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• W2000255168 abstract "Infections remain a risk to the recipients of solid organ transplantation, long after the initial posttransplant period. Factors that affect risk include the recipient's net state of immunosuppression, epidemiologic exposures and the consequences of the invasive procedures to which the recipient has been subjected (1-4). Infections can be due to endogenous organisms that reactivate during periods of excess immunosuppression, donor-acquired organisms that are discussed in Section 3 of these Guidelines, or from the environment, whether it be in the hospital setting or the community after discharge. They may also develop opportunistic infections with exogenously acquired organisms if exposed to a high inoculum or particularly virulent microbes, even during periods of minimal or maintenance immunosuppression. A major goal of transplantation is to be able to lead as healthy and normal a life as possible; accordingly the risk of exposure to infectious agents will always be present. However, various measures can be taken to reduce high-risk epidemiologic exposures in the hospital and in the community, and transplant recipients should be counseled in ways to minimize the risk of infection. Furthermore, strategies for safe living must be carefully woven with the transplant recipient's attempts to regain normal function and return to an active and productive life. Information on specific infections is available in other sections of these Guidelines, whereas this section will deal with infectious exposures that are encountered in daily life. Unfortunately, ‘hard data’ and controlled studies regarding safe living practices following solid organ transplantation are lacking. Guidelines for preventing opportunistic infections in other immunocompromised populations such as hematopoietic stem cell transplant recipients (4) and in persons infected with human immunodeficiency virus (5) have been drafted by various working groups that include the Centers for Disease Control and Prevention, Infectious Diseases Society of America, United States Public Health Service and American Society of Blood and Marrow Transplantation, and can be extrapolated to the solid organ transplant population. In addition, recently published guidelines on isolation precautions (6), hand hygiene (7) and environmental control of infection (8) provide valuable insights, although they focus primarily on health care settings. The following recommendations are based on anecdotal clinical experience, available knowledge of the mode in which various infectious agents are transmitted, the opinions of respected authorities (9) and common sense (AIII). They take into account the general recognition that solid organ transplant recipients are at greatest risk of infection during the first 6 months after transplantation or when their immunosuppression is augmented for episodes of rejection. Guidelines for the prevention of infection in solid organ transplant recipients should be tailored to the individual recipient by their health care providers with special consideration of the patient's degree of immunosuppression and personal circumstances. Most organisms are acquired from direct contact (particularly on hands or from fomites), ingestion or inhalation. Frequent and thorough hand washing is imperative as a means of preventing infections that are transmitted by direct contact (AIII). Hands should be washed with soap and water (AIII). Hygienic hand rubs are an acceptable alternative for maintaining clean hands, except when there is visible soiling of the hands or when contact is made with organisms that are known to have a spore stage (e.g. Clostridium difficile) (7). Gloves should be worn whenever handling heavily contaminated materials such as soil, moss or manure. Going barefooted should be avoided. Shoes, socks, long pants and long-sleeved shirts should be worn while doing gardening, yardwork, farming or being in parks or wooded areas (CIII). Hands should be washed (including after gloves are used) before preparing food and before eating; before and after touching wounds (whether or not gloves are used); before touching mucous membranes; after touching or cleaning up after pets and animals; after gardening or touching plants or soil; after changing diapers (though ideally other family members should change diapers rather than the transplant recipient); after touching secretions and excretions, including nose-blowing and after touching items that have had contact with human or animal feces, (e.g. bedpans, bedding, toilets, litter boxes). In addition, there is considerable potential for transmission of infections via percutaneous exposures. Transplant recipients should avoid intravenous drug use, body piercing and tattoos (9). If body piercing or tattoos are obtained, reputable centers should be used and close attention to sterile technique employed. Microbes that cause respiratory infections are transmitted by either inhalation of aerosolized organisms or direct contact from contaminated hands to mucous membranes. Accordingly, transmission of respiratory pathogens can be reduced by frequent and thorough hand washing, particularly before touching mucous membranes (BIII); avoiding close contact with persons with respiratory illnesses (AIII). If contact is unavoidable, ideally both the infected person and the transplant recipient should wear a standard surgical mask (CIII); avoiding crowded areas, such as shopping malls, subways, elevators, where close contact with persons with respiratory illness is likely (BIII). Although continually avoiding these areas is unrealistic, caution is advised during periods of enhanced immunosuppression; avoiding tobacco smoke. Smoking and exposure to environmental