Transplant Nursing Complications Infectious Diseases FINAL

TRANSPLANT NURSING
Complications of Infectious Disease
Copyright 2017. OnCourse Learning Corporation. All rights reserved.

Infectious Complications
Who needs to be evaluated for infection?
Organ Transplant
donors recipients
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•  Why is the evaluation of infectious disease

important prior to receiving a transplant?
–  Discovering contraindication for transplant
–  Treatment of active infection
–  Develop prophylactic management post-transplant

•  What is the timing for opportunistic infection to

occur?
–  Within the first month post-transplant
•  Infection spread from donor allograft
•  Infection from surgery or medical procedures
•  Pre-existing infections

•  Why are donor-transmitted infections a concern?

–  Associated with significant recipient morbidity and mortality
–  Public Health Service (PHS) developed guidelines to
minimize risk of HIV transmission and to monitor recipients
following transplantation of “high-risk” organs

•  Who are high risk donors?

–  Having sex with known or suspected person with HIV, HB or
HCV infection in last 12 months
–  Been in jail for more than 72 hours in last 12 months
–  Newly diagnosed or been treated for STD in last 12 months
–  Have injected drugs by IV, IM or SQ route for non-medical
reasons in last 12 months

What are the three periods of

post-transplant infection risk?
Early Intermediate Late

(days 0 to 30) (months 1 to 6) (> 6 months)

•  What is the early period of post-transplant risk?

–  Infection from either donor or recipient
–  Infectious complications from surgery and or hospitalization


•  What is the intermediated period of post-transplant

risk?
–  Highest risk for developing opportunistic infections
–  Reflective of local epidemiology, immunosuppression and
antimicrobial prophylaxis


•  What is the late period post-transplant risk?

–  Stable and reduced levels of immunosuppression for most patients
–  Subject to community-acquired pneumonias and late viral
infections
–  Patients with suboptimal graft function require higher than normal
levels of immunosuppression and are at highest risk for
opportunistic infections and severed illness


•  What infectious complications generally develop 2-6

months after transplant?
–  Reactivation of latent organisms
•  HSV, CMV, EBV
–  Community-acquired pathogens
–  Food-borne illnesses
–  Exposure to organisms while immunosuppressed

•  Which infections are patients

most vulnerable to >6
months following transplant?
–  Community acquired
infections (viruses)
–  Appearance of clostridium
difficile (colitis)
–  Reactivation of chronic viral
infection from host or donor
graft (HSV, EBV)
Abdominal x-ray in colitis

•  What increases the risk of a transplant patient

developing infection?
–  Pre-existing medical conditions
–  Current immunosuppressive medications
–  Disruption of skin barriers with invasive devices
–  Infectious exposures in the hospital and community

•  Where are patients exposed to potential pathogens?

–  Pre-transplant
–  In the hospital environment
–  Community
•  Airborne viruses
•  Food borne illness

•  What are clinical manifestations of infection?

–  Usual signs of infection may include:
•  Fever
•  Tachycardia
•  Hypotension can occur as a result of septic shock
–  Usual signs of infection may be replaced by non-specific
symptoms
•  Fever without localizing findings or fever with elevated WBC count
•  Anemia may occur as a result of thrombocytopenia and disseminated
intravascular coagulation (DIC)

•  Why is the onset of symptoms important to

recognize?
–  Determination of specific line of treatment:
•  Many bacterial infections will appear 24-48 hours post-
transplant
•  Reactivation of latent viruses in the host may take months

•  What are means to reduce the

risk of infection?
–  Frequent hand washing
–  Percutaneous exposures
•  Avoid practices that represent a
break in skin
–  Pet safety and animal contact
•  Wash hands
•  No birds as pets
–  Safe sex practice

•  Which viral pathogens commonly cause infection in

transplant patients?
–  Adenoviruses
–  Cytomegalovirus (CMV)
–  Epstein Barr (EBV)
–  Herpes simples (HSV)
–  Hepatitis A,B,C
–  Influenza viruses
–  Varicella
–  BK
–  Parvovirus

•  What bacterial infections occur most common in

–  Gram negative (-) bacterium
–  Gram positive (+) bacterium
–  Mycobacterium
–  Pseudomonas

•  Which fungal infections are most common in

–  Aspergillus
–  Candida
–  Cryptococcus
–  Histoplasmosis
–  Pneumocystis carinii

•  What parasitic infections may appear in the post-

transplant patient?
–  Cryptosporidium
–  Strongyloides
–  Toxoplasma gondii

•  What is important to know about the development of fever?

