Key points
- After a transplant, the immune system takes months to years to recover fully; especially in the first 6 months and at times when you are taking immunosuppressive medicines or steroids, following the infection-prevention advice carefully is vital [1].
- The most important daily task is washing your hands regularly or using alcohol hand gel: before eating, after using the toilet, after touching animals, soil and rubbish, and before and after touching your catheter [1].
- Tell your transplant team straight away about a temperature of 38 °C or higher, shivering, redness or swelling where the catheter goes in [2], and a new skin rash, diarrhoea or yellowing of the skin (possible signs of GVHD) [3].
- Take immunosuppressive medicines such as tacrolimus and ciclosporin on time and never stop them on your own; their blood levels are measured regularly, and grapefruit and many medicines (for example some antifungals and antibiotics) change their levels [4, 5].
- Medicines to prevent infection (such as aciclovir or valaciclovir and co-trimoxazole) usually continue for months after the transplant, and after an allogeneic transplant the CMV virus test is done about once a week until at least day 100 [1].
- A transplant gradually wipes out the protection from earlier vaccines, and vaccines need to be given again; most non-live vaccines start about 6 months after the transplant, and live vaccines are not allowed for at least 24 months and until immunity has recovered [6].
- Full physical and emotional recovery after a transplant takes 3 to 5 years; tiredness and worry along the way are normal, and getting help for your mental health is part of treatment [7].
What to expect after discharge
Being discharged from the transplant unit means the new stem cells have engrafted and your blood counts have reached an acceptable level, but your immune system is not yet complete. Chemotherapy or radiotherapy before the transplant, medicines to prevent graft-versus-host disease (GVHD) and sometimes the underlying illness itself leave the body vulnerable to infection for a while [6].
The immune system rebuilds itself gradually, and this usually takes up to a year. The number of helper T lymphocytes (CD4) recovers within 6 to 9 months in most children without chronic GVHD, but in adults, especially with chronic GVHD, it may take more than 2 years [1].
After an allogeneic transplant (from a donor) the risk of infection and GVHD is higher and lasts longer, and immunosuppressive medicines usually continue for several months. After an autologous transplant (the patient's own cells) the restrictions are shorter; for example, a safe diet is usually enough for up to 3 months after an autologous transplant, whereas after an allogeneic transplant it continues until all immunosuppressive medicines have been stopped [1].
In a study of 319 adults who had a high-intensity transplant for leukaemia or lymphoma, only one in 5 had fully recovered by the end of the first year, but by 5 years most of those whose illness had not come back had returned to full-time work; the researchers concluded that full recovery after a transplant takes 3 to 5 years [7]. An overview of the transplant journey is on the blood stem cell transplant page.
Preventing infection at home
The main rules for living safely after a transplant
Hand hygiene
Wash your hands with soap and water or clean them with alcohol gel, especially before eating or preparing food, after using the toilet, after touching plants, soil or animals, after going out or being in public places, after handling rubbish, and before and after touching a catheter or wound. If your hands are visibly dirty, soap and water is better. This matters most in the first 6 months and at times of strong immunosuppression, and the people around you should do it too [1].
People who are ill, and masks
Avoid close contact with people who have a cold, flu or other respiratory illness, and do not touch your eyes, nose and mouth without cleaning your hands. If contact cannot be avoided, it is better for the ill person to wear a mask or cover their mouth and nose when they cough or sneeze. Wearing a mask yourself around ill people may help, although exactly how much it protects is not known. In crowded places, especially in autumn and winter, be extra careful with hand hygiene [1].
Visitors
Anyone with a fever, a skin rash, vomiting, diarrhoea, cold symptoms or red eyes should not visit you, and all visitors should wash their hands before and after the visit [1]. If a child at home has had the oral polio vaccine (OPV), avoid close contact with them for about 4 to 6 weeks, and if that is not possible, wash your hands carefully after every contact with the child's stools or nappies [1].
Pets
You do not need to give up your pet, but leave cleaning the cat litter tray, bird cage and aquarium to others, and have the cat litter cleaned every day. Keep your cat indoors and do not feed it raw meat. Avoid contact with reptiles (such as turtles and lizards), chicks and ducklings, and exotic, stray or sick animals, and do not get a new pet, especially a kitten under 6 months old. Wash your hands after touching animals [1].
