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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Overview

Title

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

Authoring Organization

American Society of Transplantation