Infections

Two peak periods exist for infectious complications following heart transplantation. Nosocomial infections dominate the first postoperative month or early period and include catheter-related infections secondary to staphylococcal species and Gram-negative organisms. Thus all indwelling catheters should be removed early. Despite the need for continued inotropic agents, pulmonary artery and arterial catheters are generally removed on the first postoperative day. Patients receive prophylactic vancomycin for 48 h and third-generation cephalosporin antibiotics in the perioperative period. Infections during the late period (the second to fifth postoperative month) are dominated by viruses, fungi, and bacteria. Treatment is culture and serology based.

Prophylactic treatment of cytomegalovirus-seronegative recipients of cytomegalovirus-seropositive donors remains controversial and institution dependent. Many centers treat cytomegalovirus-negative heart transplant recipients who receive a cytomegalovirus-positive donor heart with ganciclovir for the first several days after transplant; others wait for symptomatic cytomegalovirus disease to manifest before treatment. Cytomegalovirus disease is usually subacute and may cause pneumonia, gastrointestinal symptoms (i.e. anorexia, nausea, epigastric pain, diarrhea), and/or bone marrow suppression (most commonly leukopenia).

Less controversy surrounds treatment of toxoplasma-seronegative recipients who receive a heart from a seropositive donor. Most centers routinely give several weeks of treatment with pyrimethamine and folinic acid. Toxoplasma gondii disease can cause a severe myositis with myocardial involvement as well as encephalitis. If disease develops, treatment consists of clindamycin or sulfadiazine plus higher doses of pyrimethamine.

Mediastinitis has traditionally been thought to be a severe and life-threatening infection following heart transplantation. However, two large series totaling over 750 patients reported no increased mortality in heart transplant recipients who developed mediastinitis. The incidence of mediastinitis reported in those reviews was less than 3 per cent.

Other practical infection control issues include the risk of Pneumocystis carinii pneumonia and oral herpes, and the need for reverse isolation. P. carinii pneumonia has become a much less commonly reported pathogen with the advent of prophylactic trimethoprim-sulfamethoxazole (co-trimoxazole) in all patients at risk. Herpes simplex virus positive recipients all receive a 3-month course of acyclovir (aciclovir) orally to prevent reactivation. Finally, from a practical standpoint, there is no need for routine reverse or protective isolation following heart transplantation.

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