Gardening, soil and dust
In the first 6 months after the transplant and at times of strong immunosuppression (for example while being treated for GVHD or taking steroids), avoid gardening, touching soil and plants, spreading manure and compost, and going near building sites or excavations; these places are a source of fungi such as Aspergillus [1]. The American Society for Transplantation and Cellular Therapy (ASTCT) guideline also advises against keeping live plants in the home, cleaning carpets and woodworking until immunity returns [8]. If you have to, wear gloves and a mask and then wash your hands with soap and water [1].
Water, swimming and travel
Avoid swimming or wading in lakes, ponds and rivers, and drinking water from a private well or untreated water [1]. Travel to areas with poor sanitation is usually not advised for allogeneic transplant recipients until 6 to 12 months after the transplant and during GVHD treatment, and for autologous recipients it may be possible after 3 to 6 months with the transplant team's agreement; check with your care team before any trip [1].
Food safety
The aim of the diet after a transplant is enough nutrition while reducing the risk of food-borne infections. This diet usually continues for up to 3 months after an autologous transplant, and after an allogeneic transplant until all immunosuppressive medicines have been stopped and your doctor allows live vaccines; your transplant doctor decides when it ends [1]. These recommendations are based mostly on experience in the general population, and their benefit must be weighed against the risk of poorer nutrition; so do not sacrifice good nutrition for unnecessary restrictions [1]. See also the guide to nutrition during cancer treatment.
| Food group | Avoid | Safer alternative |
|---|---|---|
| Meat, poultry and fish | Raw or undercooked meat, poultry, fish and seafood; sausages, salami and cold cooked meats [1] | Thoroughly cooked meat; sausages and cold meats only after heating until steaming [1] |
| Eggs | Raw or runny eggs and foods containing them such as home-made mayonnaise [1] | Thoroughly cooked eggs [1] |
| Milk and dairy | Unpasteurised milk, yoghurt and cheese; mould-ripened cheeses and soft cheeses such as brie and feta [1] | Pasteurised milk, yoghurt and cheese [1] |
| Fruit and vegetables | Raw sprouts, fresh salsa and berries; unwashed fruit and vegetables [1] | Fruit and vegetables washed well under running water; as the saying goes, "if you can't peel it or wash it, don't eat it" [1] |
| Juice and drinks | Unpasteurised fruit or vegetable juice; water from a private well or untreated water, and ice made with it [1] | Pasteurised juice; safe mains tap water or water boiled for at least 1 minute [1] |
| Other | Raw unroasted nuts or nuts in their shells, raw honey, street food, salad bars and buffets, and probiotic products [1] | Roasted nuts, freshly cooked food; in restaurants, single-portion packaged condiments [1] |
| Leftovers | Food that has been out of the fridge for more than 2 hours or in the fridge for more than 72 hours [1] | Put leftovers in shallow containers in the fridge within 2 hours and heat them until piping hot before eating; heat soups and stews until they boil [1] |
Based on the global guideline for preventing infection after transplant [1]; your transplant team may make the list simpler or stricter depending on your situation. When cooking, keep the board and knife for raw meat separate from other foods, and wash your hands and utensils with hot soapy water after handling raw meat [1].
Catheter (central line) care
Daily catheter care
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- 2
Keep the catheter site clean and dry
Keep the area around the catheter clean and dry [2]. Change the dressing and flush the catheter exactly as your transplant nurse taught you and at the set times, and ask your care team how to wash or shower with the dressing.
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Ask how long you need the catheter
Central catheters can stay in for weeks or months, and their risk of infection is much higher than an ordinary drip in the arm; ask your care team how long the catheter is needed [9].
Immunosuppressive medicines
After an allogeneic transplant, medicines such as tacrolimus or ciclosporin stop the donor's immune cells from attacking your body (GVHD). These medicines are reduced gradually over several months depending on how you are; signs of chronic GVHD often appear in the first year and most often while these medicines are being reduced [10]. Important points about taking them:
- On time and always the same way: take the medicine at fixed times every day and always either with food or without food, because food changes how well it is absorbed [4, 5].
- Blood level tests: the amount of medicine in your blood must stay within a set range, because the risk of side effects and of the medicine not working depends on its blood level [4]. This level is usually measured just before the morning dose, about 12 hours after the previous dose [5]; ask your team when to take your morning dose on test days.
- Grapefruit and St John's wort: grapefruit and its juice raise the levels of these medicines, and the herb St John's wort lowers them sharply; avoid both [4, 5].
