Infections in the first 2 or 3 weeks following lung transplantation are usually bacterial in origin and are due to colonization of the donor lung. The most common pathogens are Staphylococcus aureus, Pseudomonas aeruginosa, other Gram-negative organisms, and Candida albicans. Viral and other fungal infections tend to occur later.
Cytomegalovirus infections present a unique problem in lung transplantation because of their frequency and severity. They occur more often in the presence of cytomegalovirus mismatches (cytomegalovirus-positive donor-cytomegalovirus-negative recipient, or cytomegalovirus-negative donor-cytomegalovirus-positive recipient). Cytomegalovirus-positive recipients receiving grafts from cytomegalovirus-positive donors are also at a higher risk of developing cytomegalovirus pneumonia or disseminated infection. Cytomegalovirus can be acquired by cytomegalovirus-negative patients receiving a donor lung from a cytomegalovirus-negative donor through transfusion of contaminated blood or through a new infection. When either donor or recipient are cytomegalovirus positive, ganciclovir is started on the seventh postoperative day for cytomegalovirus prophylaxis at a dose of 5 mg/kg intravenously twice a day for 2 weeks, followed by 5 mg/kg/day for as long as 3 months. Acyclovir (aciclovir) 400 mg orally three times daily is given for herpes prophylaxis to patients who do not require ganciclovir for cytomegalovirus prophylaxis.
Antibiotics are given preoperatively and continued postoperatively. We use piperacillin-tazobactam 3.375 mg intravenously every 6 h. Antibiotic coverage is modified as soon as cultures and sensitivities become available from specimens obtained during bronchoscopy performed in the operating room at the completion of the operation. Trimethoprim-sulfamethoxazole (co-trimoxazole), one tablet double-strength three times per week, is started for Pneumocystis carinii prophylaxis 1 month post-transplant and continued for as long as a year.
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