Strategies for safe living

Strategies for Safe Living Following Solid Organ Transplantation

American Society of Transplantation

Overview
Preventing direct contact infections
Preventing respiratory infections
Water safety and cryptosporidium
Food safety
Animal contact and pet safety
Safe sexual practices
Travel safety
Citation
Strength of Recommendations
References

Overview

The risk of infection following solid organ transplantation is determined by the recipient’s net state of immunosuppression, epidemiologic exposures and the consequences of the invasive procedures to which the recipient has been subjected (1-4). Transplant recipients are at risk for developing infection with endogenous organisms that are reactivated during periods of excess immunosuppression. They may also develop opportunistic infections with exogenously-acquired organisms if exposed to a high inoculum or particularly virulent microbes, even during periods of minimal or maintenance immunosuppression(1-4). Various measures can be taken to reduce high-risk epidemiologic exposures in the hospital and in the community, and transplant recipients should be counseled in ways to minimize the risk of infection. Furthermore, strategies for safe living must be carefully woven with the transplant recipient’s attempts to regain normal function and return to normal life.
Solid organ transplant recipients are at greatest risk of infection during the first six months after transplantation and at any time that their immunosuppression is augmented for episodes of rejection. In addition to the dose and duration of immunosuppressive therapy, the type of immunosuppressive used is important in determining the risk of infection. For example, corticosteroids increase the risk for disseminating infection with fungi such as Aspergillus, Coccidioides, and Candida, whereas, anti-lymphocyte therapies (OKT3, antithymocyte globulin) are associated with cytomegalovirus (CMV) reactivation.

There are no “hard data” or controlled studies regarding safe living practices following solid organ transplantation. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients (5) and in persons infected with human immunodeficiency virus (6), drafted by various working groups that include members from the Centers for Disease Control, Infectious Diseases Society of America, United States Public Health Service, and American Society of Blood and Marrow Transplantation, were used to prepare this document. Thus, the recommendations that follow are based on anecdotal clinical experience, available knowledge of the mode in which various infectious agents are transmitted, the opinions of respected authorities, and common sense [A III]. Guidelines for the prevention of infection in solid organ transplant recipients should be tailored to the individual recipient by their physician with special consideration of the patient’s degree of immunosuppression and personal circumstances.

Prevention of Infections Transmitted by Direct Contact

Most organisms are acquired through either direct contact (carried on hands) or inhalation. Frequent and thorough hand washing cannot be over-emphasized as a means of preventing infections that are transmitted by direct contact [AIII]. Hands should be washed with an antimicrobial soap and water [AIII]. Hygienic hand rubs are an acceptable alternative for maintaining clean hands. Gloves should be worn whenever handling heavily contaminated materials such as soil, moss or manure. Going barefooted should be avoided. Shoes, socks, long pants and long sleeved shirts should be worn while doing gardening, yardwork, farming, or being in parks or wooded areas. [CIII]. Administration of insect repellent and avoidance of outdoor exposures at dawn and dusk can help to prevent exposure to West Nile virus, during the summer and early fall in areas of possible transmission.

Hands should be washed [including after gloves are used]:

before preparing food and before eating
before and after touching wounds (whether or not gloves are used)
before touching mucous membranes
after touching pets and animals
after gardening, touching plants or soil
after changing diapers
after touching secretions-and excretions
after touching items that have had contact with human or animal feces, (e.g., bedpans, bedding, toilets, litter boxes)

Prevention of Respiratory Infections

Microbes that cause respiratory infections are transmitted by either inhalation of aerosolized organisms or direct contact from contaminated hands to mucus membranes. Thus, transmission of respiratory pathogens can be reduced by:

frequent and thorough hand washing, particularly prior to touching mucus membranes [BIII]
avoiding close contact with persons with respiratory illnesses [AIII]. If contact is unavoidable, ideally both the infected person and the transplant recipient should wear a standard surgical mask [CIII].
avoiding crowded areas, such as shopping malls, subways, elevators, where close contact with persons with respiratory illness is likely [BIII]
avoiding tobacco smoke. Smoking and exposure to environmental tobacco smoke are risk factors for bacterial and community-acquired viral infections [CIII]. Marijuana smoking should also be avoided because of its association with exposure to Aspergillus spores [BIII].
avoiding exposure to people with known active tuberculosis and avoiding activities and occupational exposures that increase the risk of exposure to tuberculosis, e.g., working in prisons, jails, homeless shelters, certain health care settings [BIII]. Decisions to continue working in high risk areas should be made be made jointly by the patient and primary care physician.
avoiding construction, excavation or other dust-laden environments where there may be a high concentration of mold spores (e.g., Aspergillus).
avoiding exposure to Aspergillus and other environmental molds through soil, fertilizer, decaying vegetation including compost heaps; gardening and farming is best avoided during at least the first year after transplant, or masks can be worn if exposure is unavoidable
avoiding exposure to fungal spores (Cryptococcus, Histoplasma, Coccidioides) by avoiding plant and soil aerosols, pigeon and other bird droppings, chicken coops, and caves.