–  Onset of fever following transplant may determine causative
factors based upon timing of opportunistic infection

•  What can be a differential diagnoses for fever of

unknown origin?
–  CMV infection
–  Cryptococcal infection
–  EBV infection
–  Pneumocystis

•  Why is it sometimes difficult to identify developing

infections?
–  Prescribed immunosuppressive agents
–  Fever appearing from other developing processes (DVT,
infusion reaction, tumor causing hyperthermia)
–  Reactivation of latent infections not causing fever
–  Rejection

•  What factors need to be considered in diagnosing

cause of infection?
–  Type of organ transplant
–  Surgical history (invasive devices, ICU)
–  Exposure to pathogens post-transplant
–  Pre-transplant evaluation and medical history
–  Maintenance of immunosuppressive drugs

•  What is the difference between presence of

“disease” and active infection?
–  Infection can be present in a person and be in a latent stage
with out symptoms
–  Disease is considered present when the patient has active
signs and symptoms
–  Transplant patients are at risk for diseases to
progress to an active infection when they are
immunocompromised

What transplant population is at highest risk of developing CMV?
CMV (-)
CMV (+) pa>ents that
pa>ents given
received an organ
immunosuppressive
from a CMV (+)
globulins
donor

•  Why is cytomegalovirus
(CMV) such an important
pathogen to understand?
–  50% of transplant patients
become positive with CMV
replication post-transplant
50% of
–  Generally affecting transplant
transplant
recipients in the first month patients become
–  Can affect every organ and positive with
system of the body CMV replication
post-transplant

•  What S&S will developing CMV virus have on the

transplant patient?
–  Fever
–  Shortness of breath
–  Malaise
–  Abdominal cramps, nausea and vomiting
–  Alteration in lab values (high LFTs, low WBCs) can cause
rejection of the organ
–  Lungs can develop pneumonitis, bronchiolitis obliterans

•  What medications are given as prophylaxis for CMV

infection?
–  Ganciclovir 5mg/kg IV q12 for 7-14 days, then 5mg/kg daily
until level of immunosuppression is reached

•  What transplant population is at

higher risk for developing Epstein
Barr Virus?
–  Most individuals are seropositive for
EBV that will reactivate following
transplant with immunosuppressive
therapies
–  Primary infection community acquired
in those seronegative within 6 months
following transplant

•  What signs and symptoms may develop in a patient

with active EBV infection?
–  Fever
–  Sore throat
–  Abdominal pain (splenomegaly)
–  Enlarged lymph nodes
•  What medications are given prophylactically to

reduce incidence of EBV infection?
–  Ganciclovir 5mg/kg IV q12 for 7-14 days, then 5mg/kg daily
until level of immunosuppression is reached

•  Why is herpes simplex virus (HSV) an infection

needing prophylactic treatment?
–  Approximately 80% of adults are HSV (+)
–  Virus reactivates in 40% of transplant patients one month
post-transplant
–  Highest incidence in renal transplant patients

•  What is BK virus?
–  Approximately 80% of the general adult population is
seropositive
–  Viruses tend to persist in the kidneys, ureters, brain and
spleen
–  Recipients may have primary and reactivation infections
–  Risk factors include: HLA mismatches

•  What contributes to hepatic infections occurring in

the post-transplant patient?
–  Viruses:
•  Hepatitis B, C
–  Medications causing hepatotoxicity:
•  Immunosuppressants
•  Antihypertensives
•  Antimicrobials

•  What treatment is used for

post-transplant liver disease/
infection?
–  Administration of immune
globulins
–  Administration of interferon
–  Administration of Amphotericin-B
(disseminated aspergillus
infection)

•  Why do liver transplant patients have a higher

incidence of invasive fungal infection?
–  Aspergillus disseminates to liver after lung
–  Liver transplant necessary for hepatic failure
–  Comorbidity of CMV infection

•  The transplant nurse should be aware of what

information concerning bacterial infections?
–  Associated with increased mortality rates
–  Commonly occur post-operatively at the site
–  Bacterial pneumonia is the No. 1 most common problem in
organ recipients

•  What is clostridium difficile infection?

