Liver Transplant Surgery - Guideline for Antimicrobial Prophylaxis for

Publication: 01/03/2010  --
Last review: 11/09/2019  
Next review: 11/09/2022  
Clinical Guideline
CURRENT 
ID: 1824 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for Antimicrobial Prophylaxis for Liver Transplant Surgery

Summary of routine recommendations

This prophylaxis guideline has the following aims:

  • Surgical site infection prophylaxis
  • Invasive fungal infection prophylaxis
  • Cytomegalovirus primary infection prophylaxis
  • PCP infection prophylaxis
  • TB reactivation reduction

Below is a summary of routine recommendations:

  • General screening recommendations
  • Pre- and peri-operative MRSA prophylaxis
  • Antibacterial and antifungal prophylaxis with considerations for multi-resistance
  • Post-transplant prophylaxis against CMV, PCP and TB infections

Changes since the last guideline include:

  • Change of categories to standard elective transplants and emergency transplants
  • Re-dosing intervals during prolonged surgery
  • Introduction of considerations for anti-bacterial and anti-fungal use in special circumstances
  • Guidance for positive preservation fluid cultures
  • Requirement for G6PD level if dapsone is prescribed
  • Consideration of at-risk patients outside recognised prevalent areas for TB screening

The table following below summarises the current standard recommendations. The liver transplant waiting list population is particularly heterogeneous and thus the table should not be used in isolation form the remainder of the guideline which provides some background and special considerations.

Procedure

Prophylaxis
aims to reduce

Evidence level

NNT

Antimicrobial dose/route start at ≤1 hours before procedure

Routine

True penicillin allergy

Liver transplant:
Elective

Special circumstances:

  • Multi-resistant organisms on screens
  • Hyponatraemia in penicillin allergic individuals
  • Concurrent infection / anti-microbial use

SSI

D

N/K

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV 8-hourly for 24 hours

  • Blood loss > 1500ml redose once (and reset clock).
  • Procedure >4 hours: redose
  • Procedure >8 hours: redose again

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly for 24 hours

  • Redose at 8 hours if procedure >8 hours.
  • No need to redose with blood loss unless massive, when discussion with microbiology is advised.

Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly for 24 hours

  • Blood loss > 1500ml redose once (and reset clock).
  • Procedure >8 hours: redose again
MRSA    

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose

  • Further 200mg dose if blood loss > 1500mls within first hour of surgery

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose.

  • Further 200mg dose if blood loss > 1500mls within first hour of surgery

IFI

B

14

Fluconazole electronic Medicines Compendium information on Fluconazole 200mg IV/PO/NG once-daily for 7 days.

See below for prolonged ICU stay >5 days advice

Fluconazole electronic Medicines Compendium information on Fluconazole 200mg IV/PO/NG once-daily for 7 days.

See below for prolonged ICU stay >5 days advice

Liver transplant:
Emergency
(supra-urgent)

Special circumstances:

  • Multi-resistant organisms on screens
  • Hyponatraemia in penicillin allergic individuals
  • Concurrent infection / anti-microbial use

SSI

D

N/K

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5g IV 8-hourly for up to 5 days (review at 48 hours).

  • Blood loss > 1500ml redose once (and reset clock).
  • Procedure >4 hours: redose
  • Procedure >8 hours: redose again

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly for up to 5 days (review at 48 hours).

  • Redose at 8 hours if surgery prolonged >8 hours.
  • No need to redose with blood loss unless massive, when discussion with microbiology is advised.

Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly for up to 5 days (review at 48 hours)

  • Blood loss > 1500ml redose once (and reset clock).
  • Procedure >8 hours: redose again
MRSA    

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose

  • Further 200mg dose if blood loss > 1500mls within first hour of surgery

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose

  • Further 200mg dose if blood loss > 1500mls within first hour of surgery

IFI

B

6

Fluconazole electronic Medicines Compendium information on Fluconazole 200mg IV/PO/NG once-daily for 7 days for acute liver failure indications.