- Drug interactions: some antifungals (such as posaconazole and voriconazole), some antibiotics (such as clarithromycin and erythromycin), letermovir and some blood pressure medicines raise tacrolimus levels, and rifampicin and anti-seizure medicines such as phenytoin and carbamazepine lower them. Tell your transplant team before you start or stop any medicine, even one bought without a prescription [4].
- Side effects to report: shaky hands, headache, confusion or seizures, high blood pressure, passing less urine and high blood sugar; your doctor monitors you with tests of kidney function, potassium, magnesium and blood sugar [4, 5]. Ciclosporin can also cause gum overgrowth and extra hair growth [5].
- Live vaccines: while you are taking tacrolimus, live vaccines (such as MMR, chickenpox, oral polio and the nasal flu vaccine) must not be given [4].
- Never stop or reduce on your own: if you cannot take the medicine because of vomiting or any other reason, call your transplant team the same day; an injectable form is available for people who cannot take it by mouth [4].
If you are taking a steroid (such as prednisolone) for GVHD, you may have weight gain, thinning bones, muscle weakness, high blood sugar and blood pressure, mood swings, cataracts and a higher risk of infection; that is why the aim of treatment is the lowest effective dose and a gradual reduction [10].
Medicines to prevent infection
Show detailsHide
Treatment regimens and doses: index7 regimens
| Medicine | To prevent | Usually until when? |
|---|---|---|
| Aciclovir or valaciclovir | Reactivation of the cold sore and shingles viruses (herpes simplex and varicella-zoster) | At least 1 year after the transplant; longer with chronic GVHD or continued immunosuppressive medicines [1] |
| Co-trimoxazole (trimethoprim-sulfamethoxazole) | Pneumocystis pneumonia (PJP) and toxoplasmosis | From engraftment, for at least 6 months and for as long as immunosuppressive medicine is taken or chronic GVHD is present [1] |
| Fluconazole | Yeast infections (Candida) | In low-risk allogeneic transplant usually until about day 75, and in autologous transplant until engraftment [8] |
| Posaconazole (or voriconazole) | Mould infections such as Aspergillus in high-risk patients, especially during GVHD treatment | For as long as risk factors, such as GVHD treatment, continue [8] |
| Letermovir (for some patients) | Reactivation of the CMV virus in allogeneic transplant recipients whose CMV test was positive | Until day 100 after the transplant, and in at-risk patients until day 200 [11] |
| Preventive antibiotic in chronic GVHD (such as penicillin or co-trimoxazole) | Infection with encapsulated bacteria such as pneumococcus | For as long as systemic treatment of chronic GVHD continues [12] |
The choice of medicine and how long you take it depend on the type of transplant, your test results and your other medicines; do not stop any of them without agreeing it with your transplant team.
Pneumocystis pneumonia is rare after a transplant unless the preventive medicine is not taken, but if it happens it has a high death rate [13]. Co-trimoxazole sometimes lowers blood counts or is linked with drug allergy, raised potassium and damage to the kidneys, liver or pancreas; if you cannot tolerate it, your doctor will consider an alternative medicine or desensitisation [1].
- Azoles and calcineurin inhibitors: when posaconazole is started, reduce the tacrolimus dose to about one third and the ciclosporin dose to about three quarters, and monitor blood levels frequently during treatment and after the azole is stopped; posaconazole is contraindicated with sirolimus [14]. With voriconazole, also reduce the tacrolimus dose to one third and start level monitoring from day 1 to 3 [4].
- Letermovir: with ciclosporin, the letermovir dose is 240 mg. Letermovir raises tacrolimus, ciclosporin and sirolimus levels and lowers voriconazole levels; monitor the calcineurin inhibitor level during treatment and after letermovir is stopped [11].
- Co-trimoxazole: usually not started before engraftment because it may delay it; side effects: marrow suppression, allergy, hyperkalaemia, nephritis, hepatitis and pancreatitis. With intolerance, oral desensitisation (success about 80%) is preferred, because no alternative is as effective [1].
- Ganciclovir and valganciclovir: monitor the neutrophil count at least twice a week and adjust the dose to kidney function [1].
- Live vaccines are contraindicated while taking tacrolimus [4].