–  Thought to be caused by antibiotic therapy disrupting the
normal flora present in the bowel
–  Symptoms are diarrhea with strong odor, abdominal
cramping and may be bloody
–  Accompanied by abdominal cramping

•  What is the treatment of choice for C. difficile

infection?
–  Metronidazole (Flagyl) 500 mg by mouth TID for 14 days or
500mg IV q8 hours
–  Vancomycin 10 mg/kg/dose,125-250 mg by mouth q6
hours for 14 days

•  What is an additional bacterial

infection?
–  Tuberculosis
•  Worldwide incidence in transplant
recipients
–  Developed countries: 1 – 6%
–  Remainder of world: up to 15%
•  Mortality in transplant recipients: up to
40%
•  Clinical manifestations: nonproductive
cough, dyspnea, chest pain, fever,
excessive sweating, and weight loss

•  What are risk factors to colonizing vancomycin-

resistant enterococcus (VRE)?
–  Exposure to others with VRE or that have been in contact
with VRE
–  Immunosuppressive therapy
–  Invasive medical procedures and monitoring devices
–  Severity of illness post-transplant and comorbidity of
disease
–  Lengthy course of antibiotic use

•  Where is the primary area of colonization of

Methicillin-resistant Staphylococcus aureus (MRSA)?
–  Skin
–  Nasopharynx

•  What are treatment options for transplant patients

with MRSA?
–  Vancomycin IV
–  Linezolid (Zyvox) IV
–  May combine the above with Rifampin if severe infection

•  What is Parvovirus?
–  Commonly causes disease in animals, it was only in 1975
that the first human pathogen of this family was discovered
•  Parvovirus B19 affects humans
•  Causes Fifth Disease
–  Mild rash (slapped-cheek rash) that most commonly affects children
–  Can cause painful, swollen joints (polyarthropathy)
•  Transmission occurs through respiratory secretions
–  Symptoms include fever, malaise, headache, nausea and
rash
–  Treatment: high dose immunoglobulin therapy (IVIG) in
immunocompromised patients

•  What is the most common

bacteria to cause central
nervous system infection in
–  Listeriosis
•  Contracted by ingestion of food
contaminated with Listeria
monocytogenes

•  What is important information to know about fungal

infections in the post-transplant patient?
–  Highest rates of mortality in post-transplant patients with
less incidence than viral or bacterial infection
–  Most common portal of entry is respiratory tract

•  Who is at highest risk of contracting a fungal

infection?
–  Can occur in up to 50% of liver transplant patients
–  6 months to several years post-transplant with
immunosuppressive therapy
–  Patients with other viral infections (CMV, EBV)
–  Patients receiving high-dose corticosteroid therapy
–  Use of broad-spectrum antibiotics

•  What is the most common fungal infection that also

carries the highest mortality rate?
–  Aspergillus
•  Usually begins as a lung infection
•  Mortality rates from 70%-90% with invasive disease
•  Estimated 20% of post-transplant patient deaths within 1 year
attributed to aspergillosis

•  Which parasitic infection is a post-transplant patient

most likely to develop?
–  Toxoplasmosis gondii
•  Reactivation from latent infections
•  Infection causes heart, CNS or pulmonary symptoms
–  Cryptosporidium

•  What is the most common

infection in lung transplant
patients?
–  Bacterial pneumonia
–  CMV infection (highest mortality)
–  Impaired lung function and
inflammation post-transplant
contribute to development of
infection
Pneumonia

•  What is the most common infection in heart

–  Bacterial pneumonia (r/t prolonged ventilator use)
–  CMV pneumonitis
–  Toxoplasmosis

•  Heart transplant patients presenting with infection

may display:
–  Fever
–  Respiratory difficulties or failure
–  Chest discomfort at incision
–  Obvious purulent drainage

•  Which type of infection are kidney transplant

patients susceptible to?
–  Bacterial UTI
–  Infection at surgical wound
–  Intra-abdominal infection secondary to surgery

•  Why are kidney transplant patients at high risk of

bacterial UTI infection?
–  Catheterization use
–  Renal insufficiency
–  Urine leakage following surgery
–  Use of immunosuppressive drugs

•  How would a patient present with a

urinary tract infection?
–  Decrease in graft function
–  Fever
–  Pain
–  (+)WBC, RBC in urine specimen
–  **Patients may be asymptomatic with
prophylaxis of TMP-SMX

•  What are the most common infections in liver

–  Bacterial infections
–  Post-operative wound infections
–  Abscess (liver or abdominal)
–  Peritonitis
–  Biliary infection

•  What laboratory findings would you expect in

someone developing a liver infection?
–  Increased bilirubin
–  Increased LFTs
–  Increased alkaline phosphatase
–  Leukocytosis

•  Prevention of infection
–  Hand washing techniques
–  Awareness of CMV status of patient and donor
–  Educate patient and family on universal precautions
–  Knowledge of immunosuppressive medication management
of patient

•  What prophylaxis against infection can take place

following date of transplant?
–  Keep vaccinations up to date
•  Pneumococcal vaccine
•  Tetanus boosters
•  Influenza vaccines
–  Proper understanding of medication management,
immunosuppressants