Water Safety/Exposure to Cryptosporidium

There are very few data delineating the risk for, and epidemiology of cryptosporidiosis among solid organ transplant recipients. Albeit an uncommon infection in this population, Cryptosporidium can cause severe, chronic diarrheal disease in immunocompromised hosts, particularly those receiving corticosteroids. Therefore, it is prudent for solid organ transplant recipients to decrease their exposure to this pathogen. The following precautions are suggested:

Municipal tap water (even if treated) may not be completely free of Cryptosporidium, however, there is no data to support a recommendation that all tap water be avoided unless a “boil water” advisory is issued by the authorities. During a “boil water” advisory or to completely eliminate the risk of Cryptosporidium contamination, one should only drink water that has been boiled for at least one minute [AI]. Persons avoiding tap water should be aware that ice, and fountain beverages served at restaurants, bars, theaters, sporting events, etc. are prepared with tap water.
Persons wanting to take independent action to reduce their risk of waterborne cryptosporidiosis should be aware that boiling water for one minute is the only sure way to do this. Personal-use filters and/or bottled water may serve as alternatives to boiling water but careful attention must be paid to selecting effective filters and high-quality bottled water. A list of filters certified under NSF Standard 053 for cryptosporidial cyst removal may be obtained by contacting the NSF International consumer line at 800-673-8010 or http://www.nsf.org/notice/crypto.html. Information regarding bottled water can be obtained from the International Bottled Water Association at 703-683-5213 or (http://www.bottledwater.org).
Well water from private wells or public wells in areas where it is checked infrequently for bacterial pathogens should be avoided.
Transplant recipients should not drink water directly from lakes or rivers because of the risk of cryptosporidiosis, giardiasis and bacterial pathogens [AIII].
Waterborne infection might also arise from inadvertent swallowing of water during recreational activities such as swimming in lakes, rivers or pools, or going on water rides at amusement parks [BII]. Transplant recipients should avoid swimming in water that is likely to be contaminated with human or animal waste, and should avoid swallowing water during swimming [BII].

Food Safety

Many of the following recommendations have been made for the population at large. These recommendations may be updated as new outbreaks are reported. Clearly transplant recipients should:

avoid drinking or eating food made with unpasteurized milk or drinking unpasteurized fruit or vegetable juice/cider in order to decrease their risk of infection with E coli 0157:H7, Salmonella , Brucella, Listeria,Yersinia and Cryptosporidium [AIII].
avoid eating raw or undercooked eggs including foods containing raw eggs (e.g., uncooked cake and cookie batter and some preparations of Caesar salad dressing, mayonnaise, or hollandaise sauce) [AIII].
avoid eating raw or undercooked meat, poultry or fish .
avoid all raw or undercooked seafood (oysters, clams, mussels) to prevent exposure to Vibrio species, viruses that cause gastroenteritis or hepatitis, and Cryptosporidium
avoid raw seed sprouts (alfalfa sprouts, mung beans); raw green onions (hepatitis A).
avoid cross-contamination when preparing food, (e.g., keep cooked and raw foods separate; use cleaned or separate cutting boards).
avoid soft cheeses (feta, brie, camembert) or cheese made with unpasteurized milk to decrease their risk of listeriosis.
fruits and vegetables should be peeled or very thoroughly washed
fast-food establishments and open salad bars are best avoided
hot dogs and turkey franks have been associated with Listeria and are best avoided, or very thoroughly cooked
leftovers, if consumed, should be reheated to steaming hot, since Listeria can be found in previously cooked refrigerated foods
community picnics and buffet events at which food may have been left for prolonged times at room temperature are potentially risky

Animal Contact and Pet Safety

Occupational risk
Transplant recipients who work with animals (veterinarians, pet store employees, farmers, slaughterhouse or laboratory workers) should, if possible, avoid working during periods of maximal immunosuppression [BIII]. When they return to work, they should minimize their exposure to potential pathogens by using proper precautions including hand washing, the use of gloves and masks as indicated.
Pet ownership
Health care providers must balance the psychological benefits of pet ownership with potential risks for transmission of infection when counseling solid organ transplant recipients on the safety of maintaining pets.