tobacco smoke are risk factors for bacterial and community-acquired viral infections (CIII). Marijuana smoking should also be avoided because of its association with exposure to fungal spores from Aspergillus spp. and other organisms (BIII); avoiding exposure to persons with known active tuberculosis and avoiding activities and occupational settings that increase the risk of exposure to tuberculosis, for example working in prisons, jails, homeless shelters, and certain health care settings (BIII); avoiding, if possible, other occupational risks including working in certain animal care settings, construction, gardening, landscaping, and farming. Decisions to work in high risk areas should be made jointly by the patient, transplant team and primary care physicians so that the risks and benefits can be appropriately discussed, and precautions implemented if the patient chooses to accept these risks; avoiding construction sites, excavations or other dust-laden environments where there may be a high concentration of spores from molds (e.g. Aspergillus); avoiding exposure to fungal spores (Cryptococcus, Histoplasma) by avoiding plant and soil aerosols, pigeon and other bird droppings, chicken coops and caves; consideration for wearing a mask if exposure to above high-risk areas is unavoidable (CIII). Waterborne infections most often occur from consumption of contaminated drinking water or inadvertent water ingestion during recreational activities such as swimming, diving or boating. Less frequently, infection can result from inhalation or direct contamination of the eye or a wound. In particular, cryptosporidiosis has been increasingly recognized in both healthy and immunocompromised hosts. Although only a few studies have focused on solid organ transplant recipients (10), Cryptosporidium can cause severe, chronic diarrheal disease in immunocompromised hosts, particularly those receiving corticosteroids (11). Cryptosporidium is resistant to chlorine and other chemicals and can be problematic even with treated water sources. Therefore, it is prudent for solid organ transplant recipients to decrease their exposure to this pathogen as well as others that might be found in water sources. Even treated municipal tap water may not be completely free of Cryptosporidium, however, there are no data to support a recommendation that all tap water be avoided unless a ‘boil water’ advisory is issued by the local authorities. To completely eliminate the risk of Cryptosporidium contamination, one should only drink water that has come to a rolling boil for at least 1 min (AI). Persons avoiding untreated tap water should be aware that ice, and fountain beverages served at restaurants, bars, theaters, sporting events, etc. are prepared with tap water. Personal-use filters and/or bottled water may serve as alternatives to boiling water to eradicate Cryptosporidium and other waterborne pathogens, but careful attention must be paid to selecting effective filters and high-quality bottled water. A list of filters certified under NSF Standard 053 for cryptosporidial cyst removal may be obtained by contacting the NSF International consumer line at 800-673-8010 or http://www.nsf.org/notice/crypto.html. Information regarding bottled water can be obtained from the International Bottled Water Association at 703-683-5213 or (http://www.bottledwater.org). For individuals who have treated water supplies, the expense of buying bottled water may not be warranted. Specific recommendations for water safety include: Close attention should be paid to directions given during local governmental recommendations for ‘boil water’ advisories for any waterborne pathogen. Well water from private or public wells in areas that are not screened frequently for bacterial pathogens should be avoided because of the risk of Cryptosporidium, Giardia and bacterial coliform contamination. Transplant recipients should not drink water directly from lakes or rivers because of the risk of cryptosporidiosis, giardiasis and bacterial pathogens (AIII). Waterborne infection might also arise from inadvertent swallowing of water during recreational activities such as swimming in lakes, rivers or pools, or going on water rides at amusement parks (BII). Transplant recipients should avoid swimming in water that is likely to be contaminated with human or animal waste, and should avoid swallowing water during swimming (BII). To avoid spreading infection to others, transplant recipients who have had diarrhea should not use public recreational water facilities for 2 weeks. Hot tubs have been associated with several infection risks, including Pseudomonas folliculitis, legionellosis (12) and mycobacterial infections (13); and should be avoided. Standing water in the home or basement should be promptly cleaned up to avoid growth of mold, Legionella and other pathogens. When traveling to countries with poor sanitation, drinking tap water should be avoided. Inadvertent consumption from ice cubes or during showering should also be avoided. Abrasions incurred during bathing in ocean or fresh water should be thoroughly cleaned with an uncontaminated water source. Many of the following recommendations also apply to healthy individuals. Transplant recipients should avoid the following: Drinking or eating food made with unpasteurized milk or drinking unpasteurized fruit or vegetable juice/cider in order to decrease their risk of infection with Escherichia coli 0157:H7, Salmonella, Brucella, Listeria, Yersinia and Cryptosporidium (AIII). Eating raw or undercooked eggs including foods containing raw eggs (e.g. uncooked cake and cookie batter and some preparations of Caesar salad dressing, mayonnaise or hollandaise sauce) (AIII). Eating raw or undercooked meat, poultry or fish. All raw or undercooked seafood (oysters, clams, mussels) to prevent exposure to Vibrio species, viruses that cause gastroenteritis or hepatitis, and Cryptosporidium. Raw seed sprouts (alfalfa sprouts, mung beans). Cross-contamination when preparing food (e.g. keep cooked and raw foods separate; use cleaned or separate cutting boards). Cheeses made from unpasteurized milks, and in particular, soft cheeses (feta, Brie, Camembert), to decrease the risk of listeriosis. Uncooked pate, meat spreads, cold cuts and smoked seafood, http://www.foodsafety.gob/~dms/lmrisks5.html. Transplant recipients who work with animals (veterinarians, pet store employees, farmers, slaughterhouse or laboratory workers) should, if possible, avoid working during periods of maximal immunosuppression (BIII). When returning to work, transplant recipients should minimize their exposure to potential pathogens by using proper precautions, including hand hygiene and the use of gloves and masks as indicated. Health care providers must balance the psychological benefits of pet ownership with potential risks for transmission of infection when counseling solid organ transplant recipients on the safety of maintaining pets. There are a variety of zoonoses that can be transmitted to the transplant recipient from pet animals (14). The veterinarian should be viewed as a colleague, both to the transplant clinician and the transplant recipient, because maintenance of pet health can help reduce human risk (15). In general, transplant recipients should avoid contact with animals that have diarrhea (BIII); keep their pets healthy by feeding them food that is not contaminated or spoiled, and seeking veterinary help at the first signs of illness; wash hands carefully after handling pets; avoid cleaning bird cages, bird feeders, litter boxes and handling animal feces. If this is not possible, the use of disposable gloves and a standard surgical mask should be employed; avoid stray animals; avoid animal bites and scratches (do not pet stray animals); avoid contact with nonhuman primates (monkeys); wear gloves to clean aquariums or have someone else in household do the cleaning; consider waiting to acquire a new pet until after the first year from transplant and at a period when the patient is on stable immune suppression; consider the type of pet and specific risks for infections; rodents have a risk of transmitting lymphocytic choriomeningitis virus; young cats have risk of transmitting Bartonella henselae; cats have a risk of transmitting Toxoplasma gondii; reptiles (snakes, iguanas, lizards and turtles), chicks and ducklings have a risk of transmitting Salmonella infection. Cats can spread Toxoplasma, Cryptosporidium, Salmonella, Campylobacter (contaminated feces) and Bartonella (fleas and scratches). Young cats carry the highest risk for transmitting Bartonella (cat scratch). Cat litter boxes should be changed daily (preferably not by transplant recipients), because it takes longer than 24 h for Toxoplasma oocysts to become infectious. Although dogs are generally considered safer pets than cats, birds and reptiles, there are documented instances of infections transmitted by dogs without a bite, such as cases of Bordetella bronchoseptica (the agent of ‘kennel cough’) in lung transplant recipients (16). Many infections can be transmitted during sexual contact. Some of these can be reduced by having a long-term monogamous relationship or decreasing the number of sexual partners. Sexually active transplant recipients should always use latex condoms during sexual contact outside of long-term monogamous relationships to reduce exposure to CMV, hepatitis B and C, HIV, HPV, HSV and other sexually transmitted diseases (AIII); consider using latex condoms during sexual activity with long-term monogamous partners during periods of increased immunosuppression (CIII); avoid exposure to feces during sexual activity (AIII). Education in safer sex practices is an important component of medical care, particularly for adolescents with recent or imminent sexual debut (17). Travel to developing countries poses substantial risk to transplant recipients, particularly during periods of maximal immunosuppression (AIII). Expanded recommendations can be found in the comprehensive review by Kotton et al. (18) and the sections on Travel Medicine (Section 33) and Parasitic Infections (Section 28) in the current Guidelines. Plans to travel should be discussed with the transplant recipient's physician at least 2 months prior to the planned departure date. All items discussed earlier are applicable for safe living during travel. Updated travel advisories should be obtained from the CDC website, http://www.cdc.gov. While traveling in developing countries, the transplant recipient should avoid consuming tap water, ice and beverages made with tap water; fresh fruit juices; unpasteurized milk and dairy products; raw, unpeeled fruits and vegetables; raw or undercooked meat, poultry, fish and seafood; raw or undercooked eggs. To ensure their safety, transplant recipients should ingest fruits and vegetables that they can peel; ingest steaming hot foods; drink bottled and canned processed drinks. Tap water can be boiled or disinfected with iodine or portable filters; avoid street vendor food. Whereas routine antimicrobial prophylaxis for diarrhea is not recommended, travelers should be given antibiotics to take with them and instructed on their use should diarrhea develop. Malaria prophylaxis should be provided as indicated by the travel plans and after careful consideration of any potential drug interactions. Travelers should take with them a sufficient supply of medications that they may require. A copy of their medication list, signed by a physician, should also be taken in case they are questioned about their medications, particularly