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Over the last half a century, there have been innumerable advances in our understanding of the human immune system. We now have a better understanding not only of the ways our innate and adaptive immune pathways interact to seek out and control infection and malignancy, but we are closer to understanding some of the control mechanisms behind tissue rejection. Organ allograft rejection, with consequent loss of graft function, remains one of the most challenging problems facing solid organ...

The opioid epidemic has resulted in an increase in organ donors with hepatitis C virus (HCV) infection in the United States. With the development of direct-acting antiviral regimens that offer high sustained virologic response rates even in the setting of immunosuppression after transplantation, these HCV-viremic organs are now being offered to transplant candidates with or without preexisting HCV infection. Strategies for HCV treatment with HCV-viremic organs have included delayed and...

Altered mental status is common in the solid organ transplant recipient. A variety of etiologies, including infections, metabolic abnormalities, medications, malignancies, and rejection, can lead to altered mental status in a transplant patient. Timeline after transplantation as well as organ transplanted have significant impact on etiology. Detailed physical examination, comprehensive laboratory evaluation, and in many cases imaging can help elucidate the etiology. Urgent treatment of underlying etiology can improve prognosis.

Solid organ transplantation and hematopoietic cell transplantation are life-saving procedures, yet carry significant infection risk due to the significant and prolonged immunosuppression they entail. Infection prevention strategies using antibiotic prophylaxis can mitigate problems that arise through immunosuppression, especially if clinicians have a keen awareness for local epidemiology and patient-specific microbiological factors. Antifungal prophylaxis, especially in stem cell...

In order to minimize a solid organ transplant (SOT) recipient’s risk for infection and injury, it is important to anticipate the risks post-transplantation inherent in routine and not so routine activities of daily living. The benefits of longevity by virtue of organ transplantation need to be closely protected by education before, during, and after transplantation about potential infectious risks and measures to mitigate such exposures. SOT recipients cannot stand alone in their efforts...

Cytomegalovirus (CMV) is among the most common of infections after transplant. In addition to causing viral infection, it increases the risk for a negative outcome for the organ or bone marrow graft, as well as for higher overall morbidity and mortality. Risk of CMV is especially high in transplant recipients previously nonimmune to the virus. Prevention is key for optimal outcomes, both for individuals and for transplant programs. Optimal disease recognition, diagnostics, prevention, and...

Infectious complications are a major cause of morbidity and mortality in both solid organ and hematopoietic stem cell transplant patients. The risk of infection by common opportunistic pathogens like cytomegalovirus can be mitigated with the optimal use of molecular diagnostics and antiviral prophylaxis. Novel and emerging bacterial, viral, fungal, and parasitic pathogens may be more successfully managed with early diagnosis and therapy. In the care of solid organ and hematopoietic stem cell...

This chapter reviews the epidemiology, clinical impact, diagnosis, prevention, and management of tuberculosis (TB) in solid organ and hematopoietic stem cell transplantation. Given the limitations of screening for latent TB using either the tuberculin skin test or interferon gamma release assays, it is important to also consider exposure history and chest imaging; promising new TB diagnostic strategies are currently under development. The clinical manifestations of active tuberculosis in...

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation will review the current state of the art of donor-derived infections. Specifically, the guideline will summarize standardized definitions and approaches to defining imputability, updated data on the epidemiology of donor-derived infections, and approaches to risk mitigation against transmission of infections. This update will additionally provide guidance on the use of HIV+...

Infectious and noninfectious pulmonary syndromes remain significant contributors to morbidity and mortality after solid organ and hematopoietic stem cell transplantation. Multiple factors increase the risk of pulmonary complications including the surgical trauma related to solid organ transplantation, chemotherapy and radiation prior to hematopoietic stem cell transplant, the degree of immunosuppression, and immune factors contributing to rejection and graft-versus-host disease. The first...

Nontuberculous mycobacteria (NTM) are ubiquitous environmental organisms found in soil and water. The expansion of the transplant population combined with an increase in environmental exposures and improvements in mycobacterial diagnosis has contributed to a rise in the diagnosis of NTM infections among transplant recipients, who are at particular risk for infection as well as increased associated morbidity and mortality.

Cytopenias are a common occurrence in both hematopoietic stem cell and solid organ transplant recipients, particularly in the early post-transplant time period. The etiology is frequently multifactorial, reflecting the simultaneous interplay of infection, immunologic derangements, and medication effects in this patient population. These factors continually change over time, further adding to the complexity of diagnosis and management. Thorough evaluation of the individual’s medical history,...

Transplantation in recent years has become a viable option to treat end stage organ failure in people living with HIV infection. Significant advances in the understanding of appropriate immunosuppression management and infection prevention have resulted in graft and patient survival comparable to HIV-negative recipients in many cases. Given the higher incidence of end stage organ disease in HIV positive patients, particularly liver cirrhosis and dialysis dependent renal failure, transplant...

Characteristics of transplant candidates can significantly impact risk for infection after transplantation and immunosuppression start. These characteristics include a wide variety of risk factors for potential infection ranging from country of origin and travel history to history of immunosuppression, to certain comorbid conditions, and to diet and occupation. Increased mobility and medical complexity of transplant patients, and the changing epidemiology of pathogen distribution, can...

Chronic hepatitis C virus (HCV) infection related liver diseases are a leading indication for liver transplantation (LT) worldwide, responsible for about 20% of all LT performed in Europe and the United States. In the context of liver transplantation, treatment of HCV infection has been classically challenging because of therapies’ low efficacy and safety concerns associated with interferon-based regimens, so that patients with decompensated cirrhosis and liver graft recipients have been...

Acinetobacter infections have emerged as an important pathogen in transplant recipients. It is a major cause of multidrug-resistant nosocomial infections, particularly pneumonia and bloodstream infections, and is associated with high morbidity and mortality. Given the organism’s propensity to develop resistance to multiple classes of antibiotics, treatment options can be limited but frequently include carbapenems, polymyxins, sulbactams, tetracyclines, and glycylcyclines. Infection...

Candida remains a common infectious complication in the setting of solid organ transplantation. The rates of invasive Candida infection vary among organ transplant, with small bowel accounting for the majority of cases. In this chapter, we review the epidemiology of Candida infections following organ transplantation. While C. albicans continues to be the most common fungal species isolated, more recent data show that non-albicans Candida species are on the rise, specifically drug-resistant...

Infection of the anogenital tract with human papillomavirus (HPV) is very common. Approximately 15–20 anogenital HPV types are oncogenic or “high-risk” and are associated with 99.9% of cervical cancers, 90% of anal cancers, 70% of oropharyngeal cancers, and a high proportion of vaginal, penile, and vulvar cancers. Defects in cellular immunity make solid organ transplant (SOT) recipients particularly susceptible to persistent high-risk HPV infection, development of the cancer precursor...

This chapter is a review of rare yet clinically relevant viral encephalitides that have been transmitted from organ donors to recipients. We will discuss the potential pitfalls in diagnosing and managing these illnesses and also discuss the challenges and next steps to better outcomes from these infections.

Multidrug-resistant organisms (MDROs) cause morbidity and mortality after organ transplantation. Infection from these organisms may arise from pre-transplant colonization/infectious events, and these organisms may be donor-derived. Here we review the epidemiology, clinical manifestations, disease diagnostics, and therapeutic modalities for six common MDRO bacterial pathogens in the context of solid organ and bone marrow transplantation.