For physicians
Antimicrobial prophylaxis and pre-emptive treatment after allogeneic transplant: doses and schedules
Aciclovir or valaciclovir (HSV and VZV prevention)
Allogeneic recipients seropositive for HSV or VZV (in autologous recipients with a lower level of recommendation); adults and adolescents of at least 40 kgCycle length: Continuous
Allogeneic recipients seropositive for HSV or VZV (in autologous recipients with a lower level of recommendation); adults and adolescents of at least 40 kg
Before prescribing: Shared safety points| Drug | Dose | Route | Schedule |
|---|---|---|---|
| First choice | |||
| Aciclovir | 800 mg twice a day | Oral | Daily |
| Alternative | |||
| Valaciclovir | 500 mg twice a day | Oral | Daily |
Children under 40 kg: aciclovir 60 to 80 mg/kg a day in 2 to 3 divided doses or valaciclovir 250 mg twice a day. Some specialists continue prophylaxis until 6 months after all immunosuppressive medicines are stopped. Exposure to chickenpox or shingles less than 24 months after the transplant or with immunosuppression or chronic GVHD: VZV immunoglobulin (if available) preferably within 48 and at most 96 hours, or valaciclovir 1 g three times a day from day 3 to 22 after exposure. Any VZV-like rash: pre-emptive IV aciclovir [1].
Co-trimoxazole (PJP and toxoplasmosis prevention)
All allogeneic recipients; autologous recipients with a haematological malignancy, a high-intensity conditioning regimen, graft manipulation or recent purine analoguesCycle length: Continuous
All allogeneic recipients; autologous recipients with a haematological malignancy, a high-intensity conditioning regimen, graft manipulation or recent purine analogues
Before prescribing: Shared safety points| Drug | Dose | Route | Schedule |
|---|---|---|---|
| One of three schedules | |||
| Trimethoprim-sulfamethoxazole | 1 double-strength tablet (160/800 mg) | Oral | Daily |
| Trimethoprim-sulfamethoxazole | 1 single-strength tablet (80/400 mg) | Oral | Daily |
| Trimethoprim-sulfamethoxazole | 1 double-strength tablet (160/800 mg) | Oral | 3 times a week |
| Alternative if intolerant | |||
| Dapsone | 100 mg once a day or 50 mg twice a day | Oral | Daily |
| Atovaquone | 1500 mg once a day or 750 mg twice a day | Oral, with fatty food | Daily |
| Pentamidine | 300 mg | Inhaled by nebuliser | Every 3 to 4 weeks |
Children: trimethoprim 150 mg/sulfamethoxazole 750 mg per m² a day (for example in 2 divided doses on 3 consecutive days a week); not recommended under 2 months of age because of kernicterus. Dapsone is contraindicated in G6PD deficiency and not recommended after a life-threatening reaction to co-trimoxazole; atovaquone is poorly absorbed without fatty food, and inhaled pentamidine does not prevent toxoplasmosis. Toxoplasma-seropositive recipients who cannot tolerate co-trimoxazole need a separate strategy (alternative prophylaxis or PCR monitoring) [1]. Daily co-trimoxazole also partly protects against pneumococcus [12].
Fluconazole (Candida prevention)
Autologous transplant or allogeneic transplant at low risk of AspergillusCycle length: Continuous
Autologous transplant or allogeneic transplant at low risk of Aspergillus
Before prescribing: Shared safety points| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Fluconazole | 400 mg once a day | Oral or IV | Daily |
FDA label dose for preventing candidiasis in bone marrow transplant; when severe neutropenia is expected, start a few days before and continue until 7 days after neutrophils rise above 1000/µL [15]. ASTCT suggested duration: until engraftment in autologous and until day 75 in allogeneic transplant (A-I); in patients at high risk of Aspergillus, a mould-active drug is needed [8].