Ambisome electronic Medicines Compendium information on Ambisome 1mg/kg/day IV for 5 days post-op for HAT/PNF indications (Step down to Fluconazole electronic Medicines Compendium information on Fluconazole 200mg IV/PO/NG once-daily thereafter for 5 days)

See below for prolonged ICU stay >5 days advice

Fluconazole electronic Medicines Compendium information on Fluconazole 200mg IV/PO/NG once-daily for 7 days for acute liver failure indications.

Ambisome electronic Medicines Compendium information on Ambisome 1mg/kg/day IV for 5 days post-op for HAT/PNF indications (Step down to Fluconazole electronic Medicines Compendium information on Fluconazole 200mg IV/PO/NG once-daily thereafter for 5 days)

See below for prolonged ICU stay >5 days advice

Relaparotomy post-liver transplant
(within same admission; up to 3 months)

Special circumstances:

  • Multi-resistant organisms on screens
  • Hyponatraemia in penicillin allergic individuals
  • Concurrent infection / anti-microbial use

SSI

D

N/K

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5g IV 8-hourly for 48 hours

  • Blood loss > 1500ml redose once (and reset clock).
  • Procedure >4 hours: redose
  • Procedure >8 hours: redose again

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV 12-hourly for 48 hours

  • Redose at 8 hours if surgery prolonged >8 hours.
  • No need to redose with blood loss unless massive, when discussion with microbiology is advised.

Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV 8-hourly for 48 hours

  • Blood loss > 1500ml redose once (and reset clock).
  • Procedure >8 hours: redose again
MRSA     Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose
Further 200mg dose if blood loss > 1500mls within first hour of surgery

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose.

  • Further 200mg dose if blood loss > 1500mls within first hour of surgery

IFI

B

6

Ambisome electronic Medicines Compendium information on Ambisome 1mg/kg/day IV for 5 days post-op (Step down to Fluconazole electronic Medicines Compendium information on Fluconazole 200mg IV/PO/NG once-daily thereafter for 5 days)

See below for prolonged ICU stay >5 days advice

Ambisome electronic Medicines Compendium information on Ambisome 1mg/kg/day IV for 5 days post-op (Step down to Fluconazole electronic Medicines Compendium information on Fluconazole 200mg IV/PO/NG once-daily thereafter for 5 days)

See below for prolonged ICU stay >5 days advice

Prolonged ICU stay (>5 days post transplantation)

Invasive Fungal Infection

B

6

Ambisome electronic Medicines Compendium information on Ambisome 1mg/kg/day IV for duration of ICU stay.

Ambisome electronic Medicines Compendium information on Ambisome 1mg/kg/day IV for duration of ICU stay.

N/K= not known

1. General screening recommendations

Patients undergoing liver transplantation are at risk of infection both peri- and post-operatively, including opportunistic infection e.g. Cytomegalovirus and reactivation of latent infection eg Tuberculosis. Certain other infections can be worse in immunosuppressed individuals e.g. chicken pox. There is also increasing awareness of colonisation or exposure risk with multi-resistant organisms which may require special consideration when considering anti-microbial prophylaxis.

Patients on the liver transplant waiting list are therefore screened for:

  • Methicillin Resistant Staphlococcus Aureus (MRSA)
  • Carbapenamase Producing Enterobacteriaceae (CPE)
  • Previous Cytomegalovirus (CMV) infection (as part of liver transplant assessment)

Prophylaxis approaches for these are covered in the guidance below.

A new screening consideration for previous TB exposure has been added to the guidance below.

They are also screened for previous chicken pox (VZV), herpes simplex (HSV) and Epstein Barr virus (EBV) infection. This is not for prophylaxis purposes, but for general immunosuppression and post-transplant exposure management. These are not discussed further here.

2. MRSA Screening and Prophylaxis

All patients should be considered at high risk of MRSA colonisation/infection.
The aim of prophylaxis is to reduce the risk of surgical site infection.

