Browser Not Supported

It looks like you're using an outdated browser. To view this site properly, please switch to a more modern browser such as Chrome,Firefox, or Edge.

Liver disease or transplant - prevention and management of infection

Date last published:

Management of complications from liver disease or transplant

This document is only valid for the day on which it is accessed. Please read our .
Starship clinical guidelines

Antibiotic choice in liver disease and transplant

Transplant prophylaxis

Elective patients

 
Standard patientsCefazolin 30 mg/kg (maximum 2 g) IV, q8h for 24 hours from the time of induction (three doses):
First dose given at induction, repeat dose if surgery >4 hours or if excessive blood loss
Penicillin anaphylaxis (not "rash") or MRSA colonisationVancomycin 15mg/kg (max 2g)IV q6h for 24 hours from the time of induction (four doses) and
Gentamicin single dose IV; 5mg/kg (max 360mg) administered as a 30 minute infusion.
ESBL+ve MRO colonisationCefazolin IV and
Amikacin single dose IV; 15mg/kg (max 1500mg) administered as a 30 minute infusion.
MRO status and any special requirements are to be documented on the transplant waiting list 
Sclerosing cholangitis/recurrent bacterial cholangitisStandard regimens as above, making certain that the regimen is effective in vitro against the last isolated infecting organism. If not, discuss alternative or additional antibiotic with the Infectious Disease service.

 

Transplant for acute liver failure (ALF), re-transplant for primary non-function 
Standard patientsCefazolin 30 mg/kg (maximum 2 g) IV q8h for 48 hours from the time of induction (six doses)
Penicillin anaphylaxis (not "rash") or MRSA colonisationVancomycin 15 mg/kg IV q6h for 48 hours from the time of induction (8 doses) and
Gentamicin 5mg/kg (max 360mg) IV q24h for 48 hours (2 doses)
ESBL+ve MRO colonisationCefazolin 30 mg/kg (maximum 2 g) IV q8h for 48 hours from the time of induction (6 doses) AND Amikacin IV 15 mg/kg (max 1500 mg) q24 hr for 48 hours (2 doses)
Antifungal prophylaxis: (ALF, retransplant and second laparotomy)Liposomal amphotericin 1mg/kg IV daily for 5 days

Percutaneous transhepatic cholangiography (PTC) ± ERCP ± cholangiography

For procedureAmoxicillin 50mg/kg (max 2g) IV q8h at induction (single dose or continue for 24 hours (total three doses) if complicated) and
Gentamicin single dose IV; 5mg/kg (max 360mg) administered as a 30 minute infusion
Oral prophylaxis for children with PTC tube or biliary stentCo-trimoxazole 12mg/kg combined (max 480mg) oral once daily

Liver biopsy

Immunosuppressed patients but otherwise at low risk for biliary complicationsCefazolin 30mg/kg (max 2g) IV given at induction as a single dose
High risk patients (unwell or biliary complications)Amoxicillin 50mg/kg (max 2g) IV q8h for 24 hours and
Gentamicin 5mg/kg (max 360mg) IV; single dose. If there is renal impairment replace gentamicin with ceftriaxone 50mg/kg (max 1g) IV single dose. 

Cholangitis

First Line therapyAmoxicillin 50mg/kg (max 2g) IV q8h and
Gentamicin 7mg/kg (max 360mg) IV q24h. If there is renal impairment replace gentamicin with ceftriaxone 50mg/kg 24 hourly IV (max 1g per dose)
Treat for 7 days
Second line therapy    Piperacillin-tazobactam 90mg/kg (max 4.5g) IV q8h 
Suspected respiratory infection
Cefuroxime 30mg/kg (max 1.5g) IV q8h 
Abdominal sepsis
Amoxicillin 50mg/kg (max 2g) IV q8h and
Metronidazole 7.5mg/kg (max 500mg) IV q8h and
Gentamicin 7mg/kg (max 360mg) IV q24h or  if there is renal impairment replace gentamicin with ceftriaxone 50mg/kg 24 hourly IV (max 1g per dose)
NB: If there is evidence of wound infection then consider rationalising to amoxicillin clavulanate ( to provide staphylococcal cover) plus gentamicin 

Spontaneous Bacterial Peritonitis

Initial therapyAmoxicillin 50mg/kg (max 2g) IV q8h and
Gentamicin 7mg/kg (max 360mg) IV q24h. If there is renal impairment replace gentamicin with ceftriaxone 50mg/kg 24 hourly IV (max 1g per dose)
Antibiotic choice to be altered according to results of ascitic tap
ProphylaxisCo-trimoxazole 12mg/kg (max 480mg) oral once daily
Recurrent cholangitisCo-trimoxazole 12mg/kg combined (max 480mg) oral once daily 2 weeks alternating with
Ciprofloxacin 10mg/kg (max 500mg) oral bd 2 weeks This requires ID approval, and NPPA funding for community use.

