Chapter 126. Infections in Transplant Recipients (Part 8) Kidney Transplantation (See Table 126-4) Table 126-4 Common Infections after Kidney Transplantation Period after Transplantation Infection Site Early (<1 Month) Middle (1–4 Months) Late (>6 Months) Urinary tract Bacteria (Escherichia coli , Klebsiella, Enterobacteriaceae, Pseudomonas, Enterococcus) associated with bacteremia and pyelonephritis; Candida CMV (fever, bone marrow suppression, hepatitis); BK virus (nephropathy, graft failure, vasculopathy) Bacteria (late urinary tract infections usually not associated with bacteremia); BK virus (nephropathy, graft failure, generalized vasculopathy) Lungs Bacteria (Legionella in endemic settings) CMV disease; Pneumocystis; Legionella Nocardia; invasive fungi Central nervous system Listeria (meningitis); Toxoplasma gondii CMV disease; Listeria (meningitis); Cryptococcus (meningitis); Nocardia Note: CMV, cytomegalovirus. Early Infections Bacteria often cause infections that develop in the period immediately after kidney transplantation. There is a role for perioperative antibiotic prophylaxis, and many centers give cephalosporins to decrease the risk of postoperative complications. Urinary tract infections developing soon after transplantation are usually related to anatomic alterations resulting from surgery. Such early infections may require prolonged treatment (e.g., 6 weeks of antibiotic administration for pyelonephritis). Urinary tract infections that occur >6 months after transplantation may be treated for shorter periods because they do not seem to be associated with the high rate of pyelonephritis or relapse seen with infections that occur in the first 3 months. Prophylaxis with TMP-SMX [1 double-strength tablet (800 mg of sulfamethoxazole, 160 mg of trimethoprim) per day] for the first 4–6 months after transplantation decreases the incidence of early and middle-period infections (see below, Table 126-4, and Table 126-5). Table 126-5 Prophylaxis of Infections in Transplant Recipients Risk Factor Organism Prophylactic Antibiotics Examination(s) a Travel to or residence in area with known risk of fungal infection Coccidioides, Histoplasma, Blastomyces Consider imidazoles Chest radiography, antigen testing, serology Latent viruses HSV, VZV, EBV, CMV Acyclovir after hematopoietic stem cell transplantation to prevent HSV and Serologic test for HSV, VZV, CMV, HHV-6, EBV, KSHV VZV; ganciclovir to prevent CMV in some settings Latent fungi and parasites Pneumocystis jiroveci , Toxoplas ma gondii Trimethoprim -sulfamethoxazole (dapsone or atovaquone) Serology for Toxoplasma Histor y of exposure to tuberculosis or latent tuberculosis Mycobacteriu m tuberculosis Isoniazid if recent conversion for positive chest imaging and/or no previous treatment Chest imaging; PPD and/or cell- based assay a Serologic examination, PPD testing, and interferon assays may be less reliable after transplantation. Note: CMV, cytomegalovirus; EBV, Epstein-Barr virus; HHV- 6, human herpesvirus type 6; HSV, herpes simplex virus; KSHV, Kaposi's sarcoma– associated herpesvirus; PPD, purified protein derivative; VZV, varicella- zoster virus. . Chapter 126. Infections in Transplant Recipients (Part 8) Kidney Transplantation (See Table 126- 4) Table 126- 4 Common Infections after Kidney Transplantation Period after Transplantation. months after transplantation decreases the incidence of early and middle-period infections (see below, Table 126- 4, and Table 126- 5). Table 126- 5 Prophylaxis of Infections in Transplant Recipients. surgery. Such early infections may require prolonged treatment (e.g., 6 weeks of antibiotic administration for pyelonephritis). Urinary tract infections that occur >6 months after transplantation