2.1 Waiting list
All patients should continue to be screened for MRSA whilst on the waiting list at 3 monthly intervals.
If screen positive, decolonisation should be attempted whilst on the waiting list *.
Up to 2 attempts can be given, if remains positive please discuss with microbiology.

If a patient on the waiting list is admitted to the ward from another hospital, please follow the MRSA policy on the intranet (detail.aspx?ID=684)

*If MRSA screen is positive check the MRSA is susceptible to mupirocin as the guidance above will need adaptation (as per the MRSA policy). Neomycin (naseptin) would normally be used in this setting but occasionally mupirocin resistant strains can be neomycin resistant too. Please see the MRSA Policy for further information in this setting.

2.2 On admission for transplant
All patients should receive:

  • Mupirocin electronic Medicines Compendium information on Mupirocin 2% cream applied to both nostrils 8-hourly for 5 days (unless screen positive with resistant strain, see above)
  • Chlorhexidine 4% all-over body wash daily for 5 days (hair wash on two occasions during this time).

Decolonisation should be started from the day/night of admission and continued through surgery and post-operatively for 5 days.

This is for all patients regardless of screen status; the screening guidance above is to pick up screen positive patients and treat them ahead of call-in.

      • Peri-operatively

Perioperative IV Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg single dose
Give a further 200mg dose if blood loss exceeds 1500mls within first hour of surgery

2.4 If the transplant does not go ahead
If feasible stop the decolonisation if the MRSA screen on admission is negative (to reduce risk of future mupirocin resistance).

3. Antibiotic surgical prophylaxis

The following guidelines apply to bacterial surgical site infection (SSI) prophylaxis. Please note they are not guidelines for prevention of other infection, and neither are they guidelines for treatment. Evidence for prevention of infection in general with use of prophylaxis is scarce in the liver transplant literature. If infection is suspected or develops despite SSI prophylaxis, then treatment is needed, guided by the particular clinical presentation.

Similarly, where patients are already on antibiotics for treatment of an infection (suspected or confirmed), surgical prophylaxis may need to be reviewed. Please discuss with microbiology if unsure how to proceed.

Special considerations include:

3.1.1 Antibiotic prophylaxis: Resistant organisms
If patients are known to be colonised with resistant organisms (eg ESBLs, Carbapenemase Producing Enterobacteriaceae (CPEs), VRE), prophylaxis will need to be tailored to that individual. Patients on the liver transplant waiting list undergo routine screening for CPE. As a result of this, carriage of other resistant organisms may be detected. If known in advance i.e. a patient screens positive whilst on waiting list or on the ward for CPE or other resistant organisms, surgical site prophylaxis should be planned pre-transplant with advice from microbiology, and documented in the medical notes and on the transplant waiting list. This plan is communicated by the co-ordinators to the admitting doctor at the time of transplant admission and the advice is discussed with the on call microbiology StR on call to check the advice is still up to date and no new clinical information needs taking into account. This is particularly relevant to patients where a significant amount of time has elapsed between plan and transplant admission.

3.1.2 Antibiotic prophylaxis: Patients already receiving prophylaxis
Some patients are on prophylactic antibiotics prior to transplant surgery. The most common indications would be for spontaneous bacterial peritonitis (SBP) or for cholangitis. These patients may need a review of transplant prophylaxis management, especially if on a quinolone and penicillin allergic, due to known high resistance levels to quinolones. Wherever possible an attempt should be made to provide a plan ahead of surgery, with a waiting list alert so it can be communicated to the transplant admission team.

3.1.3 Antibiotic prophylaxis: Re-dosing
In the general surgical setting, guidelines recommend that antibiotics need to be re-dosed after 2 half-lives. For antibiotics with short half-lives frequent re-dosing could potentially involve additional volume and sodium loading, and may not be safe for liver transplant patients with hyponatraemia. However, most liver transplant surgery is prolonged >4 hours and the potential benefit of surgical prophylaxis may be lost without re-dosing.
We have therefore reviewed the sodium content of the antibiotics recommended in this guideline. This is shown in the table below. They can all be diluted in non N/Saline diluents if necessary, and it is noted that Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav and Teicoplanin electronic Medicines Compendium information on Teicoplanin have low sodium contents.
 