if their medications are no longer in the original prescription bottles. The transplant recipient's immunization status should be assessed well in advance of travel and appropriate vaccinations should be given (19). In general, live virus vaccines should be avoided. Routine vaccinations should be updated. The transplant recipient should be advised vaccines may not be effective. Plans for evacuation in the event of medical emergency and should be formulated. Evacuation insurance is advised. Transplant recipients should be advised about all preventive measures that pertain to their anticipated exposures (e.g. protection against arthropod vectors, swimming precautions, etc.). The use of effective insect repellents and mosquito netting may be crucial in certain areas. The earlier sections have touched on many topics relevant to potential infection hazards in the workplace. Individualized occupational counseling is important for transplant recipients contemplating return to work in such areas as health care, construction, outdoors work and other fields. Whereas some recipients may be willing to consider a career change (e.g. leaving a temporary job in a pet store), others may be strongly attached to their line of work for multiple reasons such as psychological, financial or social. In some cases, a return to work is necessary for the transplant recipient to maintain family financial stability and their health insurance. Few guidelines exist for decisions of this nature, but the vast majority of jobs can be made safer by simple measures. These include restricting patient contact for the initial phase of returning to work in a health care environment, wearing masks when there are potential exposures to fungal spores, respiratory viruses or other transmissible illnesses, and sometimes reassignment to other duties particularly during periods of intensified immunosuppression. The clinician can help by adopting an attitude of working with the transplant recipient to make the proposed work situation safer, rather than issuing an unconditional order to change jobs (with occasional exceptions). The risks of hobbies such as hunting, fishing, scuba diving or spelunking should be discussed with the transplant recipient (9). In general, athletic activities been noted to be both safe and beneficial for many transplant recipients (20), with some notable exceptions. In addition to the psychological and health benefits to the individual of sporting activities, the existence of the World Transplant Games has been reported to have increased the public's knowledge and favorable opinion of transplantation (20). Returning to an appropriate level of recreational and athletic activity can help the transplant recipient's self-esteem and guard against depression. Transplant centers often offer specific restrictions related to the outdoors, as mentioned earlier, and in addition may choose to advise against certain activities due to risk of physical injury, such as rugby and boxing (21). In addition, the overall physical state and level of immunosuppression of the particular recipient should be considered. Occasionally, unexpected consequences might occur, such as the physical effects from direct contact of climbing harnesses with kidney allografts, leading to concern about the possible effects of rock climbing, rappelling and challenge courses (22). West Nile virus (WNV) can cause severe disease in transplant recipients, who have a much higher risk of central nervous system involvement than the general population (23). Other arthropod transmitted infections can also be severe in immunocompromised hosts. Several simple measures can help to prevent infection with these pathogens. Transplant recipients should avoid going out at dawn or dusk, during peak mosquito feeding, and should use effective insect repellents that contain DEET. On average, the duration of protection offered by DEET at different concentrations is as follows: 5, 4, 2 and 1.5 h for products with DEET concentrations of 23.8%, 20%, 6.7% and 4.5%, respectively (24). In addition, transplant recipients should wear protective clothing during the high-risk season and in areas where transmission is occurring. Sources of standing water, such as old tires, should be removed from yards and property belonging to transplant recipients. Specific prophylaxis when traveling to areas with endemic mosquito-borne infections such as malaria is discussed in the chapters on Parasitic Infections and Travel Medicine (Sections 28 and 33). With the increasing longevity of transplant recipients, more and more recipients are returning to active lives, to work and to recreational activities. With the expansion of permissible activities, inevitably potential infection risks are present. With careful thought and detailed patient education, many of these risks can be prevented. Occupational counseling can enable transplant recipients to find safer ways to do the jobs that they love, and that they need to maintain financial stability and insurance coverage. Knowledge of the risks of food, animal exposures and other environmental exposures can help transplant recipients stay out of the hospital and lead healthy, meaningful and long lives. This paper was modified from an initial guideline written by George Pankey and Rosemary Soave published by the American Society of Transplantation (Am J Transplant 2004; 4[Suppl 10]: 59–65. Avery R, Green M, eds.). Avery R.: Research/Grant Support, Roche Pharmaceutical, Viropharma, Schenig-Plough, Medimmune. Michaels M.: Grant Support, Sanofi Pasteur, Roche." @default.
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• W2000255168 title "Strategies for Safe Living Following Solid Organ Transplantation" @default.
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