^^ Without prophylaxis, P. jiroveci (formerly Pneumocystis carinii) pneumonia occurs in 5% to 15% of transplant recipients.53 Antipneumocystis prophylaxis is enormously helpful and is generally used in all organ transplant recipients. The duration of prophylaxis is usually 6 to 12 months after transplant, but may be prolonged in highly immunosuppressed patients (i.e., active CMV disease, treatment for rejection) or liver or lung recipients.54 Sulfamethoxazole-trimethoprim is the preferred agent for prophylaxis. One of its major advantages is its relatively broad spectrum of activity. Not only is it effective against Pneumocystis pneumonia, but it also has activity against toxoplasmosis and other common bacterial infections. Patients who have sulfa allergies, glucose-6 phosphate dehydrogenase (G6PD) deficiency, or are unable to tolerate sulfamethoxazole-trimethoprim should be given one of the second-line treatments.9 Unfortunately, the second-line agents are antiparasitics and have no meaningful activity against common bacteria. These agents include dapsone, atovaquone, and pentamidine.
Table 55-7 Prophylactic Options for Pneumocystis jiroveci Pneumonia and CMV
450-WO mg by nikxnh Orttt i diy*
VJ*>Sfli ¡i !<»■ (ViHi/TCt Viiljtxloyii Mine*)
CMVigGtCyioijamiaiYj polyvalent MG
450-WO mg by nikxnh Orttt i diy*
S N^.-^^lïy, c^i 1.000 rrtri J ry irtCfilli three times a day"
The maiimuni ie(c«iinen<3e<l iwai desire infuiioft ¡5 150 mg/kg beginning williln 71 hours of transpiiinlalfcm. Follow up dos« ard lime inteivA depend on Ihelype-ot organ lurripiaiwd.
ywrtoiti upiit (l.i Wt) nAyetosuppiession 45- HJfltJ fttfiflO-lM
(ess 1han 19t) Hcjdmhc (l<f-Ji*>0 Siwnjcli upwt (i Fevers and chills (l-flfci
CMV.iylC*i*i|«k>yiiuy D5-. JCnJtfe-iULTKjlh (SIX? un) 5W. ICO IW) TMP); WVf/f. MctuJJy. WttlriexLuv ùîkî Frktry: S^ilrmli:- Hltfljfti MOO mg v.i.-1, $0 mg Tmtffc 51.(7, sulfanwireuuiofc; TMR iilmethopiim.
*Oi>W idjusTm^ni inquired Innenal Insufficiency. Fiom Krfs. <-A, Sî.
CMV is the most concerning opportunistic pathogen in transplantation due to its association with poor outcomes. 5 CMV infection is present in 30% to 97% of the general population, but CMV disease is typically restricted to immunocompromised hosts.56 The risk of CMV disease is highest among CMV-naive recipients who receive a CMV-positive organ (Donor +/Recipient -).55 Other factors that augment the risk of CMV disease include organ type (lung and pancreas recipients are highest risk) and immunosuppressive agents (ALA use increases risk). CMV disease characteristically occurs within the first 3 to 6 months post-transplantation, but delayed onset disease has been seen in patients receiving antiviral prophylaxis.55
^^ Several antivirals have proven efficacy in preventing and treating CMV.55 Valacyclovir and valganciclovir, prodrugs of acyclovir and ganciclovir, respectively, have improved bioavailability compared to their parent compounds and offer the advantage of less frequent dosing. CMV prophylaxis is classically continued for the first 100 days, or longer, after transplantation. 6,57 Both IV ganciclovir and oral val-ganciclovir may be used for preemptive therapy or for treatment of established CMV disease. The adverse events are similar among these agents and include myelosup-pression and GI effects.9
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