In a change from previous versions this guideline therefore now recommends re-dosing with an exclusion for penicillin-allergic patients with pre-existing hyponatraemia or peri-operative sodium shifts. When patients are re-dosed with Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin or Metronidazole electronic Medicines Compendium information on Metronidazole (after 8 hours) and surgery is ongoing, using a non-saline diluent and ongoing sodium monitoring is advised. If there is renal dysfunction the pharmacists should be asked to review the dosing intervals after the first 24 hours.

Re-dosing requirements for antibiotics not falling into the above list (ie individually tailored for resistant organisms) will require instructions from microbiology at time of transplant where possible; standard dosing intervals should otherwise apply.

4. Invasive fungal infection prophylaxis

Due to an alert from NHSBT regarding donor fungal infection transmission risk, these guidelines now incorporate anti-fungal prophylaxis for all transplant recipients.

Fluconazole electronic Medicines Compendium information on Fluconazole is first-line anti-fungal for all elective transplants and supra-urgent transplants for acute liver failure.
Ambisome electronic Medicines Compendium information on Ambisome is recommended for any post-transplant relaparotomy within the first 3 months (and therefore all supra-urgent transplants for HAT or PNF).
For patients requiring a prolonged stay on ICU (> 5 days) following their transplant, switch prophylaxis with Fluconazole electronic Medicines Compendium information on Fluconazole to prophylaxis with Ambisome electronic Medicines Compendium information on Ambisome.

Special considerations include:

4.1.1 Antifungal prophylaxis: Positive fungal cultures in preservation fluid
Positive fungal cultures in preservation fluid should lead to a 2 week course of anti-fungal prophylaxis. Use higher dose Fluconazole electronic Medicines Compendium information on Fluconazole 400mg once a day. Ambisome can be stepped down to Fluconazole electronic Medicines Compendium information on Fluconazole when clinically appropriate e.g. off ICU etc. the course can be extended if there is evidence or suspicion of fungal infection. Be aware that an audit in 2018 demonstrated a rise in tacrolimus levels when higher dose Fluconazole electronic Medicines Compendium information on Fluconazole is used, thus when it is discontinued tacrolimus levels may fall. We recommend that levels are monitored regularly for the first few days if patients remain inpatients. If they have been discharged they should be monitored and adjusted at the first available outpatient review through either of the transplant clinics in the first week post-discharge.

4.2.2 Antifungal prophylaxis: early post-transplant discharge
We have reviewed the dose of Fluconazole electronic Medicines Compendium information on Fluconazole through literature review, use in other units and in-house audit due to potential interaction with Tacrolimus electronic Medicines Compendium information on Tacrolimus. The Tacrolimus electronic Medicines Compendium information on Tacrolimus interaction is well known but mild. It is uncommon to discharge patients within 7 days before the Fluconazole electronic Medicines Compendium information on Fluconazole is stopped, and the clinical significance of any subsequent reduction in Tacrolimus electronic Medicines Compendium information on Tacrolimus is uncertain. However clinicians are reminded to be alert to this in the small cohort to whom this applies. The interaction is dose dependent and our most recent rate of IFI is 1% (Audit 2018-19), thus there is little imperative to increase the prophylaxis dose to that recommended in the American Society of Transplantation guidelines (400mg) when doses of 100-400mg have been reported to be effective.

4.2.3 Antifungal prophylaxis: ongoing renal replacement therapy post-transplant
There is not sufficient evidence to make a routine recommendation about this. Haemodialysis is a known risk factor for invasive fungal infection in the post-transplant population. It is therefore suggested that patients requiring prolonged dialysis who are not needing intensive care for other reasons or who are back on the ward are discussed on a case by case basis, perhaps looking at prolonged cholestasis with jaundice, bile leak or need for high dose immunosuppression for treatment of rejection as particular cases for consideration. Any decision to continue or restart should be documented clearly in the medical notes and e-meds with a guide for when it could be discontinued, to ensure that a consistent approach for the individual patient is taken.