Posaconazole (mould prevention in GVHD)
Allogeneic recipients with GVHD on immunosuppressive treatment (for example prednisone or equivalent 1 mg/kg a day or more) or other high-risk factors for AspergillusCycle length: Continuous
Allogeneic recipients with GVHD on immunosuppressive treatment (for example prednisone or equivalent 1 mg/kg a day or more) or other high-risk factors for Aspergillus
Before prescribing: Shared safety points| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Day 1 (loading dose) | |||
| Posaconazole delayed-release tablet | 300 mg twice a day | Oral | Day 1 |
| Maintenance | |||
| Posaconazole delayed-release tablet | 300 mg once a day | Oral | From day 2, daily |
| If unable to take by mouth | |||
| Posaconazole injection | 300 mg twice a day on day 1, then 300 mg once a day | IV | Daily |
| Alternative form (more erratic absorption) | |||
| Posaconazole oral suspension | 200 mg three times a day | Oral | Daily |
Doses as in the FDA label for prophylaxis in HSCT recipients with GVHD; monitor QTc, electrolytes and liver enzymes; avoid the IV form with eGFR below 50 mL/min/1.73 m² unless benefit outweighs risk [14]. ASTCT recommends posaconazole for prophylaxis in GVHD (A-I), prefers the tablet to the suspension, regards voriconazole as the next alternative, and targets a trough level above 0.8 µg/mL (measured on day 3 to 8) for prophylaxis [8].
Pre-emptive CMV treatment with valganciclovir or ganciclovir
At-risk allogeneic recipients (CMV-seropositive recipient or donor) with CMV detected on regular blood monitoring
At-risk allogeneic recipients (CMV-seropositive recipient or donor) with CMV detected on regular blood monitoring
Before prescribing: Shared safety points| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Induction | |||
| Ganciclovir | 5 mg/kg twice a day | IV | 7 to 14 days |
| Maintenance | |||
| Ganciclovir | 5 mg/kg once a day | IV | Until the test is negative |
| Induction (oral alternative) | |||
| Valganciclovir | 900 mg twice a day | Oral | 7 to 14 days |
| Maintenance (oral alternative) | |||
| Valganciclovir | 900 mg once a day | Oral | Until the test is negative |
| If ganciclovir is not tolerated | |||
| Foscarnet | Induction 60 mg/kg twice a day; maintenance 90 mg/kg once a day | IV | By the same duration criteria as ganciclovir |
CMV monitoring by quantitative PCR or antigenaemia about once a week from day 10 to at least day 100, and weekly after a treatment course until day 100; after day 100 in high-risk patients (chronic GVHD, steroid use, CD4 below 50/µL, seronegative donor for a seropositive recipient, unrelated, haploidentical, cord blood or T-depleted transplant) for as long as immunosuppression continues. Valganciclovir for people of at least 40 kg who can take it by mouth reliably. Reduce ganciclovir and foscarnet doses in kidney failure, and foscarnet needs prior hydration. For ganciclovir-induced neutropenia (neutrophils below 1000), add G-CSF or stop for about 2 days [1].
Letermovir (CMV prophylaxis)
CMV-seropositive (R+) allogeneic recipients; adults and children aged 12 and over weighing at least 30 kgCycle length: Daily and continuous
CMV-seropositive (R+) allogeneic recipients; adults and children aged 12 and over weighing at least 30 kg
Before prescribing: Shared safety points| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Without ciclosporin | |||
| Letermovir | 480 mg once a day | Oral (with or without food) or 1-hour IV infusion | Start between day 0 and 28 after the transplant, then daily |
| With ciclosporin | |||
| Letermovir | 240 mg once a day | Oral or IV | Daily |
In the phase 3 trial, clinically significant CMV infection by week 24 after the transplant occurred in 37.5% of the letermovir group versus 60.6% of the placebo group [16]; continuing to day 200 in high-risk patients reduced clinically significant infection between weeks 14 and 28 from 19% to 3% [17]. CMV monitoring is needed after prophylaxis ends. The IV form (containing hydroxypropyl betadex) only when oral intake is not possible and preferably for at most 4 weeks; with CrCl below 50, monitor creatinine. Contraindicated with pimozide and ergot alkaloids and, with ciclosporin, with pitavastatin and simvastatin [11].
Pre-emptive rituximab (EBV and PTLD)
Allogeneic recipients at high risk of PTLD with a significant rise in blood EBV DNA without signs of diseaseCycle length: Weekly
Allogeneic recipients at high risk of PTLD with a significant rise in blood EBV DNA without signs of disease
Before prescribing: Shared safety points| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Rituximab | 375 mg/m² | IV | Once a week |
Monitor EBV DNA by quantitative PCR from the first month until at least 4 months after the transplant, at least weekly in high-risk patients (matched related donor with a risk factor, unrelated or mismatched donor, cord blood; ATG or alemtuzumab use). No single threshold for starting treatment is recommended, and each centre sets its own based on experience. Combine with reduced immunosuppression if possible (except in severe uncontrolled GVHD). Antiviral drugs are not effective against EBV [18].
