Tissue And Blood Protozoa Including Toxoplasmosis, Chagas Disease, Leishmaniasis, Babesia, Acanthamoeba, Balamuthia, And Naegleria In Solid Organ Transplant Recipients

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

Recommendations

TISSUE AND BLOOD PROTOZOA

Toxoplasmosis

For the diagnosis of acute toxoplasmosis in SOT recipients, we recommend PCR of blood and body fluids and biopsy of involved tissues to identify tachyzoites. (Low, Strong)
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For the treatment of toxoplasmosis in SOT recipient, we recommend, induction with pyrimethamine, sulfadiazine, and leucovorin for a minimum of six weeks. (Low, Strong)
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Following induction therapy, we recommend lifelong suppression. (Low, Weak)
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To minimize the risk of donor‐derived toxoplasmosis, we recommend the following:
  • Screening all donors and recipients with IgG and use this information to identify patients at high risk (D+/R‐) and implement prophylactic strategies.
(High, Strong)
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  • Prophylaxis with TMP/SMX is recommended for D+/R‐ cardiac recipients.
(Moderate, Strong)
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  • Prophylaxis with TMP/SMX should be considered for D+/Rnon‐cardiac recipients.
(Very Low, Weak)
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Lifelong prophylaxis is recommended in high‐risk (D+/R‐) heart recipients. If prophylaxis is discontinued, ongoing clinical monitoring is recommended with expedited Toxoplasma PCR testing and empiric therapy initiation for signs and symptoms of infection. (Low, Weak)
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  • Lifelong prophylaxis is recommended in high‐risk (D+/R‐) heart recipients. If prophylaxis is discontinued, ongoing clinical monitoring is recommended with expedited Toxoplasma PCR testing and empiric therapy initiation for signs and symptoms of infection.
(Low, Weak)
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Chagas disease (American Trypanosomiasis)

To diagnose Chagas infection in transplant candidates with epidemiological risk factors, we recommend serological testing. Positive results should be confirmed with a second test using a different assay. (High, Strong)
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To diagnose Chagas reactivation in SOT recipients, with known prior infection, we recommend a combination of a parasitological method and PCR testing available through the CDC with treatment promptly initiated if reactivation is confirmed. (Moderate, Strong)
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Post‐transplant prospective monitoring for recipients of T. cruzi‐infected donor organs should include both a parasitological method and PCR with treatment promptly initiated if the diagnosis is confirmed. (Moderate, Strong)
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For the treatment of T. cruzi infection in SOT recipients, we recommend the following:
  • Benznidazole 5‐7 mg/kg/d orally in two divided doses for 60 days as the treatment of choice. Patients should be closely monitored for significant rash, cytopenia, and neurologic side effects.
(Moderate, Strong)
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Nifurtimox 10 mg/kg/d orally in 3 divided doses for 90 days is an alternative for patients who cannot tolerate benznidazole. Nifurtimox is not approved in the United States and must be obtained through the CDC. (Low, Strong)
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We recommend that all SOT recipients with epidemiological risk factors for T. cruzi infection (personal or maternal history of residence in endemic areas) be screened using a serological assay. (High, Strong)
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We recommend that deceased donors with epidemiological risk factors as above for T. cruzi infection be screened using a serological assay. (Very Low, Weak)
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Heart allografts from T. cruzi antibody‐positive donors should not be transplanted. Other organs can be used at centers where screening for infection transmission can be implemented and timely diagnosis and treatment is available. (High, Strong)
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Leishmaniasis

