Any patient with a history of solid-organ transplantation who presents with symptoms of an infection must be evaluated in an aggressive and thorough manner. Appropriate stains and cultures should be obtained to allow identification of bacterial, fungal, and viral pathogens. There should be a low threshold for instituting antimicrobial therapy while awaiting culture results and for admitting patients to the hospital for further evaluation and intravenous antibiotics. Patients with evidence of pulmonary infiltrates but without productive sputum require bronchoscopy with bronchoalveolar lavage and transbronchial biopsy for definitive diagnosis. Pulmonary infections that are frequently encountered include P. carinii, Nocardia, Legionella pneumophilia, and Aspergillus; these require special stains and studies for accurate diagnosis. Patients with gastroenteritis and nausea, vomiting, and/or diarrhea require special attention. Inability to ingest or adequately absorb immunosuppressive medications may result in the development of an episode of rejection. If there is any question about a recipient's ability to maintain adequate oral intake, the patient should be hospitalized and immunosuppressive medications be administered intravenously.
Antibiotic therapy for documented infections should be guided by appropriate culture and sensitivities and must take into account underlying renal insufficiency and potential interactions with cyclosporine or tacrolimus.
Of special note is the risk of CMV infection after cardiac transplantation. CMV is a common virus to which the majority of adults have been exposed, as demonstrated by the presence of anti-CMV IgG antibodies in the serum. Posttransplantation, CMV infections can occur due either to the reactivation of latent virus in a previously infected recipient or the development of a new infection with a different viral strain transmitted with the donor organ. The latter situation is much more serious and potentially life-threatening, particularly in recipients who were CMV-negative prior to transplantation. Routine posttransplant surveillance for CMV infection is performed utilizing serial IgG and IgM antibody testing and throat, urine, and serum buffy coat cultures. The recent development of CMV antigenemia assays has enhanced the early detection of CMV infection. CMV disease can occur in either a mild or severe form. Mild disease is manifested by a flulike illness with low-grade fever, fatigue, malaise, and nausea. Severe disease may include profound leukopenia; pneumonitis; gastroenteritis including epigastric pain, vomiting, and diarrhea; and hepatitis with elevated transaminases. CMV pneumonitis carries a mortality of greater than 50 percent. CMV infection typically occurs 4 to 12 weeks posttransplantation. The diagnosis is made by the demonstration of cytoplasmic inclusion bodies in biopsy specimens of affected organs. Treatment includes the use of intravenous ganciclovir and, in severe cases, intravenous immunoglobulin infusions. Of particular concern is the documented increased incidence of acute rejection complicating acute CMV infections. Therefore, patients with active cMv disease must be monitored carefully for signs and symptoms of rejection. An endomyocardial biopsy should be performed if there is any suspicion of rejection.
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