Antifungal prophylaxis after transplant

All patients  Nystatin 1mL (100,000 units/mL) orally q6h for four weeks post-transplant
"Swish and swallow" if able, give via NG tube if unable to swallow and if NG tube is present.
Transplant for acute liver failure or re-transplant or "return to theatre" Liposomal amphotericin B 1mg/kg IV daily for 5 days
Begin when listed for transplantation for transplant for acute liver failure and re-transplant. Give at time of return to theatre for "return to theatre" 
Suspected invasive fungal infection Discuss with Infectious Diseases Service

PJP prophylaxis after transplant

Begin one week after transplant and continue until 12 months post-transplantation, re-transplantation or treatment for acute rejection

Co-trimoxazole 15mg/kg combined orally bd for three days per week (e.g. MWF or FSS)

For patients with allergy to co-trimoxazole and are unable to be de-sensitised
High risk patients (CMV mismatch, previous PJP infection, thymoglobulin therapy)Discuss alternatives such as pentamidine or dapsone with Infectious Diseases Service.
Low risk patientsConsider close monitoring without PJP prophylaxis

Antiviral CMV prophylaxis after transplant

All patients receive prophylaxis post OLT; Start prophylaxis before day 10 provided

  • Platelet count >50 x 10⁹/L

  • Neutrophil count >1.0 x 10⁹/L

CMV and EBV status of donor and recipient to be formally documented in the clinical record.

Donor CMV StatusConfirm status with transplant co-ordinators.
Recipient CMV/EBV StatusAssessed at listing and at time of transplant
Monitoring: All patientsMonitor CMV/EBV viral load (2mL EDTA tube) 4 weekly post liver transplant for 12 months
Lab requirements: Individualised Lab request form and samples otherwise not processed

Prophylaxis

Valganciclovir 520mg/m2 (max 900mg) orally once daily

When patients are unable tolerate enteral administration by Day 10, IV ganciclovir prophylaxis can be used until enteral administration is possible.

Ganciclovir 5mg/kg IV q24h

Total duration of prophylaxis (valganciclovir and ganciclovir) is 12 weeks

Valganciclovir is a prodrug that is converted to ganciclovir which is teratogenic. Tablets should not be crushed unless required to give a part dose to smaller children. Doses should always be rounded to the nearest quarter of a tablet (i.e. 1 tablet = 450mg, ¾ tablet = 337.5mg, ½ tablet = 225mg, ¼ tablet = 112.5mg). Caregivers must be educated how to crush and administer this medicine with necessary precautions to reduce unnecessary exposure. Valganciclovir requires special authority approval prior to discharge.

A liquid formulation can be compounded by pharmacies that have the appropriate safety equipment (still air box).

The dose of valganciclovir and ganciclovir should be reduced in renal impairment according to the following algorithms (Amended from UCSF Children's Hospital)

Patients receiving thymoglobulin therapy
Start prophylaxis on day 1 of thymoglobulin therapy if:

  • Platelet count >50 x 10⁹/L

  • Neutrophil count >1.0 x 10⁹/L

Ganciclovir 5 mg/kg IV q24h until the patient is able to swallow tablets and then switch to oral valganciclovir 520mg/m2 daily for total treatment duration of six weeks. NB: Valganciclovir will require NPPA approval for this indication. Reduce doses in patients with renal impairment according to the above algorithms.

CMV treatment

Asymptomatic

  • Viral load < 2.5 logs - repeat in 3-7 days

  • Viral load ≥ 2.5 logs - treat for 14 days (treatment dose ganciclovir or valganciclovir) -repeat PCR and if negative complete 21 days and stop. Resume monthly surveillance.