For the diagnosis of VL in SOT recipients, we suggest the following:
  • Collecting tissue aspirates or biopsies specimens for smears, histopathology, culture, and PCR.
(Moderate, Strong)
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  • Bone marrow aspirate is the preferred source of a diagnostic sample. Liver biopsy and whole blood buffy coat are other potential sources.
(Moderate, Strong)
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  • Using multiple diagnostic tools to maximize the likelihood of a positive Leishmania result.
(Low, Strong)
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  • Clinicians contact the CDC before specimen collection and submission.
(Very Low, Strong)
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For the diagnosis of CL in SOT recipients, we suggest the following:
  • Obtaining a sample from the base and margins of ulcerative lesions after removal of eschars and exudates and thorough cleaning. Samples can be collected by scraping, aspiration, or biopsy.
(Low, Strong)
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  • Submitting specimens for smears, histopathology, culture, and PCR.
(Low, Strong)
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  • Using multiple diagnostic tools to maximize the likelihood of a positive Leishmania result.
(Low, Strong)
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  • Identification to the species level as treatment is species-dependent. This can be performed once promastigotes are identified by culture by isoenzyme electrophoresis, PCR, or matrix‐assisted laser desorption/ionization.
(Low, Strong)
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  • Clinicians should contact the CDC before specimen collections and submission.
(Very Low, Strong)
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For the treatment of VL in SOT recipients, we recommend the following:
  • Reduction in immunosuppression if possible.
(Very Low, Strong)
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  • Liposomal amphotericin B 4 mg/kg daily on days 1‐5, 10, 17, 24, 31, and 38 (total dose of 40 mg/kg).
(Low, Strong)
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For the treatment of CL in SOT recipients, we recommend the following:
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  • The antimicrobial agents used should be individualized considering multiple factors, in consultation with an infectious diseases expert.
(Low, Strong)
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We recommend SOT recipients visiting endemic areas minimize outdoor activities, especially from dusk to dawn. (Very Low, Weak)
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Standard protective measures include long sleeves and trousers, applying insect repellent (DEET) and using pyrethroid‐impregnated bed nets are warranted in endemic areas. (Low, Strong)
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Malaria

To diagnose malaria in transplant recipients, we recommend three sets of thick and thin smears every 12‐24 hours. (High, Strong)
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When microscopic evaluation by trained personnel is not available, we recommend rapid diagnostic tests. (Moderate, Strong)
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For the treatment of malaria in SOT recipients, we recommend an individualized approach considering severity, Plasmodium species, geographic‐resistance patterns, exposure to chemoprophylaxis, and drug availability, in consultation with an infectious diseases expert. (Moderate, Strong)
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To prevent reactivation, the recrudescence of low‐level parasitemia, and malaria donor‐derived events, we recommend screening all transplant donors and candidates with a comprehensive epidemiological history. (Very Low, Weak)
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To prevent de novo infection in travelers to endemic areas, we recommend a multi‐intervention approach that involves chemoprophylaxis and personal protective measures. (Moderate, Strong)
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Babesia

In SOT recipients with a compatible clinical presentation and exposure to Babesia, we recommend the following:
Multiple Wright‐Giemsa stained thin blood smears to identify intraerythrocytic ring forms. (High, Strong)
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PCR testing is more sensitive than blood smears but still may not detect infections with very low‐level parasitemia. (Moderate, Strong)
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For the treatment of Babesia in SOT recipients, we recommend atovaquone and azithromycin as first‐line therapy. (Moderate, Strong)
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Clindamycin and qunine is an alternative. (Moderate, Strong)
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We suggest monitoring of SOT recipients during therapy for Babesia to ensure clearance of the infection. Treatment should be extended for two weeks after resolution of parasitemia. (Moderate, Strong)
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To prevent Babesia infection, we recommend the following:
Transplant Candidates (, )
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Residents of highly endemic areas use tick repellants on skin and clothing and be vigilant for tick exposure especially between late spring and fall. (Very Low, Weak)
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FREE‐LIVING AMEBA INFECTIONS (ACANTHAMOEBA, BALAMUTHIA, AND NAEGLERIA)

