Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Infection in the solid organ transplant recipient

Jay A Fishman, MD
Section Editor
Kieren A Marr, MD
Deputy Editor
Anna R Thorner, MD


Solid organ transplantation has increased worldwide since the first successful human kidney transplant was performed in 1954. As immunosuppressive agents and graft survival have improved, infection and malignancy have become the main barriers to disease-free survival after organ transplantation. As a result of the growing population of immunosuppressed patients with prolonged survival, an increased incidence and spectrum of opportunistic infections is observed [1-3]. Guidelines for the diagnosis and treatment of infection in transplant recipients have been developed [4].

The risks of infection and an overview of specific infections in the solid organ transplant recipient will be reviewed here. The pretransplant evaluation for solid organ and hematopoietic cell transplant (HCT) recipients, prophylaxis of infections in solid organ transplant and HCT recipients, and an overview of infections following HCT are discussed separately. (See "Evaluation for infection before solid organ transplantation" and "Evaluation for infection before hematopoietic cell transplantation" and "Prophylaxis of infections in solid organ transplantation" and "Prevention of infections in hematopoietic cell transplant recipients" and "Overview of infections following hematopoietic cell transplantation".)


When infection occurs, early and specific diagnosis and rapid and aggressive treatment are essential to good clinical outcomes.

Potential etiologies of infection in these patients are diverse, including common, community-acquired bacterial and viral diseases and uncommon opportunistic infections of clinical significance only in immunocompromised hosts [1-3]. Pulmonary processes can progress rapidly and may constitute medical emergencies [1]. These include infections due to Pneumocystis jirovecii (formerly P. carinii), Nocardia asteroides, Aspergillus spp, Cryptococcus neoformans, cytomegalovirus (CMV), varicella-zoster virus (VZV), influenza, respiratory syncytial virus (RSV), Rhodococcus equi, and Legionella spp.

Inflammatory responses associated with microbial invasion are impaired by immunosuppressive therapy, which results in diminished symptoms and muted clinical and radiologic findings. As a result, infections are often advanced (ie, disseminated) at the time of clinical presentation.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Apr 22, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med 2007; 357:2601.
  2. Fishman JA, Issa NC. Infection in organ transplantation: risk factors and evolving patterns of infection. Infect Dis Clin North Am 2010; 24:273.
  3. Green M. Introduction: Infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:3.
  4. Blumberg EA, Danziger-Isakov L, Kumar D, et al. Foreword: Guidelines 3. Am J Transplant 2013; 13 Suppl 4:1.
  5. Kalil AC, Syed A, Rupp ME, et al. Is bacteremic sepsis associated with higher mortality in transplant recipients than in nontransplant patients? A matched case-control propensity-adjusted study. Clin Infect Dis 2015; 60:216.
  6. Fishman JA. Pneumocystis carinii and parasitic infections in transplantation. Infect Dis Clin North Am 1995; 9:1005.
  7. Roxby AC, Gottlieb GS, Limaye AP. Strongyloidiasis in transplant patients. Clin Infect Dis 2009; 49:1411.
  8. Antinori S, Cascio A, Parravicini C, et al. Leishmaniasis among organ transplant recipients. Lancet Infect Dis 2008; 8:191.
  9. Singh N, Paterson DL. Mycobacterium tuberculosis infection in solid-organ transplant recipients: impact and implications for management. Clin Infect Dis 1998; 27:1266.
  10. Aguado JM, Herrero JA, Gavaldá J, et al. Clinical presentation and outcome of tuberculosis in kidney, liver, and heart transplant recipients in Spain. Spanish Transplantation Infection Study Group, GESITRA. Transplantation 1997; 63:1278.
  11. Ziakas PD, Pliakos EE, Zervou FN, et al. MRSA and VRE colonization in solid organ transplantation: a meta-analysis of published studies. Am J Transplant 2014; 14:1887.
