Solid organ transplant patients

PJP prophylaxis is indicated in all patients.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications. For antimicrobial regimens, see here.

Duration of PJP prophylaxis:

The optimal duration of PJP prophylaxis is uncertain. Assess the patient’s level of immune compromise and risk of infection before stopping PJP prophylaxis. Review the benefit of ongoing prophylaxis regularly.

Continue PJP prophylaxis for at least 6 to 12 months after transplant or following treatment of rejection episodes, or indefinitely if the patient has significant ongoing immunosuppression. Some centres routinely continue prophylaxis indefinitely—consult local protocols.

Indications for CMV prophylaxis are beyond the scope of these guidelines—refer to local protocols. The choice between universal prophylaxis and pre-emptive treatment depends on several factors, including the availability of CMV monitoring, and the risk of CMV reactivation.

For universal prophylaxis, start on day 10 after transplant. For antiviral regimens, see Universal prophylaxis.

For pre-emptive treatment, start when indicated based on viral load or the rate of change in viral load. For antiviral regimens, see Pre-emptive treatment.

Duration of CMV prophylaxis:

Assess the patient’s level of immune compromise and risk of infection before stopping CMV prophylaxis.

For universal prophylaxis, continue for 3 to 6 months after transplant, or for 1 to 3 months following treatment of rejection episodes (eg with antilymphocyte therapy).

For pre-emptive treatment, continue until one or two CMV DNA nucleic acid amplification (eg polymerase chain reaction [PCR]) test results are negative—consult local protocols.

Some transplant centres give HSV prophylaxis to patients who are HSV IgG positive—consult local protocols. HSV prophylaxis is not required if the patient is receiving valganciclovir or ganciclovir for CMV prophylaxis.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications. For antiviral regimens, see here.

Duration of HSV prophylaxis:

Continue HSV prophylaxis for 1 month. Restart prophylaxis during treatment of rejection episodes and continue for 1 month.

Suppressive therapy:

If the patient has recurrent oral mucocutaneous or genital HSV infection, suppressive therapy is recommended. See Recurrent oral mucocutaneous herpes and Suppressive therapy for genital herpes.

Perform baseline Strongyloides serology in patients with a past or present epidemiological risk of acquiring S. stercoralis [NB2].

S. stercoralis prophylaxis (or pre-emptive treatment) is recommended for:

• patients with positive Strongyloides serology
• patients with negative serology who live in or visit an area in which S. stercoralis infection is endemic.

For antimicrobial regimens and duration of therapy, see here.

Perform baseline B. pseudomallei serology in patients who live or have lived in an endemic region such as tropical regions of Australia [NB3].

B. pseudomallei prophylaxis is recommended for:

• patients with positive B. pseudomallei serology
• patients with a history of melioidosis (B. pseudomallei infection) but no clinical evidence of current disease.

Consider giving primary prophylaxis during the wet season [NB4] to patients with negative B. pseudomallei serology who live in or visit an endemic area.

For antimicrobial regimens and duration of therapy, see here.

Hepatitis B virus and tuberculosis reactivation can occur—some patients require antimicrobial treatment. See Hepatitis B virus prophylaxis and Prevention of tuberculosis.

The risk of Listeria monocytogenes meningitis is increased. Consult local protocols and consider dietary and food safety measures to prevent L. monocytogenes infection [NB5].

PJP prophylaxis is indicated in all patients.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications. For antimicrobial regimens, see here.

Duration of PJP prophylaxis:

The optimal duration of PJP prophylaxis is uncertain. Assess the patient’s level of immune compromise and risk of infection before stopping PJP prophylaxis. Review the benefit of ongoing prophylaxis regularly.

Continue PJP prophylaxis for at least 6 months after transplant or following treatment of rejection episodes, or indefinitely if the patient has significant ongoing immunosuppression.

Indications for CMV prophylaxis are beyond the scope of these guidelines—refer to local protocols. The choice between universal prophylaxis and pre-emptive treatment depends on several factors, including the availability of CMV monitoring, and the risk of CMV reactivation.

For universal prophylaxis, start on day 10 after transplant. For antiviral regimens, see Universal prophylaxis.

For pre-emptive treatment, start when indicated based on viral load or the rate of change in viral load. For antiviral regimens, see Pre-emptive treatment.

Duration of CMV prophylaxis:

Assess the patient’s level of immune compromise and risk of infection before stopping CMV prophylaxis.

For universal prophylaxis, continue for 3 to 6 months after transplant, or for 1 to 3 months following treatment of rejection episodes (eg with antilymphocyte therapy).

For pre-emptive treatment, continue until one or two CMV DNA nucleic acid amplification (eg polymerase chain reaction [PCR]) test results are negative—consult local protocols.

Some transplant centres give HSV prophylaxis to patients who are HSV IgG positive—consult local protocols. HSV prophylaxis is not required if the patient is receiving valganciclovir or ganciclovir for CMV prophylaxis.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications. For antiviral regimens, see here.

Duration of HSV prophylaxis:

Continue HSV prophylaxis for 1 month. Restart prophylaxis during treatment of rejection episodes and continue for 1 month.

