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Managing the risk for infection is one of the primary tasks in optimizing outcomes for solid organ transplant recipients. Infections such as cytomegalovirus (CMV) and urinary tract infection (UTI) are common causes of morbidity and mortality in this population. For example, UTI affects approximately 80% of recipients of kidney transplantation and represents the cause of hospitalization for sepsis in roughly 30% of these patients. Further, CMV affects between 8% and 32% of patients following kidney, heart, or liver transplantation.1,2
While infection risk is highest during the first year after transplantation, ongoing vigilance is required for the remainder of the patient’s life. However, the “goal is for the recipient to be able to return to their home and live as normal a life as possible with a functioning graft,” according to a paper published online in March 2019 by Robin K Avery, MD, physician and professor of medicine in the division of infectious disease at Johns Hopkins University School of Medicine, and Marian G Michaels, MD, MPH, professor of pediatrics and surgery at the University of Pittsburgh Medical Center (UPMC) and physician at UPMC Children’s Hospital.3
Various “strategies for safe living must be carefully woven into the transplant recipient’s life as they move toward regaining normal function and return to an active and productive life,” the authors stated. Such strategies are the focus of their paper, which is a section of the recently updated American Society of Transplantation Infectious Disease (AST ID) guidelines authored by the AST ID Community of Practice. Numerous other articles within these guidelines focus on specific infections such as CMV, UTI, and pneumonia, whereas the study conducted by Avery and Michaels pertained to managing the risk for infection from a wide range of etiologies.1,3-5
Because randomized controlled trials are not possible in this setting, the recommendations are “based on available knowledge of the mode in which various infectious agents are transmitted, anecdotal clinical experience, the opinions of respected authorities, collections of case reports, and common sense,” they wrote.3 [Editor’s note: There is also a corresponding Patient Brochure in both English and Spanish on the AST website.]
Infectious Disease Advisor interviewed Dr Avery and Dr Michaels to further explore these issues and related implications for clinicians treating solid organ transplant recipients. (Responses were jointly provided by both physicians.)
Infectious Disease Advisor: What are some of the most common sources of infection in organ transplant recipients?
Avery and Michaels: Transplant recipients have weakened immune systems because of the powerful medications they must take to prevent rejection of their transplanted organs. Consequently, there are many potential sources of infection that transplant recipients should know about. Some of these infections can come from the donor, and therefore transplant teams develop protocols to try to minimize this effect.
Some infections are internal — for example, caused by organisms that live on our skin, in our lung airways, and in the intestinal tract — but external environmental exposures are also very important. Transplant recipients should be particularly careful during the first 6 months after the transplant, or after any episode of rejection when they have had increased doses of immunosuppressive medications.
Common external sources of infection include direct contact — often on the hands — with materials such as soil, dirt, and manure; inhalation of aerosolized respiratory viruses and bacteria from sick persons or from fungal spores during gardening, landscaping, or at construction sites; ingestion of contaminated food or water; contact with pets or other animals with an infection; infections transmitted by mosquito or tick bites; and recreational and occupational exposures.
Our goal is to empower transplant recipients and clinicians with information about infection prevention so that transplant recipients can have an improved quality of life and return to activities that are important and meaningful to them in a safe way.
Infectious Disease Advisor: What are examples of some of the measures that patients should take to prevent these infections?
Avery and Michaels: Every person has unique life circumstances that may affect some parts of safe living recommendations. For example, a person living on a farm is going to have unique challenges compared with someone living in an urban environment. Accordingly, early in the process of considering being a transplant recipient, patients and their family should discuss their lifestyle with their transplant team.
However, certain universal themes such as hand washing and avoiding high-risk exposures can be emphasized. Our article gives detailed advice on hand hygiene, ways to avoid acquiring infections through direct contact, prevention of respiratory infections, water and food safety, animal contact and pet safety, safer sexual practices, issues related to work, school, and recreation, and mosquito precautions.
Examples of food precautions include avoiding the following: raw or undercooked meat or eggs, unpasteurized dairy foods (such as soft cheeses), raw or undercooked seafood, raw sprouts, and smoked seafood, among others. It is also very important to heat all leftovers to steaming hot and to wash knives and cutting boards in hot soapy water to avoid cross-contamination from meat to vegetables. Transplant recipients should also be particularly cautious about salad bars, street vendors, pot luck dinners, or picnics where food has stagnated at room temperature for an extended period, or any situation in which the hygiene of food preparers is uncertain. Outbreaks of foodborne infections have been linked to all of these sources.
