Beth Israel Deaconess Medical Center
Transplant Manual
Title: Fever following Liver/Kidney/Pancreas Transplantation
Purpose: To provide instructions for the treatment of fevers in patients < 90 days
post organ transplantation
Policy Statement:
Recommendations for evaluation and treatment for patients with fever posttransplantation.
Definition:
Fever: oral temperature >100.5
Procedure:
Immediately post-op:
1) Evaluation for source of fever to include: microbiologic infection of surgical site
or anastamotic injury, lungs, bladder, blood stream and line sites, stool for c.
difficile toxin, as well as careful assessment for non-infectious causes of fever
including medications, atelectasis, and, if indicated clinically, pulmonary
embolism or other potential reasons.
2) Intravenous antibiotics will be administered based upon exposure risk,
antibiogram of the ICU or Farr 10 if appropriate, at time of initial evaluation.
3) Inpatient Infectious Disease consultation will be obtained as appropriate for
additional diagnostic and management support and suggestions for alternative
agents in persons with documented allergy to an antibiotic or who demonstrate
an allergic response to an antibiotic.
4) Once stabilized, depending upon the source of infection and organism, the
patient may be followed as an outpatient by the Transplantation Infectious
Disease physician.
Outpatient presentation:
1)
Evaluation for source of fever in patients who are discharged and return for
outpatient followup should include assessment of the wound and
anastamotic sites radiographically, lungs, urine, and other end-organ
possibilities through a thorough history and physical examination.
2)
In most cases, patients will be admitted to the hospital for more rapid
diagnostic and therapeutic interventions
3)
Microbiologic assessment to include viruses, including but not limited to:
respiratory viruses (seasonally directed): RSV, adenovirus, parainfluenza 1,
2, and 3, and influenza A and B; reactivated or primary CMV based upon
risk group (D+/R->D+/R+ or D-/R+> D-R-); EBV reactivation and B cell
infection (PTLD); if appropriate, VZV, HSV or other viruses; bacterial with
blood cultures and if needed, urine, stool or sputum cultures; assessment
for PCP/PJP if indicated by review of systems; reassessment for
reactivation of a latent infection that could not be identified pre-
1
4)
5)
6)
transplantation, including reactivated HBV, latent TB infection, infectious
granulomatous diseases such as histoplasmosis, blastomyces,
coccidiomycoses, or other endemic fungi associated with foreign travel;
reactivation of parasitic infections such as Strongyloides; and additional
thorough assessment for travel or social exposures;
Radiographic studies will be performed as indicated by physical and clinical
findings and history/review of systems.
Empiric antimicrobial coverage will be dictated by the presenting signs,
symptoms and objective findings. These may include, but not be limited to:
a) vancomycin for non-resistant gram positive infections;
b) daptomycin or linezolid for suspected resistant gram positive infections;
c) an antipseudomonal antimicrobial such as piperacillin/tazobactam or
cefepime or meropenem as indicated;
d) for suspicion of c. difficile colitis, metronidazole will be the first line
agent; in some cases, oral vancomycin will be issued;
e) for antifungal therapy, this will be determined based upon IS used, and
through consultation with Infectious Disease;
f) for antiviral therapy, this will be determined based upon condition and
through consultation with Infectious Disease;
g) for antiparasitic therapy, this will be determined based upon condition
and through consultation with Infectious Disease.
Antimicrobial agents and duration of the agents will be determined by
clinical data and identification of the etiologic agent.
The Inpatient Infectious Diseases consultation services will be consulted as needed.
Vice President Sponsor:
Approved by:
x Liver Selection Committee
Requestor Name:
Original Date Approved:
Next Review Date:
Revised:
Dianne Anderson, Sr. VP PCS
Douglas W. Hanto, MD, PhD and Michael Curry, MD
Co-Chairs
Michael Curry, MD
12/06
1/08
Eliminated:
2