Screening Of Donor And Candidate Prior To Solid Organ Transplantation
Publication Date: April 1, 2019
Last Updated: March 14, 2022
Recommendations
DONOR SCREENING
Bacterial infections
Bacterial infections of the respiratory tract, urinary tract, bloodstream infection, or the organ to be transplanted should have documented appropriate treatment with evidence of infection control prior to donation. (Low, Strong)
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If a deceased donor is determined to have active bacterial infection based on cultures obtained at the time of procurement, antibiotics should be administered to each recipient for at least 14 days for infections with Gram‐negative bacilli or Staphylococcus aureus. (Low, Strong)
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A shorter course of therapy may be considered for less virulent organisms. (Low, Weak)
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Recipient of an allograft from a deceased donor with non‐bacteremic, localized infection not involving the transplanted organ does not require treatment, with the exception of meningitis, in which occult bacteremia frequently occurs. (Moderate, Strong)
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For potential lung donors, bronchoscopy with cultures should be performed and appropriate antibiotics initiated in the recipient to cover recovered bacteria. (Low, Strong)
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Syphilis has rarely been transmitted by transplantation, but it is not a contraindication to deceased organ donation if the recipient is treated post‐transplant with an appropriate course of penicillin. (Low, Strong)
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Donors in whom active tuberculosis is a clinical possibility should not be utilized. (Moderate, Strong)
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Potential living donors should have PPD testing performed (a two-stage tuberculin skin test if from an endemic area) or IGRA testing; if either test is positive, chest radiograph should be obtained to look for evidence of active pulmonary infection. (Low, Strong)
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Deceased donors with a history of an untreated LTBI but without evidence of active disease are acceptable but warrant consideration of treatment of the recipient(s) with isoniazid. (Low, Strong)
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Fungal infections
Routine donor screening of all donors for histoplasmosis from an endemic area is not warranted; however, explanted organs that may have granuloma should prompt fungal culture and testing for antigen and antibodies to Histoplasma. (Low, Strong)
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Calcified pulmonary, hilar, and splenic granulomata that are suggestive of old Histoplasma infection are not a contraindication to donation. (Low, Weak)
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Screening for Coccidioides should be considered in living donors from endemic areas; however, universal screening is not recommended for those outside the endemic area. (Moderate, Strong)
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Screening of cryptococcosis should be considered in donors who have meningoencephalitis of unknown etiology, pulmonary nodules of unknown etiology, or fever of unknown origin if they have underlying medical conditions that predispose to this infection (eg, end stage liver/renal disease, rheumatologic disorder, sarcoidosis, or receipt of corticosteroid/immunosuppressant). (Moderate, Strong)
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Parasitic infections
OPTN/UNOS mandates Toxoplasma screening by serology in all donors. (Moderate, Strong)
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Donor seropositivity for Toxoplasma is not a contraindication to organ donation but allows for appropriate prophylaxis to be administered to the recipient. Routine trimethoprim‐sulfamethoxazole against Pneumocystis jirovecii prophylaxis or, if with sulfa allergy, atovaquone with or without pyrimethamine/leucovorin is effective in preventing toxoplasmosis transmission for mismatched heart and other organ recipients. (Moderate, Strong)
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Screening for endemic infection including T. cruzi and Strongyloides should be performed based on epidemiologic risk factors. (Moderate, Strong)
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Transplantation of the hearts from donors with positive T. cruzi serology should be avoided. (High, Strong)
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Viral infections
All donors should be screened for CMV, EBV, HBV, HCV, and HIV. (High, Strong)
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NAT is used in addition to serology for HCV screening of deceased donors. (Moderate, Strong)
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HBV, HCV, and HIV screening of living donors should be close as possible to but no longer than 28 days prior to organ procurement. (Moderate, Strong)
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Due to the low seroprevalence of HTLV‐1 in the United States and the poor positive predictive value of screening HTLV‐1/2 assays in this population, routine screening of all deceased donors is not recommended. (Moderate, Strong)
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Living donors should have WNV NAT close to time of transplant. (Low, Strong)
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Avoid donors with any form of unexplained or confirmed WNV encephalitis. (High, Strong)
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CANDIDATE SCREENING
Pre‐transplant detection of active bacterial infection in the recipient
In general, active or uncontrolled infection in the potential recipient should delay transplant until infection resolves or is controlled (eg, controlled VAD‐related infections). (Moderate, Strong)
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Knowledge of the pre‐transplant colonizing flora can assist in developing an individualized peri‐transplant prophylactic antimicrobial regimen. (Low, Strong)
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Mycobacterial infections
All candidates should have a PPD or IGRA performed prior to transplant, and those who have a positive skin test or IGRA, or a history of active tuberculosis, should undergo additional screening to rule out active disease. (Moderate, Strong)
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Candidates with LTBI should be given prophylaxis to prevent reactivation of disease in the setting of immunosuppression. (Moderate, Strong)
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Fungal infections
A pre‐transplant candidate with invasive fungal infection (rather than colonization) should be treated at least until there is radiographic, clinical, and microbiologic resolution in order to minimize the risk of this high‐mortality infection post‐transplant. (Low, Strong)
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Pre‐transplant screening for endemic mycoses is most useful in areas endemic for Coccidioides spp, where a pre‐transplant history of active disease and/or seropositivity may prompt lifelong azole prophylaxis. (Moderate, Strong)
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Pre‐transplant screening for histoplasmosis is not recommended. (Very Low, Weak)
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Parasitic infections
Candidates with known endemic exposure to Strongyloides and T. cruzi should be screened.
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Serologic screening for Strongyloides is preferred over stool examinations. (Low, Weak)
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Toxoplasma serology should be performed in all patients undergoing organ transplantation, in particular heart transplant candidates; seronegative recipients with seropositive donors and seropositive recipients should receive prophylaxis. (Low, Strong)
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Viral infections
Screening for CMV, EBV, HBV, HCV, and HIV should be performed in all transplant candidates. (High, Strong)
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Active viral infection in a potential recipient transplantation should be delayed if possible until the infection resolves. (Low, Strong)
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VZV and MMR screening of the recipient is important, with vaccination of the seronegative recipient pre‐transplant if at all possible. (Very Low, Strong)
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Recommendation Grading
Overview
Title
Screening Of Donor And Candidate Prior To Solid Organ Transplantation
Authoring Organization
American Society of Transplantation
Publication Month/Year
April 1, 2019
Last Updated Month/Year
December 2, 2022
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This updated section of the guideline from the Infectious Diseases Community of Practice of the American Society of Transplantation reviews the screening of donor and candidate prior to solid organ transplantation.
Target Patient Population
Solid organ donors and recipient
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening
Diseases/Conditions (MeSH)
D014180 - Transplantation, D019737 - Transplants, D016377 - Organ Transplantation, D060053 - Transplant Donor Site, D046148 - Donor Selection
Keywords
infection prevention, infection, organ donation, solid organ transplant, donor
Source Citation
Malinis, M, Boucher, HW; on behalf of the AST Infectious Diseases Community of Practice. Screening of donor and candidate prior to solid organ transplantation—Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019; 33:e13548