Suppressive therapy:

If the patient has recurrent oral mucocutaneous or genital HSV infection, suppressive therapy is recommended. See Recurrent oral mucocutaneous herpes and  Suppressive therapy for genital herpes.

Antifungal prophylaxis is indicated for patients at the highest risk for invasive yeast or mould infection—refer to local protocols or seek expert advice. Some centres give yeast prophylaxis because infection with Candida species is more common. However, invasive aspergillosis has higher morbidity and mortality. Examples of patients at the highest risk of fungal infection include patients undergoing a repeat transplant, patients with fulminant liver failure, and patients with kidney failure requiring renal replacement therapy.

Start prophylaxis early in the postoperative period and refer to local protocols for drug choice and duration of therapy.

Perform baseline Strongyloides serology in patients with a past or present epidemiological risk of acquiring S. stercoralis [NB2].

S. stercoralis prophylaxis (or pre-emptive treatment) is recommended for:

• patients with positive Strongyloides serology
• patients with negative serology who live in or visit an area in which S. stercoralis infection is endemic.

For antimicrobial regimens and duration of therapy, see here.

Perform baseline B. pseudomallei serology in patients who live or have lived in an endemic region such as tropical regions of Australia [NB3].

B. pseudomallei prophylaxis is recommended for:

• patients with positive B. pseudomallei serology
• patients with a history of melioidosis (B. pseudomallei infection) but no clinical evidence of current disease.

Consider giving primary prophylaxis during the wet season [NB4] to patients with negative B. pseudomallei serology who live in or visit an endemic area.

For antimicrobial regimens and duration of therapy, see here.

Hepatitis B virus and tuberculosis reactivation can occur—some patients require antimicrobial treatment. For details, see Hepatitis B virus prophylaxis and Prevention of tuberculosis.

The risk of Listeria monocytogenes meningitis is increased. Consult local protocols and consider dietary and food safety measures to prevent L. monocytogenes infection [NB5].

PJP prophylaxis is indicated in all patients.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications. For antimicrobial regimens, see here. PJP prophylaxis with trimethoprim+sulfamethoxazole also provides prophylaxis against Toxoplasma gondii.

Duration of PJP prophylaxis:

The optimal duration of PJP prophylaxis is uncertain. Assess the patient’s level of immune compromise and risk of infection before stopping PJP prophylaxis. Review the benefit of ongoing prophylaxis regularly.

Continue PJP prophylaxis for at least 6 to 12 months after transplant or following treatment of rejection episodes, or indefinitely if the patient has significant ongoing immunosuppression. Most centres routinely continue prophylaxis indefinitely—consult local protocols.

T. gondii prophylaxis is indicated if the recipient is T. gondii IgG negative but the donor is positive. T. gondii prophylaxis is not required if the patient is receiving trimethoprim+sulfamethoxazole for PJP prophylaxis. If the patient is hypersensitive to trimethoprim+sulfamethoxazole and requires prophylaxis for both PJP and T. gondii, see here for regimens.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications.

Duration of T. gondii prophylaxis:

Limited data are available to guide duration of T. gondii prophylaxis—seek expert advice. If the patient is taking trimethoprim+sulfamethoxazole for both PJP and T. gondii prophylaxis, use the duration of PJP prophylaxis as a guide.

Indications for CMV prophylaxis are beyond the scope of these guidelines—refer to local protocols. Pre-emptive treatment is not well studied in heart transplant recipients; universal prophylaxis is the preferred approach.

Start universal prophylaxis on day 1 after transplant. For antiviral regimens, see Universal prophylaxis.

Duration of CMV prophylaxis:

Assess the patient’s level of immune compromise and risk of infection before stopping CMV prophylaxis.

Continue CMV universal prophylaxis for at least 6 months after transplant, or for 1 to 3 months following treatment of rejection episodes (eg with antilymphocyte therapy). Some centres continue CMV prophylaxis indefinitely if there is a serological mismatch between the organ donor and recipient.

Some transplant centres give HSV prophylaxis to patients who are HSV IgG positive—consult local protocols. HSV prophylaxis is not required if the patient is receiving valganciclovir or ganciclovir for CMV prophylaxis.

Start HSV prophylaxis after the transplant when the patient is stable and tolerating oral medications. For antiviral regimens, see here.

Duration of HSV prophylaxis:

Continue HSV prophylaxis for 1 to 3 months. Restart prophylaxis during treatment of rejection episodes and continue for 1 to 3 months.

Suppressive therapy:

If the patient has recurrent oral mucocutaneous or genital HSV infection, suppressive therapy is recommended. See Recurrent oral mucocutaneous herpes and Suppressive therapy for genital herpes.

Perform baseline Strongyloides serology in patients with a past or present epidemiological risk of acquiring S. stercoralis [NB2].

S. stercoralis prophylaxis (or pre-emptive treatment) is recommended for:

• patients with positive Strongyloides serology
• patients with negative serology who live in or visit an area in which S. stercoralis infection is endemic.

For antimicrobial regimens and duration of therapy, see here.