5. Post-transplant prophylaxis for Pneumocystis, Cytomegalovirus and Tuberculosis

5.1 Pneumocystis jirovecii Pneumonia (PCP) Prophylaxis
Risk of PCP in liver transplant recipients is highest in periods of most intense immunosuppression, and is in the order of 5-15%.
The aim of prophylaxis is to reduce the risk of PCP infection.

All patients should therefore receive:

  1. Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole 480mg od from day 7 to day 100 post-transplant. A supply of the correct remaining duration is issued by the pharmacists at discharge.
  2. For patients with Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole allergy/intolerance, alternative agents have significant side-effect profiles and limited additional coverage, so using an alternative is not routinely recommended. However very heavily immunosuppressed individuals e.g. those being treated for steroid resistant acute rejection with ATG, or patients with a past medical history of PCP, may benefit from an alternative agent in which case Dapsone 100mg od can be used. If dapsone is prescribed, the patient should have a G6PD level sent, as deficiency can precipitate severe haemolysis.

Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole covers a range of organisms including toxoplasma, listeria and nocardia.

If Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole is not being used, be mindful of the possibility of infection with the above, particularly in the event of known donor positive toxoplasma serology/active infection. Such cases should be discussed with microbiology. Maintain a high level of vigilance for PCP infection in the 3 month post-operative period.

5.2 Cytomegalovirus infection (CMV) prophylaxis
Risk of CMV infection post liver transplant is highest in periods of most intense immunosuppression and CMV-negative recipients (R-) receiving grafts from CMV positive donors (D+). Our unit refers to this scenario as “CMV mismatch”. Donor CMV status is communicated to the medical team by the transplant co-ordinators and is documented on PPM.

The aim of prophylaxis is to reduce primary CMV infection.

All D+/R- recipients should therefore receive:

  • Valganciclovir 900mg od from day 7 to day 100 post-transplant (as per the SPC). A supply of the correct remaining duration is issued by the pharmacists at discharge.
  • Valganciclovir dosing needs to reduced in renal impairment (discuss with Liver Unit pharmacist if uncertain).

The risk of primary infection in CMV mismatch individuals persists following withdrawal of prophylaxis, particularly if immunosuppression remains high. Such patients should be screened at their clinic appointments via CMV-PCR testing until 12 months post-transplant. Monthly repeat testing is an appropriate minimum interval unless viraemia is being monitored or a clinical indication presents in the interval. This guidance was reviewed through the Liver Transplant  Forum in 2019.

5.3 Mycobacterium tuberculosis (TB) prophylaxis
Patients from high risk areas are at risk of TB reactivation. High risk areas are defined as countries where the incidence is 40 per 100 000 or higher and can be checked on www.gov.uk/government/publications/tuberculosis-tb-by-country-rates-per-100000-people.

The aim of prophylaxis is to prevent reactivation of latent TB.

Patients with a should be given prophylaxis with Isoniazid 300mg daily and Pyridoxine 10mg daily for 6 months post-transplant, starting as soon as possible and by day 10 at the latest.

Other patients may be at risk of reactivating latent TB. The transplant clinicians should bear in mind that this may include patients coming from high prevalence UK cities, excess alcohol intake and malnutrition and patients with known TB contacts, and be alert to testing in selected patients. LTHT microbiologists therefore now recommend screening some patient populations for evidence of previous TB exposure by means of a Quantiferon test. This can be ordered on the ICE system. Such patients can be screened if thought at risk in the pre-transplant clinic, and will need to be seen in a TB clinic if the results are positive. Results are usually available within 3 working days. There is rising worldwide concern about multi-resistance to anti-tuberculous drugs, and unnecessary use of TB drugs. However, a consensus to screen all patients on the waiting list in this way has not been reached at present and will be part of an ongoing review in 2020-21.

