UNIVERSITY OF PENNSYLVANIA MEDICAL CENTER

GUIDELINES FOR ANTIBIOTIC USE

PROPHYLAXIS MEDICATION GUIDELINES FOR LIVER TRANSPLANT

Indication Patient Population Medication Dose Duration of Therapy
Antiviral
 All Patients ganciclovir

6 mg/kg IV qd1

 48 hrs post-op until CMV D/R status is established
CMV D+/R- ganciclovir 6 mg/kg IV qd1 100 days
CMV D+/R+ OR CMV D-/R+ acyclovir 800 mg PO tid2 90 days
CMV D-/R- acyclovir 800 mg PO tid2 90 days
Antifungal
 All patients nystatin 5cc Swish/Swallow tid 90 days

Patients with:

1) Renal failure (SCr > 3.0) pre-transplant

2) Re-operation (including re-transplantation)

3) Prolonged operative course (> 8 hrs)

4) Roux-en-Y

5) Pre-transplant fungal colonization

6) "massive" intraoperative blood transfusions

fluconazole 200 mg PO qd3 At least one week post-transplant
PCP
 All patients cotrimoxazole4 1 SS tablet PO qd 365 days
GI
 All patients ranitidine5 150 mg PO bid While on steroid therapy only unless there is a pre-existing need.
Hepatitis B
Hep B Surface Ag Positive recipients and recipients of a Hep B Core Antibody Positive Donor lamivudine (should be Epivir-HBV brand)6 100 mg PO qd Indefinitely
  All patients receiving a liver from a Hep B Core Antibody Positive Donor HBIG (Hep B Immune globulin) 10,000 units qd7,8 3 doses
  Any recipient who is Hep B Surface Antigen Positive HBIG

10,000 units qd7,8 x 7 days then

10,000 units each week x 4 weeks then

10,000 units every month x 4 months

1 Adjust for renal insufficiency:

CrCL > 70 ml/min 6 mg/kg qd
CrCL 50 - 70 ml/min 3 mg/kg qd
CrCL 25 - 50 ml/min 1.5 mg/kg qd
CrCL 10 - 25 ml/min 0.75 mg/kg qd
CrCL < 10 ml/min 0.75 mg/kg three times weekly after dialysis
CVVHD 2.5 mg/kg qd

2 Adjust for renal insufficiency.

3 May give fluconazole 200 mg IV qd if patient cannot tolerate oral medications. Needs adjustment for renal insufficiency.

4 Cotrimoxazole is sulfamethoxazole + trimethoprim; trade names include Septra and Bactrim. A single strength (SS) cotrimoxazole tablet contains 80 mg trimethoprim and 400 mg sulfamethoxazole. If sulfa allergy: start atovaquone suspension 1500 mg PO qd. If unable to take atovaquone then check G6PD deficiency and if NOT deficient start dapsone 100 mg PO qd. If G6PD deficient check with nephrologist for alternative therapy. May need adjustment for renal insufficiency.

5 If already on a proton pump inhibitor (PPI) then continue that agent. Ranitidine needs dosage adjustment for renal insufficiency: >50 ml/min, 150 po bid; <50, 150 mg po once daily; hemodialysis, 150 mg po once daily, with administration of dose after dialysis on dialysis day.

6 Adjust for renal insufficiency

7 Infuse over 6 hours for first dose and if tolerated, 4 hours for each subsequent dose.

8 After 6 months HBIG titers will be drawn. Dose and frequency is adjusted based on titers drawn prior to infusions.

 

Anti-infective Prophylaxis During Treatment of Rejection Episodes
Treatment with Thymoglobulin, OKT3, or ATGAM Restart PCP and antiviral prophylaxis per above guidelines. Do not restart antifungal prophylaxis
Pulse Dose Steroids Alone Do not restart any anti-infective prophylaxis

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written by Emily Blumberg and Lori LaRosa, October 2005