Doses follow the trial protocol, guideline or official drug label (source given in the notes of each regimen). Before prescribing, check blood counts, renal and hepatic function, drug interactions and the patient’s condition, and adjust the dose according to the drug label.
Monitoring for CMV and EBV
If you or your donor had a positive cytomegalovirus (CMV) test before the transplant, this virus may become active again after an allogeneic transplant. So in at-risk recipients, a CMV blood test is done about once a week until at least day 100, and if the virus is found in the blood, an antiviral medicine (such as ganciclovir by injection or valganciclovir by mouth) is started before it causes illness; this is called "pre-emptive treatment" [1]. In people who have chronic GVHD, take steroids or had a transplant from an unrelated, half-matched or cord blood donor, monitoring continues after day 100 too [1].
The medicine letermovir is given as prevention to allogeneic transplant recipients whose CMV test was positive before the transplant, from the first weeks until day 100 (and in high-risk people until day 200), and in a phase 3 study it significantly reduced serious CMV infection [11, 16]. CMV tests continue after it is stopped [11].
Epstein-Barr virus (EBV) can cause an abnormal growth of lymphocytes called PTLD in some high-risk patients (for example after a transplant from an unrelated donor or cord blood, or after ATG). In these patients a weekly EBV test is recommended until at least 4 months after the transplant, and if the virus rises, rituximab is usually given. Fever and enlarged lymph nodes are the commonest symptoms of PTLD [18].
Blood and blood product transfusions
Until the new bone marrow works fully, you may sometimes need a transfusion of red cells or platelets. In stable adults, red cells are usually given when the haemoglobin falls below 7 g/dL (with heart disease or symptoms of anaemia the threshold is 8), and platelets when the count is 10,000/µL or less; with bleeding or fever the threshold is higher [19].
Blood products for transplant recipients must be irradiated so that lymphocytes in the donated blood do not cause GVHD. The British Society for Haematology guideline recommends continuing this until at least 6 months after the transplant, lymphocytes are above 1000/µL, there is no active chronic GVHD and all immunosuppressive medicines have been stopped [19]. For CMV-seronegative allogeneic recipients, blood from CMV-negative donors or leukocyte-reduced products are used [1]. If your donor's blood group is different from yours, choosing blood products is more complicated [19]; so tell every hospital that you have had a stem cell transplant and carry the letter or card from your transplant team.
Follow-up appointments and tests
The follow-up path after discharge
- 1
Until about day 100: frequent visits and tests
In this period visits and blood tests are frequent: blood count, kidney and liver function, the blood level of your immunosuppressive medicine [4], and after an allogeneic transplant a weekly CMV test [1] and, in high-risk patients, EBV [18]. Liver tests are repeated at least every 1 to 2 months in the first year [13].
- 2
- 3
6 months after the transplant
A survivorship follow-up visit (checking symptoms, medicines, mood and physical activity), a dental check-up, urine and kidney tests and a blood fat test [13], and the start of most non-live vaccines [6]. A conversation about sexual health is recommended from 3 to 6 months after the transplant [13].
- 4
1 year after the transplant
A full assessment including a thyroid test, a bone density scan, a check of sex hormones, a dental check-up and a skin check; you will also be asked about eye symptoms at every visit [13]. Details are in the guide to long-term and chronic effects after a transplant.
- 5
After that: at least yearly
Survivorship follow-up visits are recommended at least at day 100, 180 and 365 and then yearly, and most recommendations continue for life, because some late effects appear years or even decades later [13].
Vaccinations again after a transplant
A transplant gradually erases the immune memory of earlier vaccines, and antibody levels fall 1 to 4 years after the transplant; so all recipients, whether after an allogeneic or an autologous transplant, need to be vaccinated again on a schedule [6]. Chronic GVHD does not prevent non-live vaccines, but live vaccines are not allowed until immunity has recovered [1]. After rituximab, the return of B lymphocytes is usually delayed until 6 months after the last dose, while a good vaccine response needs at least partial rebuilding of B and T immunity [1]. Vaccinating your family members also protects you [20].
