Renal transplant 4 months ago on tacrolimus, mycophenolate and prednisolone; fever 38.8 °C, dry cough, creatinine up 40%
ABCDE
Resuscitate as for any sepsis, but never stop the immunosuppression reflexively — and never change a calcineurin inhibitor dose without checking what the new antibiotic does to its level.
Time since transplant frames the differential → under 1 month: surgical, line and wound infection, donor-derived infection; 1–6 months: CMV, PJP, fungal, tuberculosis, reactivation; beyond 6 months: community infections plus late opportunists
Investigate wide and early → blood and urine cultures, CMV and EBV PCR, respiratory viral panel, β-D-glucan and galactomannan, CT chest, and graft imaging with Doppler; take tissue early because the yield falls once antimicrobials start
Start broad cover → treat the likely bacterial sepsis immediately and add cover for the opportunists the timeline and the CT suggest; discuss with the transplant centre before narrowing
Adjust immunosuppression, do not abandon it → usually hold the antimetabolite (mycophenolate or azathioprine), continue the calcineurin inhibitor with level monitoring, and continue or increase steroid to cover adrenal suppression in shock
Watch the interactions → azoles, macrolides and diltiazem raise tacrolimus and ciclosporin levels sharply; rifampicin collapses them. Check a level within 24 h of any new interacting drug
Order set
- Blood cultures × 2, urine culture, sputum
- CMV and EBV PCR; respiratory viral panel
- β-D-glucan, galactomannan, cryptococcal antigen
- Tacrolimus/ciclosporin trough level
- CT chest ± graft ultrasound with Doppler
- Contact the transplant centre
- Hold antimetabolite; steroid cover in shock
Criteria
AdmitAny fever in a transplant recipient
ICUSeptic shock, hypoxaemia, graft dysfunction, or suspected CNS infection
DischargeAfebrile, organism identified or excluded, immunosuppression plan agreed with the transplant centre
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Hypoxaemia with a normal chest radiograph — think PJP
- Headache or confusion — think Cryptococcus, Listeria, Nocardia
- Rapidly rising creatinine in a renal graft
- Neutropenia on valganciclovir or mycophenolate
Differentials
- Bacterial sepsis
- CMV disease
- Pneumocystis pneumonia
- Invasive fungal infection
- Tuberculosis
- Acute rejection
- Drug fever
- Post-transplant lymphoproliferative disease
Common mistakes
- Stopping all immunosuppression and precipitating rejection
- Starting an azole without adjusting tacrolimus
- Attributing hypoxaemia to fluid overload and missing PJP
- Assuming a normal white count excludes infection
Disposition & follow-up
Every decision is taken with the transplant centre; graft function, drug levels and the infection plan are reviewed together, daily.
Discharge package
MedicationsRestart the antimetabolite only on the transplant team's instruction; prophylaxis as prescribed
Follow-upTransplant clinic with levels and creatinine within a week
LifestyleFood, water, pet and travel precautions; vaccination plan
Warning symptomsFever, breathlessness, reduced urine output, graft pain, confusion
💊 Treatment detail — doses & preparation
Tacrolimuscalcineurin inhibitor
DoseDose by trough level; target set by the transplant centre
PreparationOral, consistent timing relative to food
MonitorTrough level, creatinine, K⁺, Mg²⁺, glucose, tremor
Valganciclovir / ganciclovirantiviral
DoseValganciclovir 900 mg BD oral, or ganciclovir 5 mg/kg IV BD for CMV disease, adjusted for renal function
PreparationIV in 100 mL over 1 h
MonitorFBC (neutropenia), renal function, CMV viral load
Co-trimoxazoleantifolate antibiotic
DoseProphylaxis 480–960 mg daily; PJP treatment 15–20 mg/kg/day of trimethoprim in divided doses
PreparationIV or oral; large volumes in treatment dose
MonitorK⁺, creatinine, FBC, rash
📖 AST Infectious Diseases Community of Practice guidelines · ICU chapter 49 · The Transplant PatientReviewed September 2026