Acanthamoeba

In SOT recipients with a clinical presentation compatible with Acanthamoeba infection, we recommend the following;
  • A lumbar puncture with CSF analysis and microscopy with Wright‐Giemsa stain.
(Low, Strong)
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  • Biopsies of affected organs (brain and skin) to identify Acanthamoeba cysts.
(High, Strong)
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  • PCR of CSF and affected organs can also aid in the diagnosis.
(Low, Strong)
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For the treatment of Acanthamoeba infection in SOT recipients, we recommend combination therapy though the preferred regimen is still not well defined. Consultation with CDC experts is advised. (Low, Weak)
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The risk of donor‐derived infection in patients with CNS infection due to Acanthamoeba is unknown at this time. Most published cases have been in immunocompromised patients at increased risk of disseminated Acanthamoeba. It is essential to distinguish skin or CNS disease due to Acanthamoeba from Balamuthia infection, which is a contraindication to organ donation. Transplant programs considering the use of organs from confirmed Acanthamoeba donors should seek expert consultation and obtain informed consent from the recipient. (Very Low, Weak)
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To prevent Acanthamoeba infection, we suggest that SOT recipients avoid direct skin or mucosal contact with untreated or inadequately treated water or soil. (Very Low, Weak)
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Balamuthia

In SOT recipients with a presentation compatible with Balamuthia infection, we recommend the following:
  • Skin biopsies, which often demonstrate trophozoites.
(Low, Strong)
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  • Brain biopsy for those with CNS involvement, to assess for the presence of trophozoite and cyst forms.
(Moderate, Strong)
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  • PCR of CSF or brain tissue.
(, )
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For the treatment of Balamuthia infection in SOT recipients, we recommend early initiation of combination therapy with albendazole, pentamidine, flucytosine, amphotericin, miltefosine, an azole, a macrolide, and a sulfonamide. (Very Low, Weak)
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To prevent acquisition of Balamuthia infection, we recommend SOT recipients avoid high‐risk soil and warm freshwater exposure, especially during defined outbreaks. (Very Low, Weak)
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To prevent a Balamuthia donor‐derived event, we recommend the following:
Carefully screening deceased organ donors for evidence of CNS infection. (Moderate, Strong)
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Organs from donors with known or suspected Balamuthia infection should not be transplanted. (Low, Strong)
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All recipients of deceased donors with possible Balamuthia infection should be urgently evaluated and offered empiric treatment. (Low, Strong)
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Naegleria

For the diagnosis of Naegleria infection in SOT recipients, we suggest the following:
  • Considering the diagnosis in patients presenting with purulent hemorrhagic CSF with hypoglycorrhachia typical of bacterial meningitis but with negative gram stain or those with leptomeningeal enhancement and progressive edema.
(Very Low, Weak)
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  • A CSF wet mount should be prepared, in those with a compatible clinical presentation.
(Low, Strong)
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For the treatment of Naegleria infection, we recommend aggressive combination therapy given the poor outcomes. High‐dose amphotericin B deoxycholate is the backbone of therapy with multiple other antimicrobials frequently prescribed along with dexamethasone for cerebral edema. (Very Low, Weak)
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To prevent Naegleria infection in SOT recipients, we suggest the following:
  • Avoiding direct nasal mucosal exposure to warm freshwater or soil, especially during summer months in areas where free‐living ameba are known to be present.
(Very Low, Weak)
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  • Avoiding using tap water for nasal or sinus irrigation.
(Low, Strong)
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Transplant programs considering the use of organs from donors with Naegleria infection should seek expert consultation and obtain informed consent from the recipient. (Very Low, Weak)
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Recommendation Grading

Disclaimer

Overview

Title

Tissue And Blood Protozoa Including Toxoplasmosis, Chagas Disease, Leishmaniasis, Babesia, Acanthamoeba, Balamuthia, And Naegleria In Solid Organ Transplant Recipients

Authoring Organization

Publication Month/Year

April 1, 2019

Last Updated Month/Year

December 2, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of tissue and blood protozoal infections in the pre‐ and post‐transplant period.

Target Patient Population

Solid organ transplant patients

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D019072 - Antibiotic Prophylaxis, D014180 - Transplantation, D019737 - Transplants, D016377 - Organ Transplantation, D011528 - Protozoan Infections

Keywords

infection prevention, infection, antibiotic, solid organ transplant, protozoa

Source Citation

La Hoz, RM, Morris, MI; on behalf of the Infectious Diseases Community of Practice of the American Society of Transplantation. Tissue and blood protozoa including toxoplasmosis, Chagas disease, leishmaniasis, Babesia, Acanthamoeba, Balamuthia, and Naegleria in solid organ transplant recipients— Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019; 33:e13546.