Risk Assessment of Infections in SOT Recipients

  • Mario Fernández-Ruiz
  • Nicole M. Theodoropoulos


The susceptibility to infection among solid organ transplant (SOT) recipients is modulated by a number of pre- and post-transplant variables that must be taken into account in the risk assessment process. Causative agents of post-transplant infection may be endogenous (reactivation of a chronic or latent infection), derived from the donor or the preservation fluid or acquired from an exogenous source (through environmental, vector, or human-to-human exposure). Overall, the latter group represents the most usual mechanism of infection among SOT recipients. Due to their frequent requirement for prolonged hospitalization, invasive diagnostic and therapeutic procedures, and broad-spectrum antibiotic therapy, healthcare-associated exposure is of particular concern. The present chapter will discuss how to evaluate the individual risk of infection in an individual SOT candidate or recipient. We will cover variables such as the timing from transplant, donor and surgical factors, the impact of antimicrobial prophylaxis and antirejection therapy, and the net state of immunosuppression. The changing nature of most of these variables should motivate a dynamic risk assessment throughout the entire post-transplant period. In addition, the different strategies currently available for post-transplant immune monitoring (either non-specific or specifically focused on a given pathogen, such as cytomegalovirus) will be reviewed.


Infection risk assessment Pre-transplant factors Donor-derived infections Post-transplant factors Net state of immunosuppression Immune monitoring CMV-specific cell-mediated immunity 