Bibliography
•  Bouza E, Loeches B, Munoz P. Fever of unknown origin in solid

organ transplant recipients. Infect Dis Clin North Am.
2007;21(4):1033-1054.
•  Kumar, D. &. Humar, A. The AST Handbook of Transplant
Infections. West Sussex: Wiley-Blackwell; 2011.
•  Ohler L, Cupples S. Core Curriculum for Transplant Nurses.
Second ed. St. Louis, MO: Mosby; 2016.
•  Razonable RR, Eid AJ. Viral infections in transplant recipients.
Minerva Med. 2009;100(6):479-501.
•  Snydman DR, Limaye AP, Potena L. Zamora MR. Update and
review: state-of-the-art management of cytomegalovirus
infection and disease following thoracic organ transplantation.
Transplant Proc. 2011;43(3 Suppl):S1-S17.

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TRANSPLANT NURSING

Complications of Infectious Disease

Copyright 2017. OnCourse Learning Corporation. All rights reserved.

Who needs to be evaluated for infection?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 2

• Why is the evaluation of infectious disease

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 3

• What is the timing for opportunistic infection to

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 4

• Why are donor-transmitted infections a concern?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 5

• Who are high risk donors?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 6

What are the three periods of

Early Intermediate Late

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• What is the early period of post-transplant risk?

Early Intermediate Late

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 8

• What is the intermediated period of post-transplant

Early Intermediate Late

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 9

• What is the late period post-transplant risk?

Early Intermediate Late

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 10

• What infectious complications generally develop 2-6

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 11

• Which infections are patients

Abdominal x-ray in colitis

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 12

• What increases the risk of a transplant patient

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 13

• Where are patients exposed to potential pathogens?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 14

• What are clinical manifestations of infection?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 15

• Why is the onset of symptoms important to

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 16

• What are means to reduce the

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 17

• Which viral pathogens commonly cause infection in

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 18

• What bacterial infections occur most common in

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 19

• Which fungal infections are most common in

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 20

• What parasitic infections may appear in the post-

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 21

• What is important to know about the development of fever?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 22

• What can be a differential diagnoses for fever of

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 23

• Why is it sometimes difficult to identify developing

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 24

• What factors need to be considered in diagnosing

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 25

• What is the difference between presence of

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 26

What transplant population is at highest risk of developing CMV?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 27

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 28

• What S&S will developing CMV virus have on the

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 29

• What medications are given as prophylaxis for CMV

•  Why is the evaluation of infectious disease

•  What is the timing for opportunistic infection to

•  Why are donor-transmitted infections a concern?

•  Who are high risk donors?

•  What is the early period of post-transplant risk?

•  What is the intermediated period of post-transplant

•  What is the late period post-transplant risk?

•  What infectious complications generally develop 2-6

•  Which infections are patients

•  What increases the risk of a transplant patient

•  Where are patients exposed to potential pathogens?

•  What are clinical manifestations of infection?

•  Why is the onset of symptoms important to

•  What are means to reduce the

•  Which viral pathogens commonly cause infection in

•  What bacterial infections occur most common in

•  Which fungal infections are most common in

•  What parasitic infections may appear in the post-

•  What is important to know about the development of fever?

•  What can be a differential diagnoses for fever of

•  Why is it sometimes difficult to identify developing

•  What factors need to be considered in diagnosing

•  What is the difference between presence of

•  What S&S will developing CMV virus have on the

•  What medications are given as prophylaxis for CMV

•  What transplant population is at

•  What signs and symptoms may develop in a patient

•  What medications are given prophylactically to

•  Why is herpes simplex virus (HSV) an infection

•  What contributes to hepatic infections occurring in

•  What treatment is used for

•  Why do liver transplant patients have a higher

•  The transplant nurse should be aware of what

•  What is clostridium difficile infection?

•  What is the treatment of choice for C. difficile

•  What is an additional bacterial

•  What are risk factors to colonizing vancomycin-

•  Where is the primary area of colonization of

•  What are treatment options for transplant patients

•  What is the most common

•  What is important information to know about fungal

•  Who is at highest risk of contracting a fungal

•  What is the most common fungal infection that also

•  Which parasitic infection is a post-transplant patient

•  What is the most common

•  What is the most common infection in heart

•  Heart transplant patients presenting with infection

•  Which type of infection are kidney transplant

•  Why are kidney transplant patients at high risk of

•  How would a patient present with a

•  What are the most common infections in liver

•  What laboratory findings would you expect in

•  What prophylaxis against infection can take place

•  Bouza E, Loeches B, Munoz P. Fever of unknown origin in solid