Page 30 - Heart Transplant Protocol

Heart Function Service: Heart Transplant Protocols

Post-Transplant Infection

Prophylaxis

Mycostatin (Nystatin)
o Mycostatin (Nystatin); 100,000 units/ml
 2 ml/dose PO TID for infants
 5 ml/dose PO TID for children
 Swish for 30 seconds and swallow; avoid eating/drinking for 15-30 minutes after
 Continue for a 3 month duration
Trimethoprim/sulfamethoxazole (Bactrim)
o Trimethoprim/sulfamethoxazole (Bactrim)
 Prophylaxis against Pneumocystis jiroveci (PCP)
 Timing of initiation of Bactrim prior to discharge depends on creatinine
clearance.
 5 mg TMP/kg/day PO for infants
 80-160 mg/daily PO for adolescents
 Continue for 3 month duration

Valganciclovir (Valcyte)
o Ganciclovir IV or Valganciclovir (Valcyte) PO
 Prophylaxis against cytomegalovirus (CMV):
 Recipient Positive/ Donor Positive- Prophylaxis Daily for 6 months
 Recipient Positive/ Donor Negative – Prophylaxis Daily for 6 months
 Recipient Negative/Donor Positive – Prophylaxis daily for 6 months
 Recipient Negative/Donor Negative – No treatment
 Ganciclovir 5 mg/kg/day IV
 Valganciclovir 15 mg/kg/day PO (max dose of 900 mg/dose)

Protocols for the management of EBV infection and EBV associated PTLD

Pediatric heart transplant patients face innumerable risks in the delicate balance of immunosuppression
and infection, including infection with EBV. EBV, a herpes virus, infects B-cell lymphocytes resulting in
viral replication, B-cell lysis, and cell transformation. Immunosuppressed patients have decreased
cytotoxic T-cell function and lose control of EBV proliferation. This path can lead to post-transplant
lymphoproliferative disorder (PTLD), which occurs in 2-15% of patients. EBV infection remains the most
predictable risk factor for development of PTLD. With PTLD rates of survival as low as 67% at 5 years
after diagnosis, it is not surprising that great focus has been placed on the presence of EBV infection and
viremia in these patients. As established through both multicenter as well as single center studies, pre-
transplant EBV immune status, age at transplant, and chronicity of high levels of EBV viremia have been
shown to play an important role in the transformation from EBV infection to PTLD. It therefore becomes
necessary to identify the highest risk population so appropriate post-transplant monitoring can be
undertaken. What is less clear, however, is when one crosses a threshold at which time it becomes
necessary to transition from monitoring to actively treating EBV viremia. Clinicians have a broad range

Updated November 9, 2017 30