  12. Pappas PG, Alexander BD, Andes DR, et al. Invasive fungal infections among organ transplant recipients: results of the Transplant-Associated Infection Surveillance Network (TRANSNET). Clin Infect Dis 2010; 50:1101.
  13. Dubberke ER, Burdette SD, AST Infectious Diseases Community of Practice. Clostridium difficile infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:42.
  14. Echenique IA, Penugonda S, Stosor V, et al. Diagnostic yields in solid organ transplant recipients admitted with diarrhea. Clin Infect Dis 2015; 60:729.
  15. Paudel S, Zacharioudakis IM, Zervou FN, et al. Prevalence of Clostridium difficile infection among solid organ transplant recipients: a meta-analysis of published studies. PLoS One 2015; 10:e0124483.
  16. Morris MI, Fischer SA, Ison MG. Infections transmitted by transplantation. Infect Dis Clin North Am 2010; 24:497.
  17. Fishman JA, Greenwald MA, Grossi PA. Transmission of infection with human allografts: essential considerations in donor screening. Clin Infect Dis 2012; 55:720.
  18. Chong PP, Razonable RR. Diagnostic and management strategies for donor-derived infections. Infect Dis Clin North Am 2013; 27:253.
  19. Green M, Covington S, Taranto S, et al. Donor-derived transmission events in 2013: a report of the Organ Procurement Transplant Network Ad Hoc Disease Transmission Advisory Committee. Transplantation 2015; 99:282.
  20. Kumar D, Prasad GV, Zaltzman J, et al. Community-acquired West Nile virus infection in solid-organ transplant recipients. Transplantation 2004; 77:399.
  21. Fischer SA, Graham MB, Kuehnert MJ, et al. Transmission of lymphocytic choriomeningitis virus by organ transplantation. N Engl J Med 2006; 354:2235.
  22. Centers for Disease Control and Prevention (CDC). Brief report: Lymphocytic choriomeningitis virus transmitted through solid organ transplantation--Massachusetts, 2008. MMWR Morb Mortal Wkly Rep 2008; 57:799.
  23. Amman BR, Pavlin BI, Albariño CG, et al. Pet rodents and fatal lymphocytic choriomeningitis in transplant patients. Emerg Infect Dis 2007; 13:719.
  24. Schafer IJ, Miller R, Ströher U, et al. Notes from the field: a cluster of lymphocytic choriomeningitis virus infections transmitted through organ transplantation-Iowa, 2013. Am J Transplant 2014; 14:1459.
  25. Vora NM, Basavaraju SV, Feldman KA, et al. Raccoon rabies virus variant transmission through solid organ transplantation. JAMA 2013; 310:398.
  26. Maier T, Schwarting A, Mauer D, et al. Management and outcomes after multiple corneal and solid organ transplantations from a donor infected with rabies virus. Clin Infect Dis 2010; 50:1112.
  27. Srinivasan A, Burton EC, Kuehnert MJ, et al. Transmission of rabies virus from an organ donor to four transplant recipients. N Engl J Med 2005; 352:1103.
  28. Centers for Disease Control and Prevention (CDC). Balamuthia mandrillaris transmitted through organ transplantation --- Mississippi, 2009. MMWR Morb Mortal Wkly Rep 2010; 59:1165.
  29. Centers for Disease Control and Prevention (CDC). Notes from the field: transplant-transmitted Balamuthia mandrillaris --- Arizona, 2010. MMWR Morb Mortal Wkly Rep 2010; 59:1182.
  30. Gupte AA, Hocevar SN, Lea AS, et al. Transmission of Balamuthia mandrillaris through solid organ transplantation: utility of organ recipient serology to guide clinical management. Am J Transplant 2014; 14:1417.
  31. Hocevar SN, Paddock CD, Spak CW, et al. Microsporidiosis acquired through solid organ transplantation: a public health investigation. Ann Intern Med 2014; 160:213.
  32. Palacios G, Druce J, Du L, et al. A new arenavirus in a cluster of fatal transplant-associated diseases. N Engl J Med 2008; 358:991.
