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Characterization, Prophylaxis, and Treatment of Infectious Complications in Craniomaxillofacial and Upper Extremity Allotransplantation: A Multicenter Perspective

Broyles, Justin M. M.D.; Alrakan, Mohammed M.D.; Ensor, Christopher R. Pharm.D.; Khalifian, Saami B.A.; Kotton, Camille N. M.D.; Avery, Robin K. M.D.; Brandacher, Gerald M.D.; Lee, W. P. Andrew M.D.; Gordon, Chad R. D.O.

Plastic & Reconstructive Surgery: April 2014 - Volume 133 - Issue 4 - p 543e–551e
doi: 10.1097/PRS.0000000000000015
Pediatric/Craniofacial: Original Articles

Background: Vascularized composite allotransplants consist of heterogeneous tissues from different germ layers, which include skin, muscle, bone, fat, nerves, and lymph nodes. The antigenic diversity of these tissues, particularly of the highly immunogenic skin component, necessitates potent immunosuppressive regimens similar to that of some solid organ transplants. Indeed, the lifelong, high-dose, multidrug immunosuppressive protocols expose vascularized composite allotransplant recipients to considerable risk of infectious, metabolic, and neoplastic sequelae. In this article, the authors review the infectious risk to patients after vascularized composite allotransplantation, with special attention to the somewhat limited experience with the prophylaxis and treatment of infections after this innovative reconstructive surgery.

Methods: A review of the literature was undertaken to elucidate the characterization, prophylaxis, and treatment of all documented infectious complications.

Results: Infections in face and hand vascularized composite allotransplants follow a course similar to that of solid organ transplants. Several differences exist, including the unique flora of craniomaxillofacial transplants, the increased risk of donor-derived infections, and the alteration of the risk-to-benefit ratio for cytomegalovirus infections.

Conclusions: The patient with a face or limb transplant has many of the same infectious risks as a lung transplant recipient, which include bacterial, viral, and fungal infections. Because of the anatomy, mucosal exposure, and differing donor flora, however, the face or limb transplant is susceptible to invasive diseases from a variety of microbes.

Baltimore, Md.; Pittsburgh, Pa.; and Boston, Mass.

From the Department of Plastic and Reconstructive Surgery and the Division of Infectious Disease, Department of Medicine, The Johns Hopkins Hospital; the Department of Pharmacy and Therapeutics, University of Pittsburgh Medical Center; and the Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Harvard Medical School.

Received for publication August 22, 2013; accepted September 17, 2013.

Disclosure: None of the authors has any commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article.

Chad R. Gordon, D.O., Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, 601 North Caroline Street, 8th Floor, Baltimore, Md. 21287, cgordon@jhmi.edu

©2014American Society of Plastic Surgeons