Tacrolimus is an immunosuppressant that exerts its activity via suppression of cellular immunity by binding to FKBP-12 to form a complex with calcineurin-dependent proteins to inhibit calcineurin phosphatase activity and subsequently T lymphocyte activation. Approved by the Federal Drug Administration (FDA) under the brand name Prograf ® in 1994, immediate-release tacrolimus (IR-TAC) is now considered the backbone of maintenance immunosuppressive regimens in solid organ transplantation (SOT). In the United States (US), it is reported that more than 70% of SOT recipients are initiated on a TAC-based regimen (SRTR 2018 Annual Report). The extensive use of tacrolimus is likely attributable to its superiority in prevention of allograft rejection, particularly in the

Patients presenting with infections while receiving disease-modifying antirheumatic agents (DMARD) may be predisposed to a higher degree illness due to immunosuppression. This can be particularly problematic in patients who are receiving DMARDs with prolonged pharmacokinetic profiles. Leflunomide is a DMARD that has a prolonged half-life due to enterohepatic recirculation. We report a case of a patient with severe septic shock secondary to a prosthetic joint infection in which therapeutic levels of leflunomide were discovered, despite the patient ceasing therapy several weeks prior to admission. An orogastric cholestyramine washout was given to the patient to expedite the removal of the drug. Serum levels rapidly declined over the next several days, corresponding with resolution of her sepsis. A review of the literature relevant to the incidence of DMARD-related infections was conducted as well as discussion regarding the role of leflunomide drug monitoring and cholestyramine-facilitated removal of the drug in episodes of acute infectious syndromes.

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In conclusion, clotrimazole troches exert a meaningful interaction with tacrolimus that requires close monitoring and dose adjustment. The data from this single-center study provide novel information that could guide providers on the degree of tacrolimus dose adjustment needed when discontinuing clotrimazole prophylaxis after heart transplantation.

As immunosuppressive therapy has evolved over the years, rejection rates in solid organ transplant have declined, but infections remain a significant cause of morbidity and mortality in this population. Prophylaxis against bacterial, viral, and fungal infections is often used to prevent infection from common pathogens during high-risk periods. As an integral part of the multidisciplinary medical team, it is important that nurses caring for transplant recipients be familiar with methods to detect and prevent infectious diseases in this population. This article presents a review of risk factors for and prevalence of common infectious pathogens, as well as important considerations regarding prophylactic medications in solid organ transplant recipients.