  33. Centers for Disease Control and Prevention (CDC). Transplantation-transmitted tuberculosis--Oklahoma and Texas, 2007. MMWR Morb Mortal Wkly Rep 2008; 57:333.
  34. Aguado JM, Torre-Cisneros J, Fortún J, et al. Tuberculosis in solid-organ transplant recipients: consensus statement of the group for the study of infection in transplant recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology. Clin Infect Dis 2009; 48:1276.
  35. Grady D. Four transplant recipients contract HIV. New York Times, November 2007. www.nytimes.com/2007/11/13/health/13cnd-organ.html?em (Accessed on May 29, 2008).
  36. Centers for Disease Control and Prevention (CDC). Transmission of hepatitis C virus through transplanted organs and tissue--Kentucky and Massachusetts, 2011. MMWR Morb Mortal Wkly Rep 2011; 60:1697.
  37. Centers for Disease Control and Prevention (CDC). Notes from the field: transplant-transmitted hepatitis B virus --- United States, 2010. MMWR Morb Mortal Wkly Rep 2011; 60:1087.
  38. Glowacka I, Korn K, Potthoff SA, et al. Delayed seroconversion and rapid onset of lymphoproliferative disease after transmission of human T-cell lymphotropic virus type 1 from a multiorgan donor. Clin Infect Dis 2013; 57:1417.
  39. Zou S, Dodd RY, Stramer SL, et al. Probability of viremia with HBV, HCV, HIV, and HTLV among tissue donors in the United States. N Engl J Med 2004; 351:751.
  40. van den Berg AP, Klompmaker IJ, Haagsma EB, et al. Evidence for an increased rate of bacterial infections in liver transplant patients with cytomegalovirus infection. Clin Transplant 1996; 10:224.
  41. George MJ, Snydman DR, Werner BG, et al. The independent role of cytomegalovirus as a risk factor for invasive fungal disease in orthotopic liver transplant recipients. Boston Center for Liver Transplantation CMVIG-Study Group. Cytogam, MedImmune, Inc. Gaithersburg, Maryland. Am J Med 1997; 103:106.
  42. Fishman JA. Prevention of infection due to Pneumocystis carinii. Antimicrob Agents Chemother 1998; 42:995.
  43. Fishman JA. Treatment of infection due to Pneumocystis carinii. Antimicrob Agents Chemother 1998; 42:1309.
  44. Hadley S, Karchmer AW. Fungal infections in solid organ transplant recipients. Infect Dis Clin North Am 1995; 9:1045.
  45. Collins LA, Samore MH, Roberts MS, et al. Risk factors for invasive fungal infections complicating orthotopic liver transplantation. J Infect Dis 1994; 170:644.
  46. Issa NC, Fishman JA. Infectious complications of antilymphocyte therapies in solid organ transplantation. Clin Infect Dis 2009; 48:772.
  47. Egli A, Binet I, Binggeli S, et al. Cytomegalovirus-specific T-cell responses and viral replication in kidney transplant recipients. J Transl Med 2008; 6:29.
  48. Serban G, Whittaker V, Fan J, et al. Significance of immune cell function monitoring in renal transplantation after Thymoglobulin induction therapy. Hum Immunol 2009; 70:882.
  49. Talbot TR, Hatcher J, Davis SF, et al. Scedosporium apiospermum pneumonia and sternal wound infection in a heart transplant recipient. Transplantation 2002; 74:1645.
  50. Fishman JA. Vancomycin-resistant Enterococcus in liver transplantation: what have we left behind? Transpl Infect Dis 2003; 5:109.
  51. Bocchi EA, Bellotti G, Mocelin AO, et al. Heart transplantation for chronic Chagas' heart disease. Ann Thorac Surg 1996; 61:1727.
  52. Centers for Disease Control and Prevention (CDC). Chagas disease after organ transplantation--Los Angeles, California, 2006. MMWR Morb Mortal Wkly Rep 2006; 55:798.
