Strategies For Safe Living Following Solid Organ Transplantation

Publication Date: April 1, 2019
Last Updated: March 14, 2022



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.
  • AFTER touching items that have had contact with human or animal feces, (eg, bedpans, bedding, toilets, litter boxes).
(Moderate, Strong)


Transmission of respiratory pathogens can be reduced by the following measures:
  • Frequent and thorough hand washing, particularly prior to touching mucous membranes.
  • Avoiding close contact with persons with respiratory illnesses. If contact is unavoidable, ideally both the infected person and the transplant recipient should wear a standard surgical mask.
  • Avoiding crowded areas, such as shopping malls, subways, elevators, where close contact with persons with respiratory illness is likely. Though continually avoiding these areas is unrealistic, caution is advised during periods of enhanced immunosuppression. Likewise, caution should be increased when viruses are circulating in the community such as epidemic influenza.
  • Avoiding tobacco smoke. Smoking and exposure to environmental tobacco smoke are risk factors for bacterial and community‐acquired viral infections.
  • Marijuana smoking or vaporization of the plant product should also be avoided because of its association with exposure to fungal spores from Aspergillus spp and other organisms. While use of medical marijuana is becoming more common, transplant recipients should be aware that medical marijuana (the plant product) obtained from dispensaries has been found to contain multiple types of fungi and Gram‐negative bacteria including ones with multidrug resistance. Although further data are awaited, it is likely that oral ingestion of baked cannabis products or use of marijuana derivatives other than the plant product (such as oils) would not pose the same level of risk as smoking or vaporization of the plant product.
  • 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 healthcare settings.
  • 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 by the patient after consultation with the 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 (eg, Aspergillus, Histoplasma).
    • Home remodeling projects which may lead to increased risk of Aspergillus in the environment need to be planned cautiously. While data are not available on specific risk, it would be prudent for the transplant recipient to avoid exposure particularly early after transplantation or rejection treatment or after lung transplantation. While clinicians may counsel patients to temporarily move out of their homes when visible mold is detected and during mold‐abatement procedures, the level of infectious risk is not known.
  • Avoiding exposure to fungal spores (Cryptococcus, Histoplasma, etc) by avoiding plant and soil aerosols (such as mulching), pigeon, and other bird droppings, chicken coops, and caves.
  • Consideration for wearing a mask if exposure to above high‐risk areas is unavoidable.
(, Strong)
(low to moderate)


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.
    • During outbreaks having the water come to a rolling boil for at least 1 minute is advisable.
  • Well water from private or public wells in areas that are not screened frequently for bacterial pathogens should be avoided if possible because of potential risk of Cryptosporidium, Giardia, and bacterial coliform contamination. If well water is used, it should be tested yearly for microbial contamination (However, it is even safer to boil well water or use bottled water for drinking and brushing teeth).
  • Transplant recipients should not drink water directly from lakes or rivers because of the risk of Cryptosporidium, Giardia, and bacterial coliform contamination.
  • Waterborne infection might also arise from inadvertent swallowing of water during recreational activities such as swimming in lakes, rivers, or pools, using hotel or motel pools or spas, or going on water rides at amusement parks. 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.
  • To avoid spreading infection to others, transplant recipients who have had diarrhea should not use public recreational water facilities for 2 weeks after symptoms have resolved.
  • Hot tubs have been associated with several infection risks, including Pseudomonas folliculitis, legionellosis, and mycobacterial infections; and should be avoided.
  • Standing water in the home or basement, such as may occur with flooding, should be promptly cleaned up to avoid growth of mold, Legionella, and other pathogens. Ideally, someone other than the transplant recipient should perform the cleaning. If the transplant recipient cannot avoid exposure then waterproof boots and gloves and a mask should be worn during the cleaning process.
  • When traveling to countries with poor sanitation, drinking tap water as well as inadvertent consumption from ice cubes, brushing teeth, or during showering should be avoided.
  • Abrasions incurred during bathing in ocean or fresh water should be thoroughly cleaned with an uncontaminated water source due to risk of infection with organisms such as Vibrio species, Mycobacterium marinum, or Aeromonas spp.
(, Strong)

(low to moderate)



Transplant recipients should avoid:
  • Drinking unpasteurized milk, fruit, or vegetable juice/cider in order to decrease their risk of infection with Escherichia coli 0157:H7, Salmonella, Brucella, Listeria, Yersinia, and Cryptosporidium.
  • Eating cheeses made with unpasteurized milk (such as soft cheeses such as brie, camembert, feta, blue cheese, moldy cheese, and others) to decrease the risk of Listeria. While most feta cheese in the United States is now pasteurized, not all of it is, and it is still important to check.
  • Eating raw or undercooked eggs including foods containing raw eggs (eg, uncooked cake and cookie batter and some preparations of Caesar salad dressing, mayonnaise, or hollandaise sauce) particularly a risk for Salmonella infection.
  • Eating raw or undercooked meat, poultry, or fish with particular risk not only for bacterial contamination but also for parasitic infections such as Toxoplasma gondii, and tapeworms.
  • Eating any raw or undercooked seafood (oysters, clams, mussels) to prevent exposure to Vibrio species, viruses such as norovirus that cause gastroenteritis or hepatitis, and parasitic infections including Cryptosporidium.
  • Ingesting raw seed sprouts (alfalfa sprouts, mung beans).
  • Cross‐contamination when preparing food, (eg, keep cooked and raw foods separate; use cleaned or separate cutting boards washed with hot soapy water in between uses).
  • Eating uncooked pate, meat spreads, cold cuts, and smoked seafood.
  • Eating from public salad bars or buffets, street vendors, picnics where food has sat out at room temperature, or potluck meals especially if the hygiene standards of all participants are not known.
  • Eating any food prepared by someone with a recent diarrheal illness.
(, Strong)
(low to moderate)