  1. 1.
    Peleg AY, Husain S, Kwak EJ, Silveira FP, Ndirangu M, Tran J, et al. Opportunistic infections in 547 organ transplant recipients receiving alemtuzumab, a humanized monoclonal CD-52 antibody. Clin Infect Dis. 2007;44(2):204–12.CrossRefGoogle Scholar
  2. 2.
    Issa NC, Fishman JA. Infectious complications of antilymphocyte therapies in solid organ transplantation. Clin Infect Dis. 2009;48(6):772–86.CrossRefGoogle Scholar
  3. 3.
    Green M. Introduction: infections in solid organ transplantation. Am J Transplant. 2013;13(Suppl 4):3–8.CrossRefGoogle Scholar
  4. 4.
    Fishman JA, Practice ASTIDCo. Introduction: infection in solid organ transplant recipients. Am J Transplant. 2009;9(Suppl 4):S3–6.CrossRefGoogle Scholar
  5. 5.
    Morris MI, Fischer SA, Ison MG. Infections transmitted by transplantation. Infect Dis Clin N Am. 2010;24(2):497–514.CrossRefGoogle Scholar
  6. 6.
    Ison MG, Nalesnik MA. An update on donor-derived disease transmission in organ transplantation. Am J Transplant. 2011;11(6):1123–30.CrossRefGoogle Scholar
  7. 7.
    Wolfe C, Wilk A, Tlusty S, Sifri C, Morris M, Mehta A, et al. Donor-derived toxoplasmosis in solid organ transplant 2008–2015: Opportunities for improvement [Abstract]. Am J Transplant. 2016;16(Suppl 3):736.Google Scholar
  8. 8.
    Fischer SA, Lu K, Practice ASTIDCo. Screening of donor and recipient in solid organ transplantation. Am J Transplant. 2013;13(Suppl 4):9–21.CrossRefGoogle Scholar
  9. 9.
    Kumar D, Humar A. The AST handbook of transplant infections. Chichester: Blackwell Publishing; 2011.CrossRefGoogle Scholar
  10. 10.
    Pappas PG, Kauffman CA, Andes D, Benjamin DK Jr, Calandra TF, Edwards JE Jr, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48(5):503–35.CrossRefGoogle Scholar
  11. 11.
    Silveira FP, Kusne S, Practice ASTIDCo. Candida infections in solid organ transplantation. Am J Transplant. 2013;13(Suppl 4):220–7.CrossRefGoogle Scholar
  12. 12.
    Assi M, Martin S, Wheat LJ, Hage C, Freifeld A, Avery R, et al. Histoplasmosis after solid organ transplant. Clin Infect Dis. 2013;57(11):1542–9.CrossRefGoogle Scholar
  13. 13.
    Pappas PG, Alexander BD, Andes DR, Hadley S, Kauffman CA, Freifeld A, et al. Invasive fungal infections among organ transplant recipients: results of the Transplant-Associated Infection Surveillance Network (TRANSNET). Clin Infect Dis. 2010;50(8):1101–11.CrossRefGoogle Scholar
  14. 14.
    Singh N, Chang FY, Gayowski T, Marino IR. Infections due to dematiaceous fungi in organ transplant recipients: case report and review. Clin Infect Dis. 1997;24(3):369–74.CrossRefGoogle Scholar
  15. 15.
    Wright AJ, Humar A, Gourishankar S, Bernard K, Kumar D. Severe Legionnaire’s disease caused by Legionella longbeachae in a long-term renal transplant patient: the importance of safe living strategies after transplantation. Transpl Infect Dis. 2012;14(4):E30–3.CrossRefGoogle Scholar
  16. 16.
    Kruszyna T, Walsh M, Peltekian K, Molinari M. Early invasive Listeria monocytogenes infection after orthotopic liver transplantation: case report and review of the literature. Liver Transpl. 2008;14(1):88–91.CrossRefGoogle Scholar
  17. 17.
    Aulagnon F, Scemla A, DeWolf S, Legendre C, Zuber J. Diarrhea after kidney transplantation: a new look at a frequent symptom. Transplantation. 2014;98(8):806–16.CrossRefGoogle Scholar
  18. 18.
    Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med. 2007;357(25):2601–14.CrossRefGoogle Scholar
  19. 19.
    Fernandez-Ruiz M, Kumar D, Humar A. Clinical immune-monitoring strategies for predicting infection risk in solid organ transplantation. Clin Transl Immunology. 2014;3(2):e12.CrossRefGoogle Scholar
  20. 20.
    Egli A, Humar A, Kumar D. State-of-the-art monitoring of cytomegalovirus-specific cell-mediated immunity after organ transplant: a primer for the clinician. Clin Infect Dis. 2012;55(12):1678–89.CrossRefGoogle Scholar
  21. 21.
    Torre-Cisneros J, Aguado JM, Caston JJ, Almenar L, Alonso A, Cantisan S, et al. Management of cytomegalovirus infection in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations. Transplant Rev. 2016;30(3):119–43.CrossRefGoogle Scholar
  22. 22.
    Ravaioli M, Neri F, Lazzarotto T, Bertuzzo VR, Di Gioia P, Stacchini G, et al. Immunosuppression modifications based on an immune response assay: results of a randomized, controlled trial. Transplantation. 2015;99(8):1625–32.CrossRefGoogle Scholar
  23. 23.
    Iriart X, Challan Belval T, Fillaux J, Esposito L, Lavergne RA, Cardeau-Desangles I, et al. Risk factors of pneumocystis pneumonia in solid organ recipients in the era of the common use of posttransplantation prophylaxis. Am J Transplant. 2015;15(1):190–9.CrossRefGoogle Scholar
  24. 24.
    Martin-Gandul C, Stampf S, Hequet D, Mueller NJ, Cusini A, van Delden C, et al. Preventive strategies against cytomegalovirus and incidence of alpha-herpesvirus infections in solid organ transplant recipients: a nationwide cohort study. Am J Transplant. 2017;17(7):1813–22.CrossRefGoogle Scholar
  25. 25.
    Egli A, Fuller J, Humar A, Lien D, Weinkauf J, Nador R, et al. Emergence of Aspergillus calidoustus infection in the era of posttransplantation azole prophylaxis. Transplantation. 2012;94(4):403–10.CrossRefGoogle Scholar
  26. 26.
    Origuen J, Fernandez-Ruiz M, Lopez-Medrano F, Ruiz-Merlo T, Gonzalez E, Morales JM, et al. Progressive increase of resistance in Enterobacteriaceae urinary isolates from kidney transplant recipients over the past decade: narrowing of the therapeutic options. Transpl Infect Dis. 2016;18(4):575–84.CrossRefGoogle Scholar
  27. 27.
    Perez-Ordono L, Hoyo I, Sanclemente G, Ricart MJ, Cofan F, Perez-Villa F, et al. Late-onset Pneumocystis jirovecii pneumonia in solid organ transplant recipients. Transpl Infect Dis. 2014;16(2):324–8.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Mario Fernández-Ruiz
    • 1
  • Nicole M. Theodoropoulos
    • 2
  1. 1.Unit of Infectious DiseasesHospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), School of Medicine, Universidad ComplutenseMadridSpain
  2. 2.Division of Infectious Diseases and ImmunologyUniversity of Massachusetts Medical School, UMass Memorial Medical CenterWorcesterUSA

Personalised recommendations