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Sepsis Prophylaxis

Bacterial

Prophylaxis for bacterial infection is guided by donor specimens (washings obtained during the donor bronchoscopy, as well as swabs from the donor bronchus at the time of implantation) and swabs from the recipient bronchus at the time of recipient pneumonectomy. If no organisms are identified in these specimens, then a cephalosporin is utilized for 3 or 4 days postoperatively.

If gram positive organisms are identified, vancomycin 1 g q12hrs is the regimen of choice. If gram negative organisms are seen, ceftazidime 1 to 2 g intravenously q8hrs can be used. However, if there is a progression of pulmonary infiltrates despite use of intravenous ceftazidime, then conversion to imipenem 500 mg intravenously q6hrs should be considered.

In patients with chronic septic lung disease (for example cystic fibrosis), initial antibiotics are directed at the recipient's organisms based on pre-operative culture and sensitivity data.35 Aerosolized colistin or tobramycin can also be utilized.

Viral

Routine use of acyclovir has eliminated herpes infection as a postoperative complication. However, CMV infection remains a significant problem in lung transplant recipients. The reported incidence of CMV infection and disease following lung transplantation in the post-ganciclovir era ranges from 35% to 86% with an associated mortality rate of 2% to 12%.36 The highest risk occurs in the case of the CMV mismatch. The seronegative recipient of a CMV-positive organ is at the highest risk of developing severe, sometimes fatal disease. It is critical to define CMV infection and disease.37 Cytomegalovirus infection is defined by isolation of the virus or by demonstrating its presence by immunologic or molecular techniques or by seroconversion. Currently available techniques include the shell vial assay, pp65 antigenemia, polymerase chain reaction or hybrid capture assays for CMV DNAemia. Cytomegalovirus disease is diagnosed by histologic evidence of tissue invasion or a characteristic syndrome after exclusion of other etiologies in the presence of CMV infection.

Three potential mechanisms of CMV infection have been recognized: transmission by the donor organ; transmission by blood products; or reactivation of latent virus in the recipient. In the absence of endogenous antibody protection, primary CMV infections, particularly CMV pneumonitis or gastrointestinal disease, may be quite severe with mortality rates of 2% to 20%.

Based on the potential mechanisms on infection, four strategies to prevent CMV infection have been utilized:

a. matching the donor-recipient pair by CMV serologic status b. use of CMV-negative blood products c. use of antiviral agents to suppress viral replication d. use of immunoglobulin (Ig) preparations to provide passive immunization.

However, to date, primarily due to the lack of randomized, controlled trials comparing regimens, the "ideal" strategy for the prevention, monitoring and treatment of CMV remains controversial. Several protocols have been utilized for pro

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