Antimicrobial prophylaxis after lung transplantation*

IV: intravenously.
* The approach to antimicrobial prophylaxis varies by transplant center and by the patient's individual risk factors. Some examples of agents for prophylaxis are listed above. Refer to the appropriate UpToDate topic reviews for specific prophylaxis indications and recommendations.
¶ The standard regimen should be adjusted as indicated to include coverage for any other known preoperative pathogens in the recipient. This is particularly indicated for recipients with cystic fibrosis, bronchiectasis, and other septic lung diseases. Coverage should also be modified to include any additional organisms identified from donor bronchial washings. For patients whose chest is left open post-transplant, we also add a systemic antifungal agent (eg, an echinocandin such as micafungin).
Δ Doses should be adjusted for renal insufficiency.
◊ If ceftazidime is not available, alternative beta-lactams with anti-pseudomonal activity include cefepime and piperacillin-tazobactam. Patients who are allergic to beta-lactams should receive levofloxacin 750 mg IV approximately 60 minutes before incision, then 750 mg every 24 hours.
§ The optimal duration of antimicrobial prophylaxis is uncertain, varies at different transplant centers, and is determined based upon several patient-specific factors. For patients without septic lung disease (eg, cystic fibrosis) who have an uncomplicated course following transplantation, we typically continue systemic antibacterial prophylaxis for at least 72 hours to allow time to determine whether donor cultures are positive. For patients with septic lung disease or complicating factors such as a chest that remains open following transplantation, longer durations are appropriate.
¥ Systemic antifungal prophylaxis with voriconazole is given to selected patients at increased risk for invasive fungal infections. Refer to the topic review on fungal infections in lung transplant recipients for indications for systemic antifungal prophylaxis with voriconazole.
‡ When voriconazole (or another azole) is used, the clinician must be aware of its significant interactions with tacrolimus, cyclosporine, and sirolimus and reduce the dose of the immunosuppressant agent accordingly.
† Intravenous voriconazole should generally be avoided in patients with renal insufficiency (CrCl <50 mL/min) due to accumulation of the cyclodextrin vehicle; oral voriconazole does not contain the cyclodextrin vehicle. Refer to the UpToDate topic review on pharmacology of azoles for additional details. 
** Alternate choices for patients with sulfonamide hypersensitivity: Atovaquone 1500 mg orally once daily with food or dapsone 50 mg or 100 mg orally once daily or aerosolized pentamidine 300 mg monthly or 4 mg/kg pentamidine IV monthly, continuing indefinitely.
¶¶ For Toxoplasma gondii mismatch (donor seropositive/recipient seronegative), trimethoprim-sulfamethoxazole should be dosed at 1 double-strength tablet orally once daily.
ΔΔ The duration of cytomegalovirus (CMV) prophylaxis varies. Refer to the UpToDate topic review on prevention of CMV in lung transplant recipients for detailed recommendations.  
◊◊ CMV prophylaxis with valganciclovir or ganciclovir will effectively prevent most cases of herpes simplex virus (HSV) and varicella-zoster virus (VZV). Specific HSV and VZV prophylaxis is therefore indicated only for patients not receiving CMV prophylaxis. HSV and VZV prophylaxis is typically given for three to six months following transplantation and during periods of lymphodepletion for the treatment of rejection.