What are the NOTTO (National Organ and Tissue Transplant Organization) guidelines for infectious disease screening in organ transplantation at a transplant center in a specific location?

NOTTO Guidelines for Infectious Disease Screening in Organ Transplantation

I cannot provide specific NOTTO (National Organ and Tissue Transplant Organization) guidelines as the evidence provided does not contain any NOTTO-specific protocols or recommendations. The available evidence consists of international guidelines from the Clinical Microbiology and Infection society, CDC, and American Society of Transplantation, but no NOTTO-specific guidance is present in the provided materials. 1

Standard International Screening Framework (In Absence of NOTTO-Specific Guidelines)

Since NOTTO guidelines are not available in the evidence, I will outline the internationally recognized screening standards that transplant centers typically follow:

Mandatory Universal Screening for All Donors and Recipients

Blood-Borne Viral Pathogens

• HIV antibody/antigen testing is required for all donors and recipients, with nucleic acid testing (NAT) mandatory for high-risk donors to reduce the window period from 22 days to 5-10 days. 1
• HBV screening must include HBsAg and total HBcAb for all donors; recipients require sequential testing starting with HBsAg, followed by anti-HBs quantification if negative (protective immunity ≥10 IU/mL). 1
• HCV screening requires third-generation EIA for all donors and recipients, with NAT strongly recommended for high-risk donors to detect infection during the window period. 1
• CMV and EBV serology must be performed on all donors and recipients to establish risk stratification, particularly critical for pediatric recipients where EBV D+/R- status carries highest risk for post-transplant lymphoproliferative disorder. 1

Bacterial and Parasitic Infections

• Syphilis screening with non-treponemal assay (rapid plasma reagin) is required for all donors, confirmed with treponemal immunoassay; positive results do not contraindicate donation but require penicillin treatment of recipients. 1
• Tuberculosis screening with tuberculin skin test or interferon-gamma release assay (IGRA) is mandatory for all recipients without prior TB history; IGRA may be considered for donors. 1

Geography-Based Enhanced Screening Requirements

Travel and Endemic Exposure Assessment

• Origin and travel history of both donor and recipient is paramount for screening geographically restricted infections; local epidemiology must always guide decision-making beyond national guidelines. 1
• Donors and recipients from malaria-endemic areas require NAT testing (more sensitive than blood films) to rule out parasitemia; organs should be rejected if donor death is secondary to malaria (RL1), otherwise treat both donor and recipient (RL3). 1

Specific Endemic Pathogens

• Trypanosoma cruzi (Chagas disease) requires two different serology-based tests for all donors/recipients from endemic areas; use of heart or intestine from donors with chronic infection is contraindicated (RL1), while other organs carry increased but acceptable risk (RL2-3) with close NAT follow-up. 1
• Strongyloides screening via stool larvae visualization and serology is required for all donors/recipients from endemic zones; treatment must occur before transplantation to prevent fatal hyperinfection syndrome post-transplant. 1
• Coccidioides and Histoplasma screening (serology with ID, CF, EIA) is indicated for donors/recipients from endemic areas with pulmonary disease history or suggestive radiographic findings; positive donors for lung transplantation require 6-month fluconazole prophylaxis in recipients. 1

Helminthic Infections

• Schistosoma, Clonorchis, Opistorchis screening via stool/urine examination for ova and serology is required for donors/recipients from endemic areas, especially with peripheral eosinophilia; donation is not contraindicated but requires specific treatment and strict follow-up. 1

Risk Stratification Framework for Donor Utilization

The Alliance-O classification system provides the decision-making structure: 1

Risk Level 1 (RL1) - Absolute Contraindication

• Active untreated HIV, HCV viremia in standard-risk donors, acute malaria causing donor death, Trypanosoma cruzi in heart/intestine donors, Echinococcus multilocularis infection. 1
• Exception: Life-saving transplantation in absence of other therapeutic options may proceed on case-by-case basis. 1

Risk Level 2 (RL2) - Increased but Acceptable Risk

• HBsAg-positive donors for HBsAg-positive recipients or those with protective immunity (anti-HBs ≥10 IU/mL); requires hepatitis B immunoglobulin plus antiviral prophylaxis post-transplant. 1
• HBcAb-positive, HBsAg-negative donors for non-liver organs in immune recipients (no therapy needed); non-immune recipients and liver recipients require serial HBV testing or lamivudine prophylaxis. 1

Risk Level 3 (RL3) - Calculated Risk

• Documented bacteremia with ≥24 hours of targeted broad-spectrum antibiotics, CMV/EBV transmission (manageable with prophylaxis/monitoring), syphilis-positive donors (treat recipient with penicillin). 1

Critical Timing Considerations

• All infectious disease testing must be current within 28 days of donation for living donors; testing should occur 2-4 weeks after return from endemic area travel to allow adequate detection time beyond window periods. 2
• Blood cultures should be collected if donor hospitalized >48-72 hours before procurement. 2

Common Pitfalls to Avoid

• Hemodilution from transfusions/infusions causes false-negative results; always use pre-transfusion samples when possible. 3
• Window period infections missed by antibody testing alone; NAT reduces but does not eliminate this risk (HIV 5-10 days, HCV 3-5 days, HBV 20-22 days). 2, 3
• Failing to consult infectious disease specialists when evaluating donors with endemic area exposure leads to inadequate risk assessment. 2
• Each donor-recipient combination must be assessed individually; active infections in donors do not automatically preclude donation if close monitoring and preemptive measures are implemented. 1

Post-Transplant Recipient Monitoring

• HIV testing of solid organ recipients should occur immediately pre-transplant and at 3 months post-transplant; if recipient tests HIV-positive, immediately notify state health department, tissue procurement organization, and Scientific Registry for Transplant Recipients. 1
• Infectious disease physician participation within the transplant team is essential; communication between donor and recipient hospitals must be optimized for rapid recognition of positive cultures. 1

For location-specific NOTTO guidelines, you must contact the National Organ and Tissue Transplant Organization directly or consult your regional transplant authority, as these protocols are not available in the current evidence base.