Symptomatic/ tissue invasive disease irrespective of initial CMV viral load

  • Treatment dose valganciclovir

  • CNS/severe/significant GI disease: IV ganciclovir until stable and then switch to valganciclovir

  • PCR (viral load) monitoring weekly. Continue treatment for two weeks after viral load negative

Tissue positive PCR with negative serum PCR

Valganciclovir treatment dose 2-3 weeks - using precipitating symptom as treatment guide

Failure to respond to treatment

In the absence of an alternative diagnosis:

  • Ongoing symptomatology with positive serum PCR or

  • Ongoing symptomatology in patient with initial serum PCR negative

Consider change to alternative agent (especially in previous CMV disease or previous valganciclovir treatment):

  • Discuss with Infectious Diseases Service

  • Consider further tissue specimen

  • If no previous CMV and no previous valganciclovir treatment then consider stopping

GFR (ml/min/1.73m2)Dose recommendation
ValganciclovirStandard dose = 520 mg/m2 (max 900 mg twice daily)
> 60No dose reduction
40-59260mg/m2 (max 450mg) once daily
25-39260mg/m2 (max 450mg) alternate days
10-24260mg/m2 (max 450mg) twice a week
<10Avoid; use ganciclovir as below
Ganciclovir
>70No dose reduction 
50-705mg/kg q24h
25-502.5mg/kg q24h 
10-251.25mg/kg q24h 
<10 (or on HD)1.25mg/kg q48h 

EBV Treatment

Monitor CMV/EBV viral load (2mL EDTA tube) 4 weekly post liver transplant for 12 months. Monitoring continues if the patient has demonstrated persistent carriage. Discontinue at 12 months if negative; for testing as clinically indicated.

If there is a rising viral load

  • Reduction of immunosuppression as clinically appropriate

  • Discuss with Infectious Diseases Service - antivirals will need NPPA approval

  • Review for evidence of PTLD/ EBV infection

  • Repeat viral load in 2 weeks

Liver transplant immunisation

For further information on immunisations please refer to the current Immunisation Schedule in the Immunisation Handbook or www.immune.org.nz

Post-transplant 
6 months post-transplantHep A and B revaccination for non-immune patients
Pneumococcal vaccine (23PPV)
12 months post-transplant Resume schedule immunisations -not live vaccines unless in discussion, benefit deemed to exceed risks
Annual check Measles/ varicella immune status. Discuss with infectious diseases team if non-immune
Hepatitis A/B immune status. Revaccinate if non-immune
Annual influenza immunization for patient. Recommend vaccination for siblings and parents
Ensure routine immunisation of siblings is up-to-date and recommend varicella vaccine for all non-immune household members. Varicella vaccine is funded for susceptible household contacts of transplant patients.

The Starship liver team will advise when it is safe to recommence vaccination after transplant. These patients will be on the accelerated immunisation schedule as per the national immunisation handbook - vaccines for special groups.

COVID-19 vaccine

It is recommended that all eligible post-transplant patients receive the 3 primary vaccines as per the Ministry of Health guidelines, and any boosters required (if not given prior to transplant).

Live vaccines post liver transplant

Live vaccines are not generally indicated post liver transplant due to the risk of immunosuppression.

However Varicella and MMR vaccination can be considered if the recipient is greater than 1 year post liver transplant and maintained on low level single agent immunosuppression. The decision needs to be discussed with the Starship liver team prior to administration.

Accelerated immunisation schedule (funded) for infants in whom liver or kidney transplant is likely

Refer to the Pharmaceutical Schedule (www.pharmac.govt.nz) for any changes to funding decisions. See Ministry of Health funded vaccines for special groups for accelerated immunisation schedule.

Post-transplant patients should receive immunoglobulin (IG) prophylaxis* if Varicella or Measles exposed AND:

  • known seronegative

  • OR if status is unknown and urgent result cannot be obtained

  • OR if patient has recently had increased immunosuppression (pulse steroids/ ATG/ increased baseline IS) without subsequent VZV/measles IgG result.

*For varicella exposure IG prophylaxis is given as VZIG (i.m.) or IVIG as soon as possible, but up to 10 days following exposure may be beneficial. If IG given greater than 96hours post exposure Acyclovir can also be offered for post exposure prophylaxis: oral acyclovir 20mg/ kg four times daily for 7 days from day 7 post exposure, plus strict instruction to present to medical care if lesions develop. In severely immune suppressed patients both modalities may be offered.

For measles exposure IG prophylaxis is given as normal IG (i.m.) or IVIG, as soon as possible within 6 days of exposure.

Additionally, ensure household contacts are immunised/ have immunity:

  • Varicella vaccine is now funded for all household contacts of immunosuppressed patients and should be given to household contacts with no prior history of chicken pox or vaccination

  • MMR vaccine is on the National Immunisation schedule and is free for any susceptible individual: all household contacts should have received 2 doses of measles containing vaccine (unless born prior to 1969).

Note: There is no prophylaxis available for mumps

Tools