory tract pathogens
18. Radiographic imaging prn

Question 10

What prophylaxis is required?

Answer 10

1. Bacterial infection - perioperative antimicrobial regimen for all recipients
2. HSV: acyclovir x 3m in seropositive recipients
3. CMV: IV ganciclovir +/- IVIG x 3m (2w-6m)
4. EBV for high risk patients no established regimen
5. Candida species in high risk patients only (liver, intestinal transplants) fluconazole x 4w, lipid amphotericin B selectively
6. Aspergillus in lung/heart lung recipients voriconazole/itraconazole x 4-6m, amphotericin B if high risk factors are present
7. PJP all recipients TMP/SMX x 6-12mo
8. Toxoplasma gondii Pyrimethamine/sulfadiazine for donor seropositive, recipient seronegative heart/heart-lung recipients or TMP/SMX for recipient seronegative patients x 6m

Question 11

What are some immunosuppressive medications used in organ transplantation?

Answer 11

Polyclonal antibodies

1. Thymoglobulin (rabbit antithymocyte globulin) –> SE: anaphylaxis, infusion-related effects
2. Atgam (equine antithymocyte globulin)

Monoclonal antibodies

1. Simulect (Basiliximab antibody IL2 receptor) –> SE hypersensitivity
2. Rituxan (Rituximab, anti-CD20 antibody)–> SE: infusion related reactions, angioedema, pancytopenia

Corticosteroids

1. Prednisone
2. Methylprednisolone
   - -> SE: hypertension, diabetes, salt/water retention, osteopenia, hyperlipidemia, Cushingoid features, hirsutism, acne, growth retardation

Calcineurin inhibitors

1. Cyclosporin A –> SE: Hirsutism, gingival hyperplasia, nephrotoxicity, hypertension
2. Tacrolimus –> SE Tremor, dose-dependent neuropathy, nephrotoxicity, hypertension, hyperglycemia

Antiproliferative agents

1. MMF or Cellcept –> SE: Leukopenia, anemia, thrombocytopenia, gastrointestinal symptoms
2. Azathioprine (Imuran) –> SE: Leukopenia, anemia, thrombocytopenia

mTOR inhibitors:

1. Sirolimus (rapamycin) –> SE: Delayed wound healing, aphthous ulcers, hyperlipidemia, bone marrow suppression, pneumonitis
2. Everolimus (Afinitor)

Question 12

What are inducers of cP450 (decrease levels of immunosuppressants)?

Answer 12

1. Rifampin
2. Rifabutin
3. Caspofungin
4. Nevirapine
5. Efavirenz

Question 13

What are inhibitors of cP450 (increase levels of immunosuppressants)?

Answer 13

Azithromycin
Clarithromycin
Erythromycin
Metronidazole
Levofloxacin
Ciprofloxacin
Fluconazole
Ketoconazole
Itraconazole
Voriconazole
Indinavir
Nelfinavir
Ritonavir
Lopinavir
Amprenavir
Saquinavir