In general, transplant recipients should:
  • Avoid contact with animals that have diarrhea.
  • Keep their pets healthy by feeding them food that is not contam‐ inated or spoiled, and seeking veterinary help at the first signs of illness.
  • Take the pet regularly to the veterinarian for checkups.
  • 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).
  • Ensure that areas near the home are free of raccoon latrines.
  • 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 a period when the patient is on stable immune suppression (at least 6‐12 months after transplantation).
  • Consider the type of pet and specific risks for infections.
    • Reptiles and amphibians (snakes, iguanas, lizards, and turtles) have a high risk of Salmonella infection and should be avoided.
    • Chicks and ducklings have a risk of transmitting Salmonella infections and should be avoided.
    • Rodents have a risk of transmitting lymphocytic choriomeningitis virus.
    • Young cats have risk of transmitting Bartonella henselae.
    • Cats have a risk of transmitting T. gondii.
    • Puppies, kittens, and chicks have a risk of transmitting Campylobacter infections.
    • Exotic pets are best avoided.
    • Regarding pet vaccines, it is best to confer with the veterinar‐ ian. When effective nonlive vaccines exist it is preferable to administer these. If live vaccines are given, (eg, live attenuated vaccine for B. bronchiseptica [kennel cough]) it would be advis‐ able to not to have the transplant recipient hold the dog during vaccination to avoid direct contact with the vaccine and to pay extra attention to avoiding direct contact with the dogs nose mouth or face after vaccination.
(Low, Strong)


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 infections.
  • Consider using latex condoms during sexual activity even with long term monogamous partners during periods of increased immunosuppression.
  • Avoid exposure to feces during sexual activity.
    • Immunize against HBV and HPV at appropriate ages, and when possible prior to transplantation to achieve greatest efficacy (see Vaccine section of 4th edition of AST ID Guidelines).
  • Education in safer sex practices is an important component of medical care, particularly for adolescents with recent or imminent sexual debut. Immunization against HPV is particularly warranted in adolescents and young adults and has been shown in immunocompetent individuals to be most efficacious when administered prior to initiation of sexual intercourse. In addition, the vaccine may prevent development of HPV‐related malignancies, for which transplant recipients are at increased risk, although data are limited in this population.
(, Strong)

(moderate to high)



With regards to returning to work and school, transplant recipients should:
  • Seek guidance from their transplant teams and/or transplant infectious disease consultants regarding the optimal timing of returning to work or school, depending on their degree of immunosuppression and clinical course.
  • Seek guidance from their transplant teams and/or transplant infectious disease consultants regarding mitigating potential infectious risks in the workplace, or possibly seeking another job altogether, depending on the occupation, the particular work‐related duties, and flexibility (or lack thereof) regarding job modifications.
  • Seek guidance from their transplant teams and/or transplant infectious disease consultants regarding reported outbreaks of infections in the workplace or at school.
(Low, Strong)


In general, transplant recipients should:
  • Seek guidance from their transplant teams regarding sports and athletic activities that they wish to resume (particularly at the 6‐ and 12‐month post‐transplant follow‐up visits).
  • Seek guidance from their transplant teams and/or transplant infectious disease consultants regarding resuming recreational activities which may increase their risk of tick bites, mosquito bites, or exposures to dirt, soil, unchlorinated water, and other potential infection hazards.
(Low, Strong)

Recommendation Grading




Strategies For Safe Living Following Solid Organ Transplantation

Authoring Organization

Publication Month/Year

April 1, 2019

Last Updated Month/Year

December 2, 2022

Document Type


External Publication Status


Country of Publication


Document Objectives

The present AST‐IDCOP guidelines update information on strategies for safe living after organ transplantation.

Target Patient Population

Solid organ transplant recipients

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Diagnosis, Prevention, Management

Diseases/Conditions (MeSH)

D019072 - Antibiotic Prophylaxis, D019737 - Transplants, D016377 - Organ Transplantation, D011183 - Postoperative Complications, D000890 - Anti-Infective Agents, D011315 - Preventive Medicine


prophylaxis, antimicrobial prophylaxis, infection, solid organ transplant

Source Citation

Avery, RK, Michaels, MG; on behalf of the AST Infectious Diseases Community of Practice. Strategies for safe living following solid organ transplantation—Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019; 33:e13519.