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Background information

These guidelines were first produced following a meeting on 8th July 2009 attended by Dr Rebecca Jones and Dr Charles Millson, Transplant Hepatologists, Mrs Faye Croxen, Liver Unit Pharmacist, Dr Nick Foster and Dr Jonathan Sandoe, Microbiologists, Drs C Flynn and A Ford, Medical SpRs on Liver Unit and Mr A Shah, Surgical Transplant Fellow. Presentations were given on antibiotic prophylaxis in acute and sub-acute liver failure, antifungal prophylaxis in acute and sub-acute liver failure and in the post-transplant group and antibiotic prophylaxis in liver transplant surgery. A benchmarking exercise with other liver transplant units within the UK was also carried out.

The 2015 review was carried out by Dr Rebecca Jones (Hepatology), Dr Nicola Young (Microbiology) and Ms Rebecca Smith (Liver Unit Pharmacist) with input from Dr Tim Collyns (Microbiology) and Dr Phil Howard (Pharmacy). Since the original guideline was produced, the spectrum of resistant organism detection through CPE screening has increased in the liver transplant population, necessitating an individual approach for some patients which cannot be covered by a “cover-all” policy.

The 2019 review was carried out by Dr Rebecca Jones (Hepatology), Dr Chloe Walsh (Microbiology), Dr Fiona McGill (Microbiology) and Mr Dane Howard (Liver Pharmacy), with the Liver Unit clinicians through the Liver Transplant Forum, and in consultation with Dr Watson (respiratory, TB) and Dr Denton (Microbiology, Mycobacteria). The guideline was also informed by an expert review in invasive fungal infection 2018 by Dr Miruna David (Microbiologist, QEH, Birmingham) and a detailed review of CMV practice 2019 by Drs Sern Yeoh and Joanna Moore (Hepatology, LTHT).

There is variation both within the UK and worldwide regarding approaches to prophylaxis, with evidence often being contradictory, hence the need for a consensus approach in the Leeds Liver Unit, being mindful of the published evidence and the experience of the unit.

Bacterial infection and surgical site infection remains a concern for post-liver transplant outcomes, and prophylaxis has to fit alongside an overall infection prevention approach throughout the unit, including scrupulous attention to hand hygiene and source isolation procedures.

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Special antimicrobial prophylaxis recommendations

  1. MRSA prophylaxis in liver transplant surgery - as per LTHT guidelines, considering all such patients to be high risk as almost all will have spent some time hospitalised within 6 months of surgery. (C,D)

  2. Antibiotic and antifungal prophylaxis in emergency transplantation for acute and sub-acute liver failure patients, where duration will depend somewhat on the presentation and recovery progress post-transplant, recognised to be highly heterogenous in this (rare) group. (C,D)

  3. Antifungal prophylaxis post liver transplant and risk factors for invasive fungal infection (A)

  4. Antibiotic prophylaxis post liver transplant surgery - as per LTHT guidelines for surgical prophylaxis taking into account whether patients are likely to be antibiotic naïve at point of surgery or not, and screening results for multi-resistance. (C,D)

Provenance

Record: 1824
Objective:
Clinical condition: Liver transplant surgery in adults
Target patient group: Liver transplant patients
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

Evidence level (A,B,C,D)

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus (no national guidelines exist, guidelines from different learned bodies   contradict each other, or no evidence exists)

References

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Rolando N et al. Bacterial and fungal infection in acute liver failure. Seminars in Liver Disease 1996;16:389-402

Snydman DR. Epidemiology of infections after solid-organ transplantation. Clinical Infectious Diseases 2001;33(suppl 1):S5-8

Kusne S and Blair JE. Viral and fungal infections after liver transplantation- Part II. Liver Transplantation 2006;12:2-11

Bratzler DW et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013;70:195-283

Garcia Prado ME et al. Surgical site infection in liver transplant recipients: impact of the type of perioperative prophylaxis. Transplantation 2008;85:1849-1854

Asensio A et al. Effect of antibiotic prophylaxis on the risk of surgical site infection in orthotopic liver transplant. Liver transplantation 2008;14:799-805

Singhal S et al. Targeted prophylaxis with amphotericin B lipid complex in liver transplantation. liver Transplantation 2000;6:588-595