| Vaccine | Timing and schedule |
|---|---|
| Flu (injected, non-live) | From 6 months after the transplant and then every year for life; if needed from 4 months, with a second dose considered [6] |
| COVID-19 | From about day 100 after the transplant [13] |
| Pneumococcus (conjugate vaccine) | 4 doses of PCV20 starting 3 to 6 months after the transplant: three doses 4 weeks apart and a fourth dose 6 months after the third or 1 year after the transplant, whichever is later; or 3 doses of PCV15 4 weeks apart followed by the PPSV23 polysaccharide vaccine a year later (with GVHD, a fourth dose of PCV15 instead of PPSV23) [6] |
| Haemophilus influenzae type b (Hib) | 3 doses starting 6 months after the transplant, at least 1 month apart [6] |
| Tetanus, diphtheria and whooping cough | 3 doses (DTaP, or 1 dose of Tdap and 2 doses of Td or DT) [6] |
| Hepatitis B, hepatitis A, injected polio (IPV), meningococcus and HPV at the relevant ages | Most non-live vaccines from 6 months after the transplant [6] |
| Shingles (recombinant vaccine) | 6 to 12 months after an allogeneic and 3 to 12 months after an autologous transplant; preferably 2 months before the preventive antiviral medicine is stopped [6] |
| MMR and chickenpox (live) | Only if at least 24 months have passed since the transplant, you have no GVHD and your doctor judges your immunity to be adequate [6] |
| Vaccines not allowed after a transplant | BCG, live nasal flu vaccine, typhoid vaccine and rotavirus [6] |
| People around the patient | Yearly injected flu vaccine, and injected rather than oral polio; MMR and chickenpox are allowed for household members, but if they develop a rash after the vaccine, avoid close contact [1] |
A summary of the CDC recommendations for stem cell transplant recipients [6]; your transplant team sets the exact schedule based on your immune status, medicines and any immunoglobulin or rituximab you have received.
Daily life: sun, driving, work, school, sex and pregnancy
Sun and skin
Avoid direct sun without protection: cover-up clothing, a hat and a sunscreen with UVA and UVB protection. This matters especially if you take immunosuppressive medicines or voriconazole, had total body irradiation (TBI) or have skin GVHD [13]. Sunlight can make skin GVHD worse, and voriconazole raises both the risk of severe sun reactions and of skin cancer [12].
Driving
Agree with your transplant team when to start driving again. Tiredness, muscle weakness from steroids and eye problems such as dryness, sensitivity to light and blurred vision are common after a transplant and can affect safe driving [13].
Work and school
When to return to work or school varies from person to person and there is no single agreed time; most survivors go back to work and study, and phased return-to-work plans help [13]. Working in healthcare, prisons or with animals (such as veterinary work, farming and abattoirs) carries a higher risk of infection in the first 6 months and at times of strong immunosuppression and should be discussed with your doctor [1]. For children, an assessment of mental development and school progress is recommended before returning to school [13]. See also the guide to returning to work and everyday life.
Sex
Agree with your transplant team when to resume sex. Condoms are recommended to reduce the risk of infections such as CMV, herpes, HPV and hepatitis, and during strong immunosuppression it is better to avoid contact of mucous membranes with saliva, semen or vaginal fluids [1]. Vaginal dryness, pain during sex, lower sex drive or erection problems are common and treatable, and a lubricant is recommended for all women after a transplant [12]. Your doctor should talk with you about sexual health from 3 to 6 months after the transplant [13].
Pregnancy and contraception
Fertility may be reduced after a transplant but is not always lost; if your fertility is uncertain, use contraception [13]. Tacrolimus may harm an unborn baby and has been linked with premature birth, malformations and low birth weight [4]. Pregnancy after a transplant should be supervised by a high-risk pregnancy specialist; in women who have not had radiotherapy to the womb or whole body, the miscarriage rate is similar to the general population, but radiotherapy to the womb raises the risk of miscarriage, premature birth and low birth weight, especially if the pregnancy happens in the first year after radiation [13]. See the guide to fertility and sex during cancer treatment.
Mental health and the carer's role
Anxiety, depression, poor sleep and tiredness are common after a transplant: about one in 10 survivors has severe anxiety and up to 3 in 10 have depression; these can be treated [13]. Mental health screening at follow-up visits is recommended [13]. For moderate symptoms, cognitive behavioural therapy, behavioural activation, mindfulness and regular physical activity are suggested, and medicines are prescribed if needed [21]. Family members and carers are sometimes under even more strain than the patient, and their quality of life cannot be guessed from how the patient is doing; they need support too [13].
Carer's checklist at home
- Keep an up-to-date list of medicines and times, and use a pill box or reminders; sticking to medicines is checked at every visit [13].