Perform baseline B. pseudomallei serology in patients who live or have lived in an endemic region such as tropical regions of Australia [NB3].

B. pseudomallei prophylaxis is recommended for:

• patients with positive B. pseudomallei serology
• patients with a history of melioidosis (B. pseudomallei infection) but no clinical evidence of current disease.

Consider giving primary prophylaxis during the wet season [NB4] to patients with negative B. pseudomallei serology who live in or visit an endemic area.

For antimicrobial regimens and duration of therapy, see here.

Hepatitis B virus and tuberculosis reactivation can occur—some patients require antimicrobial treatment. For details, see Hepatitis B virus prophylaxis and Prevention of tuberculosis.

The risk of Listeria monocytogenes meningitis is increased. Consult local protocols and consider dietary and food safety measures to prevent L. monocytogenes infection [NB5].

PJP prophylaxis is indicated in all patients.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications. For antimicrobial regimens, see here. PJP prophylaxis with trimethoprim+sulfamethoxazole also provides prophylaxis against Toxoplasma gondii.

Duration of PJP prophylaxis:

The optimal duration of PJP prophylaxis is uncertain. Assess the patient’s level of immune compromise and risk of infection before stopping PJP prophylaxis. Review the benefit of ongoing prophylaxis regularly.

Continue PJP prophylaxis for at least 6 to 12 months after transplant or following treatment of rejection episodes, or indefinitely if the patient has significant ongoing immunosuppression. Most centres routinely continue prophylaxis indefinitely—consult local protocols.

T. gondii prophylaxis is indicated for heart–lung transplant recipients who are T. gondii IgG negative, but the donor is positive. T. gondii prophylaxis is not required if the patient is receiving trimethoprim+sulfamethoxazole for PJP prophylaxis. If the patient is hypersensitive to trimethoprim+sulfamethoxazole and requires prophylaxis for both PJP and T. gondii, see here for regimens.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications.

Duration of T. gondii prophylaxis:

Limited data are available to guide duration of T. gondii prophylaxis—seek expert advice. If the patient is taking trimethoprim+sulfamethoxazole for both PJP and T. gondii prophylaxis, use the duration of PJP prophylaxis as a guide.

Indications for CMV prophylaxis are beyond the scope of these guidelines—refer to local protocols. Pre-emptive treatment is not well studied in lung and heart–lung transplant recipients; universal prophylaxis is the preferred approach.

Start universal prophylaxis on day 1 after transplant. For antiviral regimens, see Universal prophylaxis.

Duration of CMV prophylaxis:

Assess the patient’s level of immune compromise and risk of infection before stopping CMV prophylaxis.

Continue CMV universal prophylaxis for at least 6 months after transplant, or for 1 to 3 months following treatment of rejection episodes (eg with antilymphocyte therapy). Some centres continue CMV prophylaxis indefinitely if there is a serological mismatch between the organ donor and recipient.

Some transplant centres give HSV prophylaxis to patients who are HSV IgG positive—consult local protocols. HSV prophylaxis is not required if the patient is receiving valganciclovir or ganciclovir for CMV prophylaxis.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications. For antiviral regimens, see here.

Duration of HSV prophylaxis:

Continue HSV prophylaxis for 1 to 3 months. Restart prophylaxis during treatment of rejection episodes and continue for 1 to 3 months.

Suppressive therapy:

If the patient has recurrent oral mucocutaneous or genital HSV infection, suppressive therapy is recommended. See Recurrent oral mucocutaneous herpes and Suppressive therapy for genital herpes.

Some centres recommend routine antifungal prophylaxis against mould infection, while others recommend prophylaxis only for high-risk patients—refer to local protocols.

Prophylaxis is typically started on day 1 after transplant or early in the postoperative period. Antifungal regimens vary between centres; see here for example regimens.

Duration of antifungal prophylaxis:

Antifungal prophylaxis is often continued for 3 months; consult local protocols.

Perform baseline Strongyloides serology in patients with a past or present epidemiological risk of acquiring S. stercoralis [NB2].

S. stercoralis prophylaxis (or pre-emptive treatment) is recommended for:

• patients with positive Strongyloides serology
• patients with negative serology who live in or visit an area in which S. stercoralis infection is endemic.

For antimicrobial regimens and duration of therapy, see here.

Perform baseline B. pseudomallei serology in patients who live or have lived in an endemic region such as tropical regions of Australia [NB3].

B. pseudomallei prophylaxis is recommended for:

• patients with positive B. pseudomallei serology
• patients with a history of melioidosis (B. pseudomallei infection) but no clinical evidence of current disease.

Consider giving primary prophylaxis during the wet season [NB4] to patients with negative B. pseudomallei serology who live in or visit an endemic area.

For antimicrobial regimens and duration of therapy, see here.

Hepatitis B virus and tuberculosis reactivation can occur—some patients require antimicrobial treatment. See Hepatitis B virus prophylaxis and Prevention of tuberculosis.

The risk of Listeria monocytogenes meningitis is increased. Consult local protocols and consider dietary and food safety measures to prevent L. monocytogenes infection [NB5].