Transplant recipients should also pay particular attention to food recalls that are reported locally. Infections from food or water contamination can be much more severe or prolonged in a transplant recipient. One specific example is the Listeria spp, which is found in a variety of foods, especially unpasteurized cheeses and deli meats, and can cause meningitis in transplant recipients.
Another example is norovirus, which is best known as the “cruise ship virus,” but is now found throughout the food supply and is the most frequent cause of foodborne infections in the United States. While members of the general population may experience a gastrointestinal-based illness, with vomiting and diarrhea for 1 to 2 days, transplant recipients can develop a severe diarrheal illness that waxes and wanes for months, with weight loss and dehydration and, occasionally, damage to the transplanted organ.
Pets are an important part of many transplant recipients’ lives, and we offer tips to make pet ownership safer. Examples of pet and animal safety include avoiding reptiles, amphibians, chicks, and ducklings because of the increased risk for infection with Salmonella spp and other pathogens and avoiding exotic pets and stray animals. Further, it is not recommended to get a new pet in the first 6 to 12 months post-transplant, or at times of increased immunosuppression.
Ideally, transplant recipients should not handle cat litter, bird droppings, or other animal feces, and should have other individuals do this. If that is not possible, then the transplant recipient should wear disposable gloves and a mask when cleaning up after pets and remember to wash their hands afterwards. All pets should be followed by a veterinarian.
These are just a few examples of the types of advice that can help ward off harmful infections and allow transplant recipients to live safely.
Infectious Disease Advisor: For primary care physicians and others involved in the patient’s care post-transplant, what are ways in which they can support these patients in reducing the risk for infection?
Avery and Michaels: The primary care provider has a very important role to play in the prevention of infections in patients who have received a transplant. While our article does not cover immunizations, as another AST ID Guideline section covers immunizations in detail, pre-transplant immunization is one of the most important ways for a primary care team to help prevent infections after transplantation. As such, immunizations should be updated before transplant whenever possible.
Likewise, while many questions will be directed to the patient’s transplant team during the first year after transplant, over time the primary care provider will increasingly be the first clinician to see the patient for any acute illnesses and will often be asked questions regarding infection exposures and prevention. The primary care physician or provider can reinforce the messages in our article and can communicate rapidly with the transplant team if any infection is detected that requires their involvement. Communication with the transplant team is also necessary when a new medication is initiated because of concerns regarding drug interactions with transplant medications.
The primary care physician should administer a yearly influenza vaccine and can update other immunizations that were not given prior to transplant. Patients should be referred to the other sections of the AST ID Guidelines in the same issue on immunizations and travel and the transplant recipient.6 We highly recommend these as part of safer living strategies.
It’s also important for physicians in the community to recognize that infections in transplant recipients can take unusual forms or can be more prolonged and severe than in the general population. Norovirus diarrhea, for example, frequently goes undiagnosed for long periods of time because clinicians are accustomed to categorizing such infection as rapidly resolving and do not consider it as a cause of protracted diarrhea.
With any unusual syndrome, consultation with the patient’s transplant team and a transplant infectious disease physician is recommended. This is particularly true for patients who are many years post-transplant, who may be regionally removed from their original transplant center and may only travel back there infrequently, if at all.
Infectious Disease Advisor: What are other takeaways for clinicians, remaining research needs in this area, or any other points you would like to mention about the topic?
Avery and Michaels: We would like to have a stronger evidence base for counseling patients regarding the magnitude of the risks associated with their proposed activities — for example, patients who are contemplating returning to work after their transplant in an occupation with potential for infection exposures. More research is needed to try to define these risks more precisely. We do encourage transplant recipients and family members to ask as many questions as possible of their transplant team, whenever necessary, because it’s much better to prevent these severe infections than to treat them. Although not all infections are preventable, following these principles should help to minimize risk and assist transplant recipients in leading the lives they want to lead.
References
1. Goldman JD, Julian K. Urinary tract infections in solid organ transplant recipients: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019;33:e13507.
2. Azevedo LS, Pierrotti LC, Abdala E, et al. Cytomegalovirus infection in transplant recipients. Clinics (Sao Paulo). 2015;70(7):515-523.
3. Avery RK, Michaels MG; AST Infectious Diseases Community of Practice. Strategies for safe living following solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019;33:e13519.
4. Razonable RR, Humar A. Cytomegalovirus in solid organ transplant recipients-guidelines of the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019;33:e13512.
5. Dulek DE, Mueller NJ; AST Infectious Diseases Community of Practice. Pneumonia in solid organ transplantation: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019;33:e13545.
6. Buchan CA, Kotton CN; AST Infectious Diseases Community of Practice. Travel medicine, transplant tourism, and the solid organ transplant recipient-guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019;33:e13529.