Cruciani M et al. Antifungal prophylaxis in liver transplant patients: a systematic review and meta-analysis. Liver Transplantation 2006;12:850-858

Playford EG et al. Systematic review and meta-analysis of antifungal agents for preventing fungal infections in liver transplant recipients. Eur J Clin Microbiol Infect Dis 2006;25:549-561

Hellinger WC et al. Risk stratification and targeted antifungal prophylaxis for prevention of aspergillosis and other invasive mold infections after liver transplantation. Liver Transplantation 2005;11:656-662

Singh N et al. Antifungal management practices in liver transplant recipients. American Journal of Transplantation 2008;8:426-431

Singh N et al. Donor-derived fungal infections in organ transplant recipients: Guidelines of the American Society of Transplantation, Infectious Diseases Community of Practice. American Journal of Transplantation2012; 12: 2414–2428

Eschenauer GA et al. Antifungal prophylaxis in liver transplant recipients. Liver Transplantation 2009;15:842-858

Evans JD et al. Antifungal prophylaxis in liver transplantation: a systematic review and network meta-analysis. Am J Transplant 2014;14:2765-76

Eschenauer GA et al. Targeted versus universal antifungal prophylaxis among liver transplant recipients.Am J Transplant. 2015 Jan;15(1):180-9.

Vandecasteele E et al. Antimicrobial prophylaxis in liver transplant patients - a multicentre survey endorsed by the European Liver and Intestine Transplant Association. Transplant Int. 2010;23:182-190.

Healthcare Improvement Scotland: Recommendations for re-dosing antibiotics for surgical prophylaxis. 2018 https://www.sapg.scot/media/4105/good-practice-recommendations-for-re-dosing-antibiotics-for-surgical-prophylaxis.pdf

Healthcare Improvement Scotland: Good Practice Recommendations for Surgical and Procedural Antibiotic Prophylaxis in Adults in NHS Scotland. 2018 https://www.sapg.scot/media/4109/good-practice-recommendations-for-surgical-and-procedural-antibiotic-prophylaxis-in-adults-in-nhs-scotland.pdf

Mumtaz K et al. Universal prophylaxis or preemptive strategy for cytomegalovirus disease after liver transplantation: a systematic review and meta-analysis. Am J Transplant 2015;15:472-481

Hodson EM et al. Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2013;2:CD003774.doi:10.1002/14651858.CD003774.pub4

Rolando et al. Antibiotics in humans with acute liver failure: A randomised controlled trial. Hepatology 1993;17:196-201

Rolando et al. Antibiotics in humans with acute liver failure. J Antimicrob Chemother 1992;30:215-220

Salmeron et al. Antibiotics in humans with acute liver failure: an observational study. J Hepatol 1992;14:280-285

Adamu B et al. Antibiotic prophylaxis for preventing post solid organ transplant tuberculosis. Cochrane Database Syst Rev 2014 3:CD008597.doi:10.1002/14651858

Fabrega E et al. Chemoprophylaxis with isoniazid in liver transplant recipients. Liver transplantation 2012;18:1110-1117

Rajagopala S et al. Latent Mycobacterium tuberculosis infection in liver transplant recipients - controversies in current diagnosis and management. J Clin Exp Hepatol 2011;1:34-37

Holty JE et al. Tuberculosis in liver transplant recipients: a systematic review and meta-analysis of individual patient data. Liver Transplantation 2009;15:894-906
Sarwar S et al. Low incidence of Pneumocystis jirovecii pneumonia in an unprophylaxed liver transplant cohort. Transpl Infect Dis. 2013;15:510-515

Trotter JF et al. Absence of Pneumocystis jiroveci pneumonia in liver transplantation recipients receiving short-term (3-month) prophylaxis.Transpl Infect Dis. 2008 Oct;10(5):369-71.

Shah PM et al. Impact of extended vs short course per-operative antibiotics on surgical site infection in liver transplant patients. Surgical Infections 2016; 17 (s1) Abstract 001

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.1

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