Beth Israel Deaconess Medical Center
Transplant Manual
Title: Antimicrobial Prophylaxis - Liver Transplantation
Purpose: To provide consistent antimicrobial care to liver transplant patients
Policy Statement:
Liver transplant recipients are at increased risk of bacterial, viral and fungal infections
as a consequence of their illness, surgery and immunosuppression. This antimicrobial
strategy is used to reduce the risk of infection and decreased morbidity and mortality.
1.
2.
Anti-bacterial prophylaxis
a.
Peri-operative antibiotics (2-5 days)
 Standard practice
Unasyn* 3 g IV q 6 hours
 Penicillin-allergic
Levofloxacin* 500 mg IV q 24 hours
Flagyl 500 mg IV q 8 hours
Vancomycin* 1 g IV q 24 hours
 MRSA colonized/hospitalized by >72 hours/admitted from rehab etc.
Unasyn* 3 g IV q 6 hours
Vancomycin* 1 g IV q 12 hours
b.
Life-long antibiotics
 Standard practice
Bactrim SS po once daily
 Sulfa-allergic
Nebulized pentamidine 300 mg monthly
Anti-viral prophylaxis
a.
Peri-operative antiviral therapy
 All patients will get CMV prophylaxis with Valcyte* 450 mg po BID.
 Donor positive to recipient negative (D+/R- [CMV High Risk]) patients
are treated for 6 months and all others are treated for 3 months.**
b.
All patients not receiving CMV prophylaxis or those finished prophylaxis
should have routine surveillance with CMV PCR every 14 days, and
CMV IgG for CMV HR patients at month 7,9, and 12 following
transplant.
c.
CMV PCR should be performed every 14 days per month after
prophylaxis has been completed.
* these drugs require dose adjustment depending on renal function
1
**CMV HR: Valcyte 900 mg po daily in 2 divided doses renally adjusted per standard
recommendations.
D+/R- (CMV HR): 180 day (6 month) duration standard from time of transplant. IF
acute rejection and IS is boosted or patient receives new organ or receives antibody
therapy (ATG, OKT3, rituximab), then prophylaxis time is “restarted” and extended for
an additional 180 days.
D+/R+ or D-/R+ (CMV moderate risk) and D-/R- (CMV low risk): 90 days (3 months)
duration standard from time of transplant. IF acute rejection and IS is boosted or
patient receives new organ or receives antibody therapy (ATG, OKT3, rituximab), then
prophylaxis time is “restarted” and extended for an additional 90 days.
3.
Anti-fungal prophylaxis
a.
b.
c
All patients listed for liver transplantation receive clotrimazole troche 10
mg po 5 times per day prior to transplantation.
Patients will receive fluconazole* 400 mg po x 1 dose pre-transplant.
All patients will receive fluconazole* 400 mg po daily for 3 months
following transplantation.
Vice President Sponsor:
Approved by:
x Liver Selection Committee
Requestor Name:
Original Date Approved:
Next Review Date:
Revised:
Dianne Anderson, Sr. VP PCS
Douglas W. Hanto, MD, PhD and Michael Curry, MD
Co-Chairs
Michael Curry, MD
2/02
1/08
Eliminated:
2