From the Guidelines
Prophylactic antimicrobial regimens for pediatric heart transplant recipients should include trimethoprim-sulfamethoxazole (TMP-SMX) for Pneumocystis jirovecii pneumonia prevention, with a minimum duration of 12 months post-transplant, as recommended by the study published in Kidney International 1. The recommended dose of TMP-SMX is 5 mg/kg/day of the TMP component given twice daily on 2-3 consecutive days per week. Antifungal prophylaxis with nystatin oral suspension (100,000-400,000 units 4 times daily) or fluconazole (3-6 mg/kg/day) is also recommended for 1-3 months. For cytomegalovirus (CMV) prophylaxis, valganciclovir is given at 16-20 mg/kg/dose twice daily for 3-6 months, with duration depending on donor/recipient CMV serostatus, as suggested by the study published in Kidney International 2. Some key points to consider when implementing these prophylaxis regimens include:
- Dosing should be adjusted for renal function
- Drug interactions with immunosuppressants must be monitored
- Regular laboratory monitoring for adverse effects and therapeutic drug levels is essential for safe and effective prophylaxis
- High-risk patients (donor CMV+/recipient CMV-) may require longer prophylaxis
- Some centers also provide prophylaxis against Toxoplasma gondii with pyrimethamine plus folinic acid in high-risk patients. These antimicrobial prophylaxis regimens are crucial because post-transplant immunosuppression significantly increases infection risk, and the duration of prophylaxis should be guided by the type of transplant and the unit's outbreak status, as recommended by the study published in Kidney International 1.
From the FDA Drug Label
2.3 Recommended Dosage in Pediatric Patients Prevention of CMV Disease in Pediatric Heart Transplant Patients: For pediatric heart transplant patients 4 month to 16 years of age, the recommended once daily mg dose (7x BSA x CrCL) should start within 10 days of transplantation until 100 days post-transplantation
The prophylaxis antimicrobial for pediatric patients with post heart transplant is valganciclovir. The recommended dosage is calculated based on body surface area (BSA) and creatinine clearance (CrCL) using the equation:
- Pediatric Dose (mg) = 7 x BSA x CrCL The dosage should start within 10 days of transplantation and continue until 100 days post-transplantation 3.
Key points:
- The recommended dosage is based on body surface area (BSA) and creatinine clearance (CrCL)
- The dosage should start within 10 days of transplantation
- The treatment should continue until 100 days post-transplantation
- Valganciclovir is used for the prevention of CMV disease in pediatric heart transplant patients at high risk [4] [5].
From the Research
Prophylaxis Antimicrobial for Pediatric Patients with Post-Heart Transplant
- The use of prophylaxis antimicrobial for pediatric patients with post-heart transplant is a common practice to prevent Pneumocystis jirovecii pneumonia (PJP) 6.
- Trimethoprim/sulfamethoxazole (TMP/SMX) is the first-line agent for PJP prophylaxis, with a duration of 4-6 months being the most frequent for heart transplant recipients 6.
- The tolerability of low-dose TMP/SMX for PJP prophylaxis has been studied, and it has been found to be well-tolerated in kidney transplant recipients 7.
- Alternative prophylactic therapies, such as dapsone, pentamidine, atovaquone, and clindamycin, may be used in cases of intolerance or allergy to TMP/SMX 8.
- The efficacy of twice weekly prophylaxis with TMP/SMX for PJP in pediatric oncology patients has been evaluated, and it has been found to be insufficient to prevent PJP in children with hematologic malignancies 9.
- A phase III randomized, placebo-controlled, dose-comparison trial is currently underway to compare the efficacy and safety of low-dose TMP-SMX with the standard of care for the treatment of PJP 10.
Duration of Prophylaxis
- The duration of PJP prophylaxis varies by center and organ type, with 4-6 months being the most common for renal, liver, and heart transplant recipients 6.
- Some centers provide lifelong prophylaxis, especially for lung transplant recipients 6.
- The decision to restart prophylaxis after completion is often based on the risk of acute graft rejection 6.