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

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 l patient. Renal function returned to normal in all patients after treatment was stopped.