Effective prevention, diagnosis, and treatment of infectious diseases after transplantation are key factors contributing to the success of organ transplantation. Most transplant patients experience different kinds of infections during the first year after transplantation. Children are at particular risk of developing some types of infections by virtue of lack of immunity although they may be at risk for other types due the effect of immunosuppressive regimens necessary to prevent rejection. Direct consequences of infections result in syndromes such as mononucleosis, pneumonia, gastroenteritis, hepatitis, among other entities. Indirect consequences are mediated through cytokines, chemokines, and growth factors elaborated by the transplant recipient in response to microbial replication and invasion, which contribute to the net state of immunosuppression among other effects. This review summarizes the major infections that occur after pediatric organ transplantation, highlighting the current treatment and prevention strategies, based on the available data and/or consensus.
Organ transplantation is the most practical means of rehabilitating patients with a variety of forms of end organ dysfunction. This procedure is arguably the outstanding clinical biomedical accomplishment of the last 3 decades. Potent immunosuppressive drugs have dramatically reduced the incidence of rejection of transplanted organs, but have also increased the susceptibility of patients to opportunistic infections. Thus, the success of organ transplantation is dependent in part on effective prevention, diagnosis, and treatment of infectious diseases after transplantation. To this end, emphasis is increasingly being placed on prevention. Most transplant patients will have evidence of microbial invasion in the first year after transplant. The effects of this microbial invasion are diverse, resulting in direct and indirect consequences. The direct consequences result in a variety of clinical infectious disease syndromes such as mononucleosis, pneumonia, gastroenteritis, hepatitis, among other entities. The indirect consequences are mediated through cytokines, chemokines, and growth factors elaborated by the transplant recipient in response to microbial replication and invasion, which contribute to the net state of immunosuppression, the pathogenesis of acute and chronic allograft injury, and in some cases, the development of lymphoproliferative or malignant disorders.
General principles and risk factors for infection
The risk of infection in the solid organ transplant patient is largely determined by the interaction of 3 factors: technical/anatomic factors that involve the transplant procedure itself, and the perioperative aspects of care such as the management of vascular access, drains, and the endotracheal tube; environmental exposures ( Box 1 ); and the patient’s net state of immunosuppression ( Box 2 ). In the case of technical/anatomic mishaps, the best way to prevent infection is to correct the anatomic abnormality under coverage of appropriate antimicrobial therapy as antimicrobial treatment alone will not eliminate the risk of developing recurrent infections related to the uncorrected problem. As a consequence, the transplant recipient remains at high risk of subsequent infections with an increased risk of developing antimicrobial resistance until successful correction of the underlying abnormality.
- A.
In the community
- 1.
Mycobacterium tuberculosis
- 2.
Geographically restricted systemic mycoses
Blastomycosis, coccidioidomycosis, histoplasmosis
- 3.
Strongyloides stercoralis
- 4.
Respiratory viruses
Influenza
Parainfluenza
Respiratory syncytial virus
Adenoviruses
- 5.
Infections acquired by the ingestion of contaminated food/water
Salmonella species
Campylobacter jejuni
Listeria monocytogenes
Giardia lamblia
- 6.
Environmental fungi ( Aspergillus species and others)
- 7.
Vector-borne (eg, West Nile virus)
- 1.
- B.
In the hospital
- 1.
From the contaminated air
Aspergillus species
Pseudomonas aeruginosa and other gram-negative bacilli
- 2.
From contaminated potable water
Legionella pneumophila
Other Legionella species
- 3.
Unwashed hands of medical personnel
Candida species (including azole resistant)
Methicillin-resistant Staphylococcus aureus
Vancomycin-resistant enterococci
Highly resistant gram-negative bacilli
- 1.
- C.
Global travel (selected examples only)
- 1.
Gastrointestinal bacterial and viral pathogens
Salmonella , Shigella , Campylobacter , Vibrio
Escherichia coli (multiple types)
Viral gastroenteritis (eg, on cruise ships)
- 2.
Parasitic infections
Malaria
Strongyloidiasis and other intestinal parasitic diseases
Leishmaniasis
- 3.
Respiratory infections
SARS coronavirus
- 4.
Viral hepatitis
Hepatitis A, E or hepatitis B for long-term travel or residence
- 1.
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