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Prophylaxis of infections in solid organ transplantation

Barbara D Alexander, MD, MHS
Jay A Fishman, MD
Section Editor
Carol A Kauffman, MD
Deputy Editor
Sheila Bond, MD


Solid organ transplant recipients are considered to be at "high risk" for developing infection; individual risk is determined by a relationship between the epidemiologic exposures of the individual and the patient's "net state of immunosuppression" [1]. The successful prevention of infection in the solid organ transplant recipient requires an understanding of these factors in order to develop a preventive strategy adapted for each individual. (See "Evaluation for infection before solid organ transplantation" and "Infection in the solid organ transplant recipient".)

Epidemiologic exposures may have occurred many years before transplantation or at any point following the transplant procedure. The range of pathogens to which patients are exposed has increased as transplantation has become available to a broader range of individuals with more varied epidemiologic exposures and as transplant recipients survive longer, remaining on lifelong immunosuppression. Thus, clinicians must obtain a detailed history of encounters with potential pathogens, even if the exposure was relatively remote [2,3].

The use of antimicrobial agents for prophylaxis varies by the disease being targeted for prevention and the nature of the recipient's risks. Strategies include universal prophylaxis and preemptive therapy:

Universal prophylaxis involves giving an antimicrobial agent to all patients considered to be at increased risk for infection during a defined period. Trimethoprim-sulfamethoxazole (TMP-SMX) is given universally to all transplant recipients who do not have sulfa allergies. TMP-SMX is effective for the prevention of Pneumocystis pneumonia (PCP), which occurs in many United States transplantation centers at an overall rate of 10 to 14 percent [4]. It provides effective prophylaxis against other pathogens, including Listeria monocytogenes and Toxoplasma gondii. (See 'Pneumocystis pneumonia' below.)

A preemptive approach involves using sensitive assays (eg, antigen detection or molecular assays) to monitor patients at predefined intervals to detect pathogen replication (eg, viremia) before infection progresses to invasive disease. A positive assay triggers the initiation of antimicrobial therapy, a reduction in the intensity of immunosuppression, and/or intensified monitoring.

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Literature review current through: Nov 2017. | This topic last updated: Sep 10, 2017.
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