In general, transplant recipients should:

avoid contact with animals that have diarrhea [BIII]
keep their pets healthy by feeding them food that is not contaminated or spoiled, and seeking veterinary help at the first signs of illness.
wash hands carefully after handling pets
avoid cleaning bird cages, litter boxes, and animal feces. If this is not possible, the use of disposable gloves and a standard surgical mask should be employed.
avoid stray animals.
avoid animal scratches.(do not pet stray animals)
avoid contact with reptiles (snakes, iguanas, lizards and turtles) chicks, and ducklings, to decrease the risk of Salmonella infection.
avoid contact with non-human primates (monkeys).
wear gloves to clean aquariums.
avoid acquiring pets, especially cats that are less than 1 year of age as they are at greatest risk of being infected.
avoid mosquito bites

Cats can spread Toxoplasma, Cryptosporidium, Salmonella, Campylobacter (contaminated feces) and Bartonella (fleas and scratches). Cat litter boxes should be changed daily (preferably not by transplant recipients), because it takes longer than 24 hours for toxoplasma oocysts to become infectious.

Safe Sexual Practices.

Sexually active transplant recipients should:

avoid exposure to feces during sexual activity [AIII].
always use latex condoms during sexual contact when not in long term monogamous relationships to reduce exposure to CMV, hepatitis B and C, HIV, and HSV, and other sexually transmitted diseases [AIII].
consider using latex condoms during sexual activity with long term monogamous partners during periods of increased immunosuppression [CIII].

Travel Safety

Travel to developing countries poses substantial risk to transplant recipients, particularly during periods of maximal immunosuppression [AIII]. Plans to travel should be discussed with the transplant recipient’s physician at least two months prior to the planned departure date. All items discussed above are applicable for safe living during travel. Updated travel advisories should be obtained from the CDC website www.cdc.gov .

While traveling in developing countries, the transplant recipient should avoid consuming:

tap water, ice and beverages made with tap water.
fresh fruit juices.
unpasteurized milk and dairy products.
raw fruits and vegetables.
raw or undercooked meat, poultry, fish, and seafood.
raw or undercooked eggs.

To insure their safety transplant recipients should:

ingest fruits and vegetables that they can peel
ingest steaming hot foods
drink bottled and canned processed drinks
boil their tap water or disinfect it with iodine or portable filters.

Whereas routine antimicrobial prophylaxis for diarrhea is not recommended, travelers should be given antibiotics to take with them and instructed on their use. Other issues related to travel safety include:

Malaria prophylaxis should be provided as indicated by the travel plans, and after careful consideration of interactions with the drugs that the transplant recipient is taking. Travelers should take with them a sufficient supply of medications that they may require.
The transplant recipient’s immunization status should be assessed well in advance of travel and appropriate vaccinations should be given. In general, live virus vaccines should be avoided. Routine vaccinations should be updated. The transplant recipient should be advised vaccines may not be effective.
Transplant recipients should be advised about all preventive measures that pertain to their anticipated exposures (e.g., protection against arthropod vectors, swimming precautions, etc).
The risks of hobbies such as hunting, fishing, scuba diving, spelunking, etc. should be discussed with the transplant recipient.

Citation

Strategies for safe living following solid organ transplantation. Am J Trasnplant 2004; 4(Suppl 10): 156-9.

Strength of Recommendations

Strength of Recommendations
A - Strongly recommended
B - Generally recommended
C - Optional
D - Generally not recommended
E - Never recommended

Quality of Evidence
I - Evidence from at least one well-executed RCT
II - Evidence from at least one well-designed clinical trial without randomization; cohort or case-controlled studies; analytic studies (preferably from more than one center); multiple time-series studies; or dramatic results from uncontrolled experiments
III - Evidence from opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees.

References

1.   Schaffner A, Rubin, R.H., and Speich, R., editors. Immunocompromised Host Society Consensus Conference on epidemiology, prevention, diagnosis, and management of infections in solid-organ transplant patients. Clin Infect Dis 2001;33:S1-S65.
2.   Rubin RH, and Young, L. S., editors. Clinical Approach to Infection in the Compromised Host. New York: Plenum; 2002.
3.   Fishman JA, Rubin RH. Infection in organ-transplant recipients. N Engl J Med 1998;338(24):1741-51.
4.   Bowden RA, Ljungman, P, and Paya, C. V., editors. Transplant Infections, Second Edition. Philadelphia: Lippincott Williams and Wilkins; 2003.
5.   Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Recomm Rep 2000;49(RR-10):1-125, CE1-7.
6.   Kaplan JE, Masur H, Holmes KK. Guidelines for preventing opportunistic infections among HIV-infected persons--2002. Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America. MMWR Recomm Rep 2002;51(RR-8):1-52.