Infections in liver transplant recipients

Table 2 Suggested prevention and treatment regimens for various infections after liver transplantation

Infection	Prevention	Treatment
Bacterial infections	According to risk factors (i.e. cephalosporins or vancomycin)	Susceptibility-guided antimicrobial treatment
Herpes simplex virus	Acyclovir 400 mg PO BID for 4 wk (if they are not receiving drugs for CMV prevention)	Acyclovir 5 mg/kg every 8 h for mucocutaneous disease or 10 mg/kg every 8 h for encephalitis
		Valacyclovir 1 gram PO BID for less severe disease
Cytomegalovirus	Valganciclovir 900 mg daily for 3-6 mo	Valganciclovir PO 900 mg BID or ganciclovir IV 5 mg/kg BID.
	Oral ganciclovir, 1 gram TID for 3-6 mo	If severe or life-threatening disease, initiate therapy with IV ganciclovir.
	Preemptive therapy (guided by CMV PCR or antigenemia)	Treatment must continue until viral eradication is achieved, but not shorter than 2 wk
		CMV Ig may be considered for severe forms of disease like pneumonitis.
Varicella zoster virus	Pre-transplant vaccination	Valacyclovir 1-gram PO TID or IV acyclovir 10 mg/kg every 8 h
		Initiate with IV acyclovir for disseminated disease such as pneumonia or encephalitis
		VZV immunoglobulin adds no additional benefits and not recommended
Candida species	Fluconazole, echinocandin, or amphotericin B in high-risk recipients for 4 weeks	Amphotericin B 3 to 5 mg/kg IV daily
		Fluconazole 800 mg loading dose, then 400 mg PO daily
		Caspofungin at an initial dose of 70 mg followed by 50 mg daily
		Anidulafungin initial dose of 200 mg first day followed by 100 mg daily
Aspergillus species	Voriconazole, echinocandin, or amphotericin B in high-risk patients	Voriconazole 6 mg/kg IV BID on day 1 followed by 4 mg/kg BID daily; transition to oral regimen when clinically stable
		Echinocandins (caspofungin or anidulafungin)
		Amphotericin B preparations
Cryptococcus neoformans	Not recommended	Amphotericin B (conventional or liposomal) and flucytosine (5-FC) for at least 2 wk then fluconazole as long-term maintenance (e.g. 6 mo)
		Fluconazole 800 mg loading dose, then 400 mg PO daily for limited disease
Pneumocystis jirovecii	TMP- SMX 160/800 mg daily or three times per week	TMP- SMX preferred; 15-20 mg/kg per day of TMP component in 3-4 divided doses (keep the sulfa level above 100); transition to oral regimen when clinically stable
	Alternative: TMP-SMX 80/400 mg daily
		Alternatives: Pentamidine isethionate, trimethoprim-dapsone (in patients who are not deficient in glucose-6-phosphate dehydrogenase), atovaquone, and clindamycin-primaquine.
Toxoplasma gondii	TMP- SMX 160/800 mg daily	Pyrimethamine in combination with sulfadiazine or clindamycin.
Listeria monocytogenes	Not recommended but TMP- SMX for Pneumocystis prophylaxis may prevent some infections	Ampicillin 2 g IV every four hours plus Gentamicin 3 mg/kg per day IV in three divided doses
		Alternatives:
		TMP- SMX 10-20 mg/kg IV per day divided every 6 to 12 h
		Meropenem 2 g IV every eight hours
Nocardia asteroides	Not recommended but TMP- SMX for Pneumocystis prophylaxis may prevent some infections	TMP-SMX preferred; 8-10 mg/kg per day of TMP component in 2-4 divided doses; higher doses may be used in severe disease; transition to oral therapy when clinically stable

CMV: cytomegalovirus; VZV: Varicella zoster virus; HSV: herpes simplex virus; TMP–SMX: trimethoprim sulfamethoxazole.