  53. Fernàndez-Sabé N, Cervera C, Fariñas MC, et al. Risk factors, clinical features, and outcomes of toxoplasmosis in solid-organ transplant recipients: a matched case-control study. Clin Infect Dis 2012; 54:355.
  54. Doucette K, Fishman JA. Nontuberculous mycobacterial infection in hematopoietic stem cell and solid organ transplant recipients. Clin Infect Dis 2004; 38:1428.
  55. Mendez JC, Dockrell DH, Espy MJ, et al. Human beta-herpesvirus interactions in solid organ transplant recipients. J Infect Dis 2001; 183:179.
  56. Kalil AC, Levitsky J, Lyden E, et al. Meta-analysis: the efficacy of strategies to prevent organ disease by cytomegalovirus in solid organ transplant recipients. Ann Intern Med 2005; 143:870.
  57. Terrault NA, Wright TL, Pereira BJ. Hepatitis C infection in the transplant recipient. Infect Dis Clin North Am 1995; 9:943.
  58. Beck S, Barrell BG. Human cytomegalovirus encodes a glycoprotein homologous to MHC class-I antigens. Nature 1988; 331:269.
  59. Reinke P, Fietze E, Ode-Hakim S, et al. Late-acute renal allograft rejection and symptomless cytomegalovirus infection. Lancet 1994; 344:1737.
  60. Gardner SD, MacKenzie EF, Smith C, Porter AA. Prospective study of the human polyomaviruses BK and JC and cytomegalovirus in renal transplant recipients. J Clin Pathol 1984; 37:578.
  61. Randhawa PS, Finkelstein S, Scantlebury V, et al. Human polyoma virus-associated interstitial nephritis in the allograft kidney. Transplantation 1999; 67:103.
  62. Nickeleit V, Hirsch HH, Binet IF, et al. Polyomavirus infection of renal allograft recipients: from latent infection to manifest disease. J Am Soc Nephrol 1999; 10:1080.
  63. Balba GP, Javaid B, Timpone JG Jr. BK polyomavirus infection in the renal transplant recipient. Infect Dis Clin North Am 2013; 27:271.
  64. Singh N, Carrigan DR. Human herpesvirus-6 in transplantation: an emerging pathogen. Ann Intern Med 1996; 124:1065.
  65. Eid AJ, Brown RA, Patel R, Razonable RR. Parvovirus B19 infection after transplantation: a review of 98 cases. Clin Infect Dis 2006; 43:40.
  66. Barzon L, Murer L, Pacenti M, et al. Investigation of intrarenal viral infections in kidney transplant recipients unveils an association between parvovirus B19 and chronic allograft injury. J Infect Dis 2009; 199:372.
  67. Falagas ME, Snydman DR, George MJ, et al. Incidence and predictors of cytomegalovirus pneumonia in orthotopic liver transplant recipients. Boston Center for Liver Transplantation CMVIG Study Group. Transplantation 1996; 61:1716.
  68. Waggoner JJ, Soda EA, Deresinski S. Rare and emerging viral infections in transplant recipients. Clin Infect Dis 2013; 57:1182.
  69. Hamandi B, Husain S, Humar A, Papadimitropoulos EA. Impact of infectious disease consultation on the clinical and economic outcomes of solid organ transplant recipients admitted for infectious complications. Clin Infect Dis 2014; 59:1074.
  70. Lake KD. Drug interactions in transplant patients. In: Handbook of Cardiac Transplantation, Emery RW, Miller LM (Eds), Hanley and Belfus, Philadelphia 1995. p.173.
  71. Venkataramanan R, Habucky K, Burckart GJ, Ptachcinski RJ. Clinical pharmacokinetics in organ transplant patients. Clin Pharmacokinet 1989; 16:134.
  72. Amacher DE, Schomaker SJ, Retsema JA. Comparison of the effects of the new azalide antibiotic, azithromycin, and erythromycin estolate on rat liver cytochrome P-450. Antimicrob Agents Chemother 1991; 35:1186.