Chapter 40
Suggested Prophylaxis Regimens in Organ Transplant Recipients
| Pathogen/organ | Prophylactic regimens/comments |
| Cytomegalovirus (see Chapter 14 for more details) | |
| Heart, kidney, liver, pancreas | Valganciclovir 900 mg PO daily or ganciclovir 1 g PO TID for 3 months or valacyclovir 2 g PO QID (kidney only) or pre-emptive therapy Universal prophylaxis is preferred over pre-emptive therapy for D+/R−. Consider 6 months’ prophylaxis for D+/R− Note: valganciclovir is not FDA-approved for liver transplantation, but many centers use it |
| Lung, heart–lung (D+/R−, R+) | Ganciclovir 5 mg/kg IV daily or valganciclovir 900 mg PO daily × 3–12 months Universal prophylaxis is preferred Some centers add CMVIg (e.g. 150 mg/kg within 72 hours and at 2, 4, 6, and 8 weeks post-transplant) in high-risk patients. A recent study showed that 12 months better than 3 months |
| Hepatitis B virus (see Chapter 22 for more details) – liver | HbsAg-positive recipients: indefinite nucleos(t)ide analogue therapy ± HBIg. Discontinuation of HBIg may be considered in patients with low/undetectable HBV DNA at transplant anti-HBc-positive recipients: indefinite nucleos(t)ide analogue therapy |
| HSV/VZV – all organs | Acyclovir 200 mg PO TID or 400–800 mg BID or valacyclovir 500 mg PO BID or famciclovir 250–500 mg PO BID × ≥ 1 month. Not necessary if receiving prophylaxis for CMV |
| Aspergillus sp. (Also see Chapters 11 and 25) | |
| Livera | Lipid formulation of amphotericin B (3–5 mg/kg/day) or an echinocandin. Duration: initial hospital stay or for 4 weeks post-transplant. Risk factors: retransplantation, renal failure requiring renal replacement therapy, reoperation, transplant for fulminant hepatic failure |
| Lunga | Voriconazole 200 mg PO BID or inhaled amphotericin B 10–20 mg BID or inhaled ABLC 50 mg/day × 4 days followed by 50 mg/week or inhaled L-AmB 25 mg three times per week for the first 60 days after transplantation, 25 mg /week between 60 and 180 days, and 25 mg once every 2 weeks thereafter or itraconazole 200 mg PO BID. Duration is guided by airway inspection, surveillance respiratory cultures, and risk factors Risk factors include: Aspergillus colonization, CMV, rejection, airway ischemia |
| Hearta | Itraconazole 200 mg PO BID or voriconazole 200 mg PO BID for 50–150 days Risk factors: Aspergillus colonization, CMV disease, renal replacement therapy |
| Candida sp. | |
| Liver | Fluconazole 200-400 mg IV/PO daily or echinocandin Risk factors: reoperation; retransplantation; renal failure; massive transfusion, biliary complications, Candida colonization. Duration: 4 weeks but adjust according to ongoing risk Observing liver transplant recipients with low risk for invasive fungal infection is safe. Use of fluconazole prophylaxis is associated with increased rate of non-albicans Candida infections |
| Small bowel | Fluconazole 200-400 mg IV/PO daily × 4 weeks but adjust according to ongoing risk; continue until anastomosis is healed and rejection is not present Consider use of echinocandin or L-AmB if risk factors for non-albicans Candida are present |
| Pancreas | Can consider fluconazole 200–400 g IV/PO daily for patients with risk factors including colonization, intra-abdominal abscess, vascular thrombosis, and pancreatitis Optimal duration: adjust according to risk factors Consider use of echinocandin or L-AmB if risk factors for non-albicans Candida are present |
| Kidney, heart, lung | No recommendation for Candida prophylaxis |
| Coccidioides immitis – all organs | If there is past history of Coccidioides infection or POSITIVE serologies, give fluconazole 200–400 mg IV/PO daily Same regimen for active infection/positive serologies in organ donor Duration: unknown, may be indefinite in some |
| Pneumocystis jiroveci – all organs | First line: TMP-SMX 1 SS tab PO daily or 1 DS tab PO three times/weekb. Duration: for renal and liver, 6–12 months; for lung, lifelong; for heart, may depend on risk of toxoplasmosis Second line: dapsone 50–100 mg PO daily or atovaquone 1500 mg PO daily or aerosolized pentamidine 300 mg q3-4 weeks. Daily TMP-SMX regimens may be effective for prevention of other post-transplant infections, such as Toxoplasma, Nocardia, Listeria, common respiratory, urinary, and GI pathogens. Dapsone is contraindicated in G6PD deficiency |
| Toxoplasma gondii – heart (D+/R− or R+) | First line: TMP-SMX 1 SS tab PO daily or 1 DS tab PO three times/week. If D+/R− for Toxoplasma, can consider 1 DS tab PO daily, but preceding doses should be adequate. Optimal duration unknown; lifelong for D+/R− Second line: pyrimethamine and folinic acid. |
ABLC, amphotericin B lipid complex; BID, twice daily; CMV, cytomegalovirus; D+/R−, donor positive/recipient negative; GI, gastrointestinal; anri-HBc, hepatitis B core antibody; HBV, hepatitis B virus; HSV, herpes simplex virus; Ig, immunoglobulin; L-AmB, liposomal amphotericin B; PO, by mouth; QD, once a day; QID, four times daily; R+, recipient positive; TID, three times daily; TMP-SMX, trimethoprim- sulfamethoxazole; VZV, varicella zoster virus.
aFor all organs, target prophylaxis for high-risk patients.
bDS, double strength: TMP, 160 mg/SMX, 800 mg; SS, single strength: TMP 80 mg/SMX 400 mg.
References: [1] Am J Transplantation 2009; 9(s4): S78; [2] Am J Transplantation 2009; 9(s4): S116; [3] Am J Transplantation 2009; 9(s4): S108; [4] Am J Transplantation 2009; 9(s4): S104; [5] Am J Transplantation 2009; 9(s4): S180; [6] Am J Transplantation 2009; 9(s4): S173; [7] Am J Transplantation 2009; 9(s4): S199; [8] Am J Transplantation 2009; 9(s4): S227; [9] Am J Transplantation 2009; 9(s4): S234.