- Check the patient's temperature, catheter site, skin, stools and how much they eat and drink every day, and report a temperature of 38 °C or higher straight away [2].
- You and other family members should wash your hands regularly; if you become ill yourself, avoid close contact or wear a mask [1].
- Prepare the patient's food following food safety rules: keep raw meat separate, cook thoroughly and store leftovers properly [1].
- Clean the cat litter tray, bird cage and aquarium and handle the rubbish yourself [1].
- Have the injected flu vaccine every year; if a child at home has the oral polio vaccine, the patient should avoid close contact and touching their nappies for 4 to 6 weeks [1].
- Write down appointment and test dates and keep the transplant team's 24-hour contact number to hand.
- Look after yourself too: rest, accept help from others and talk to a counsellor or peer support groups [13].
When should I call my doctor?
In these situations call your transplant team straight away or go to the emergency department; do not take fever medicine before speaking to your care team, because it may hide the signs of infection [2]:
- A temperature of 38 °C or higher, shivering, a cough or sore throat, or cloudy, bloody or painful urine [2].
- Redness, swelling or pain at the catheter site [2, 9].
- A new rash or redness of the skin, diarrhoea, ongoing nausea and vomiting, or yellowing of the skin and eyes; these may be signs of GVHD, especially while immunosuppressive medicines are being reduced [3].
- Breathlessness, wheezing or a new cough [2, 3].
- Being unable to take your medicines because of vomiting or any other reason [4].
- Painful skin blisters (possible shingles) or close contact with someone with chickenpox or shingles; preventive treatment after contact should start preferably within 48 hours and at most 96 hours [1].
- Bleeding that does not stop, black or bloody stools, pink or red urine, a severe headache or changes in vision [22].
- Confusion, seizures, severe shaking or a severe headache; these symptoms may be side effects of tacrolimus or ciclosporin [4].
In an emergency, call your local emergency number.
Frequently asked questions
When can I go back to work or school?
The answer is different for every patient and depends on the type of transplant, GVHD and immunosuppressive medicines, and there is no single agreed time [13]. In one study, full recovery took 3 to 5 years, but by 5 years most of those whose illness had not come back had returned to full-time work [7]. Phased return-to-work plans help [13].
Do I have to give my pet away?
Usually not. Guidelines do not advise transplant recipients to give up their pets; it is enough to leave cleaning the cat litter, cage and aquarium to others, keep the animal healthy and vaccinated, wash your hands after contact and keep away from reptiles, chicks and stray animals [1].
How long do I need a special diet?
Usually for up to 3 months after an autologous transplant; after an allogeneic transplant until all immunosuppressive medicines are stopped and your doctor allows live vaccines. The final decision rests with your transplant doctor [1].
Why do I need the vaccines I had as a child again?
Because a transplant gradually erases immune memory, and the effect of earlier vaccines wears off over the following years; this is why transplant patients are more defenceless against infections such as pneumonia [6]. Vaccine-preventable infections have been reported more than 30 times more often in transplant survivors than in the general population [13].
Do I have to wear a mask at home all the time?
How much a mask worn by the patient protects is not known exactly, and the most important measures are hand hygiene and keeping away from ill people. If a family member has a cold, it is better for them to wear a mask. A mask (and gloves) is recommended for you when contact with soil and plants or handling large amounts of rubbish cannot be avoided [1].
How long will it take before I feel like my old self?
Can I take herbal remedies or supplements?
Scientific evidence
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Related guidelines
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Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update
Management of Fatigue in Adult Survivors of Cancer: ASCO–Society for Integrative Oncology Guideline Update
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References
23 referencesShow all references, 3 with a study cardClose the reference list
Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
- 1Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective
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- 15DIFLUCAN (fluconazole) tablets and oral suspension — Prescribing Information
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- 17Efficacy and safety of extended duration letermovir prophylaxis in recipients of haematopoietic stem-cell transplantation at risk of cytomegalovirus infection: a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial
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- 20Vaccination of Adults With Cancer: ASCO Guideline
- 21Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update
- 22Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment
- 23Management of Fatigue in Adult Survivors of Cancer: ASCO-Society for Integrative Oncology Guideline Update
This page is based on reputable scientific sources and was last updated on 28 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.
Printed from the website; the full and up-to-date version: https://drdabiri.com/en/guides/transplant-after-discharge/