Renal Transplant Surgery in Adults - Guideline for Antimicrobial Prophylaxis

Publication: 01/03/2010  --
Last review: 23/02/2018  
Next review: 23/02/2021  
Clinical Guideline
CURRENT 
ID: 1868 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

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 renal transplant surgery in adults

  1. Summary table of routine recommendations
  2. Background information
  3. Standard approaches
  4. Special antimicrobial prophylaxis recommendations

1. Summary table of routine recommendations

It is the responsibility of the surgical team to prescribe the antibiotics & the anaesthetist to ensure they are given before incision.

Procedure

Recommendation for antibiotic prophylaxis

Evidence level

Aim of prophylaxis

NNT

Antimicrobial dose/route
Give ≤1 hours before procedure

Routine

Penicillin allergy

*MRSA risk

Renal transplant recipient surgery (living or deceased donor).

Recommended

A(1)

Prevention of surgical site infection & early post-operative UTI

n/a

Co-amoxiclav Description: electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin 400mg IV + Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin 400mg IV (both single dose)

add Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin 400mg IV single dose to routine Co-amoxiclav (Amoxicillin-Clavuluante) Description: electronic Medicines Compendium information on Co-amoxiclav prophylaxis

Donor nephrectomy

Recommended

A(1)

SSI

n/a

Flucloxacillin Description: electronic Medicines Compendium information on Flucloxacillin 1g IV + Gentamicin 2mg/Kg IBW iv single -dose

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin 400mg IV + Gentamicin 2mg/Kg IBW iv single -dose

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin 400mg IV + Gentamicin 2mg/Kg IBW iv single -dose

*MRSA risk = previous MRSA infection or known colonisation

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2. Background information

The previous guideline for antimicrobial prophylaxis in renal transplant surgery at Leeds was prompted by the root cause analysis of two Clostridium difficile infections in patients during their surgical admission. Prior to the previous guideline, recipients received Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime1.5 gram IV at induction followed by 750mg IV 12-hourly for 48 hours. Known penicillin or cephalosporin allergic patients received Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin 200mg IV at induction and 250mg PO 12-hourly for 48 hours. The elimination half-life of both these agents is extended where the patient experiences delayed graft function (DGF) resulting in a more prolonged exposure to antibiotic. Both Clostridium difficile infections occurred in patients with DGF prescribed Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime. There was a desire to avoid cephalosporins for prophylaxis.

Although renal transplantation is clean-contaminated surgery the risks of surgical site infection (SSI) are increased by the patient being most heavily immunosuppressed at induction and then for the first three months after. A ureteric stent is placed during surgery which remains in situ for the early post-operative period. The purpose of antibiotic prophylaxis is to prevent SSI and early urinary tract infection (UTI). Variable rates of SSI have been described in renal transplantation ranging from 3% to 11%. These involve superficial soft tissue infections, deep organ space infections including perinephric abscess and pyelonephritis (1).

The 2014 Scottish Intercollegiate Guideline Network (SIGN) surgical prophylaxis guidelines specifically exclude transplant surgery (2). There are no British Transplant Society or CDC guidelines for this area.

An informal survey of the first and second line agents for surgical prophylaxis at other UK renal transplant units in June 2009 yielded results from eleven centres. Six of the eleven preferentially use a single dose of Co-amoxiclav (Amoxicillin-Clavulunate) Description: electronic Medicines Compendium information on Co-amoxiclav 1.2g IV at induction, one uses single dose Meropenem Description: electronic Medicines Compendium information on Meropenem 1g IV, two use Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin (one centre with Vancomycin Description: electronic Medicines Compendium information on Vancomycin & continued for seven days) and one centre uses single dose Gentamicin with Flucloxacillin Description: electronic Medicines Compendium information on Flucloxacillin. The choices of antibiotic where the patient has known allergy to the first-line agent always includes either the Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime or Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin we are trying to avoid.

The choice of agents was discussed at the Renal Transplant Service Team meeting on 24th November 2009 and subsequently with the trusts Microbiology department to get their perspective.

Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin 400mg IV was selected where there are known MRSA risk factors in line with currently approved guidelines for urological, liver transplant, upper & lower GI and hepatobiliary surgery in Leeds.

The renal transplant surgeons and physicians were ask via email on 3rd November 2017 for their opinions on the current guidelines for both the renal transplant recipient transplant and live donor nephrectomy antibiotic regimes. Only one reply was given with the feedback that although they prefer to give co-amoxiclav (amoxicillin-clavulunate) for both types of surgery they were happy to agree to using flucloxacillin and gentamicin for the live donor nephrectomies.

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3. Standard approaches

Co-amoxiclav (Amoxicillin-Clavulunate) Description: electronic Medicines Compendium information on Co-amoxiclav 1.2 gram IV single dose. Repeat doses should not be required as the half-lives of Amoxicillin Description: electronic Medicines Compendium information on Amoxicillin and clavulanic acid are sufficiently long with this degree of renal impairment to cover the duration of the procedure. Evidence level D
If true penicillin allergy then replace with,
Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin 400mg IV single dose plus Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin400mg IV single dose. Evidence level D
If MRSA risk, as defined, add the following to Co-amoxiclav Description: electronic Medicines Compendium information on Co-amoxiclav,
Teicoplanin Description: electronic Medicines Compendium information on Teicoplanin 400mg IV single dose. Evidence level D

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4. Special antimicrobial prophylaxis recommendations

For all patients, results from any recent urine isolates should be used to inform the choice of prophylaxis (i.e. Co-amoxiclav Description: electronic Medicines Compendium information on Co-amoxiclav would not be the most appropriate agent where a patient had a recent urinary ESBL E. coli isolated - prophylaxis should be discussed with the Microbiology service).

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Provenance

Record: 1868
Objective:
Clinical condition:

Renal transplant surgery in adults

Target patient group: All patients undergoing renal transplant surgery
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

Evidence base
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

  1. Anesi JA et al. Perioperative Antibiotic Prophylaxis to Prevent Surgical Site Infections in Solid Organ Transplantation. Transplantation. 2017. Prior to publication.
  2. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2014

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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