Prevention and treatment of selected fungal and viral infections in pediatric liver transplant recipients

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Abstract
Infection continues to be a significant cause of morbidity and mortality after transplantation. Three pathogens that cause significant morbidity are Candida, cytomegalovirus, and Epstein‐Barr virus. Routine culture of the Roux‐En‐Y limb at the time of biliary reconstruction, coupled with routine surveillance for Candida colonization, identified a group of children at risk for candida sepsis. With positive cultures, 7‐ to 10‐day courses of amphotericin B decreased the incidence of symptomatic and asymptomatic Candida infection by 50%. Epstein‐Barr virus (EBV) remains a difficult infection to detect. EBV hepatitis is a diagnosis of exclusion. Epstein‐Barr virus hepatitis is often initially treated as rejection (100%), can relapse (40%), and can result in graft loss (20%). Treatment with high‐dose intravenous acyclovir (45 mg/kg/day) can resolve the infection in 57% of cases. Cytomegalovirus (CMV) continues to be a major cause of morbidity after transplantation. The use of prophylactic i.v. IgG decreased the incidence of asymptomatic and symptomatic CMV infection by 50%. Symptomatic CMV disease can be successfully treated with intravenous ganciclovir with 87% survival. Ganciclovir caused minimal bone marrow suppression in this series; however, 75% of children treated exhibited at least a doubling of their creatinine during therapy, and necessitated dialysis in 1 patient. Renal function returned to normal in all patients after treatment was stopped.