A 55-year-old man is evaluated prior to hospital discharge. The patient underwent allogeneic renal transplantation for end-stage renal disease 5 days ago. His postoperative course was uncomplicated, and the transplanted kidney is functioning well. The patient is on maintenance immunosuppression with prednisone and tacrolimus. Temperature is 36.6 C (97.9 F), blood pressure is 130/65 mm Hg, pulse is 80/min, and respirations are 14/min. The surgical wound is healing well with no signs of infection. Which of the following should be added to this patient's medication regimen to prevent opportunistic infections?
Patients who receive solid organ transplantation require high-dose immunosuppressant medication to prevent organ rejection. This creates an immunocompromised state with a high risk for opportunistic infection, most notably Pneumocystis pneumonia (PCP) and cytomegalovirus.
Oral trimethoprim-sulfamethoxazole (TMP-SMX) is the most effective and well-tolerated medication for PCP prophylaxis (patients with sulfa allergy should undergo desensitization if possible). TMP-SMX also has efficacy against most strains of Listeria monocytogenes and Toxoplasma gondii, as well as many common infections of the upper respiratory, gastrointestinal, and urinary systems. Because immunosuppressive regimens are generally tapered over time, patients can often stop TMP-SMX prophylaxis 6-12 months after transplant.
Other potential infections are also commonly addressed in the peritransplant period. Vaccinations for pneumococci and hepatitis B are typically given prior to transplant to ensure an adequate immune response, and an inactivated, intramuscular influenza vaccine is usually given yearly. Many patients also receive prophylaxis with ganciclovir or valganciclovir for cytomegalovirus, depending on the serostatus of the donor and recipient.
(Choice A) Azithromycin was previously used in patients with advanced AIDS (CD4 counts <50 mm3) to prevent Mycobacterium avium complex (MAC), but this medication is no longer recommended due to the low overall incidence of MAC, cost, and risk of antimicrobial resistance. MAC prophylaxis is not typically required in patients who have had solid organ transplants.
(Choice B) Fungal prophylaxis is required in patients with some solid organ transplantations (eg, lung, liver) but is not usually needed in patients with renal transplants.
(Choices C and D) Influenza and pneumococcal vaccines are preferred to oseltamivir and penicillin for prophylaxis. In addition, patients receiving immunosuppressant medications often have penicillin-resistant Streptococcus. Penicillin is sometimes used for secondary prophylaxis in patients with a history of acute rheumatic fever.
(Choice F) Varicella zoster vaccines are not usually administered in the immediate posttransplant period due to an increased risk of organ rejection and a reduced ability to generate an immune response (because of immunosuppressive medication).
Educational objective:
Oral trimethoprim-sulfamethoxazole is the primary agent used for prophylaxis for Pneumocystis pneumonia in patients who have had solid organ transplantation. Many patients also require cytomegalovirus prophylaxis with ganciclovir or valganciclovir.