2011 University of Colorado Denver Health Science Center Liver Transplant antibiotic prophylaxis protocol

Pierre Moine, Susan Mandell, Gerard Barber, Marilyn Levi

Low-risk LT patients (All 6 positive criteria)
1.  MELD* score <20
2.  Normal renal function
3.  No prior intra-abdominal sepsis
4.  Standard donor
5.  Child’s Pugh Turcotte score¶ <7
6.  No biliary disease / Antibiotic prophylaxis ║
-  cefotaxime 2 g iv loading dose. Then, a continuous infusion (c.i.) of 2 g over 6 h is immediately started. This c.i. dose regimen (2g/6h) will be repeated until surgery completion..
Intermediate-risk LT patients (At least 1 negative criteria from the low-risk LT patient list or only 1 positive criteria from the high-risk LT patient list) / Antibiotic prophylaxis ║
-  cefotaxime 2 g iv loading dose. Then, a c.i. of 2 g over 6 h is immediately started. This c.i. dose regimen (2g/6h) will be repeated until surgery completion.
-  unasyn 3 g (ampicillin 2g and sulbactam 1g) g iv loading dose. Then, a c.i. of 3 g over 8 h is immediately started. This c.i. dose regimen (3g/8h) will be repeated until surgery completion. †
High-risk LT patients (At least 2 positive criteria of 8)
1.  MELD* score >29
2.  Renal failure / dialysis §
3.  Prior intra-abdominal sepsis / Antibiotic treatment for >5 days within the last 90 days
4.  Expanded criteria donor #
5.  Child’s Pugh Turcotte score¶ >9
6.  Biliary disease / Biliary drain / Choledochojejunal reconstruction/biliary-enteric anastomosis
7.  Current hospitalization >48h / Antibiotic prophylaxis ║
-  cefotaxime 2 g iv loading dose. Then, a c.i. of 2 g over 6 h is immediately started. This c.i. dose regimen (2g/6h) will be repeated until surgery completion.
-  unasyn 3 g (ampicillin 2g and sulbactam 1g) g iv loading dose. Then, a c.i. of 3 g over 8 h is immediately started. This c.i. dose regimen (3g/8h) will be repeated until surgery completion. †
-  micafungin 100 mg iv

# Expanded criteria donor ECD: Donors age 70 to 80, or donors older than age 60 with a significant medical history, or donors with a history of high-risk social behaviors, or donors with a history of Hepatitis B or C exposure.

* Model for End-Stage Liver Disease MELD score: Appendix 1

¶ Child’s Pugh Turcotte score: Appendix 2

† The total dose of sulbactam should not exceed 4 grams per day.

§ Revised classification system of renal dysfunction in patients with cirrhosis: Appendix 3

║Antibiotic prophylaxis and penicillin allergy and/or cephalosporin allergy: Different antibiotic prophylaxis regimen would be acceptable:

-  clindamycin 600-900 mg iv within 30 min (redosing interval 8 h) and gentamicin 1.5-2 mg/kg iv within 30 min once at induction of anesthesia

-  vancomycin 10-15 mg/kg iv within 2 hours (redosing interval 12 h – once if renal failure (CrCl ≤50 mL/min) and/or hemodialysis) and ciprofloxacin 400 mg iv (redosing interval 8 h - once if renal failure (CrCl <30 mL/min) and/or hemodialysis)

-  vancomycin 10-15 mg/kg iv within 2 hours (redosing interval 12 h – once if renal failure (CrCl ≤50 mL/min) and/or hemodialysis) and aztreonam 2g (redosing interval 4 h - if renal failure 10 ≤ CrCl <30 mL/min redose aztreonam 1 g / 4 h – if CrCl < 10 mL/min and/or hemodialysis redose aztreonam 500 mg / 4 h)


Appendix 1

Model for End-Stage Liver Disease MELD score

MELD = 3.78[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.57[Ln serum creatinine (mg/dL)] + 6.43


Appendix 2

Child-Turcotte-Pugh score

Measure / 1 point / 2 points / 3 points
Total bilirubin, mmol/l (mg/dl) / <34 (<2) / 34-50 (2-3) / >50 (>3)
Serum albumin, g/dl / >3.5 / 2.8-3.5 / <2.8
INR (PT prolongation) / <1.7 (<4 s) / 1.7-2.3 (4-6 s) / >2.3 (>6 s)
Ascites / None / Mild (easily controlled) / Severe
Hepatic encephalopathy / None / Grade I-II (or suppressed with medication) / Grade III-IV (or refractory)


Appendix 3

1.  Revised classification system of renal dysfunction in patients with cirrhosis (Wong F et al. Working party proposal for a revised classification system of renal dysfunction in patients with cirrhosis. Gut 2011; 60:702-709)

Diagnosis / Definition /
Acute kidney injury / Rise in serum creatinine of ≥50% from baseline or a rise of serum creatinine by ≥26.4μmol/l (≥0.3mg/dl) in <48h
HRS type 1 is a specific form of acute kidney injury *
Chronic kidney disease / Glomerular filtration rate of <60ml/min for >3months calculated using MDRD6 formula
HRS type 2 is a specific form of chronic kidney disease ¶
Acute-on-chronic kidney disease / Rise in serum creatinine of ≥50% from baseline or a rise of serum creatinine by ≥26.4μmol/l (≥0.3mg/dl) in <48h in a patient with cirrhosis whose glomerular filtration rate is <60ml/min for >3months calculated using MDRD6 formula †

* HRS type 1 or acute HRS is characterised by a rapidly progressive reduction of renal function as defined by a doubling of the initial serum creatinine to >220μmol/l (2.5mg/dl) or a 50% reduction in the initial 24h creatinine clearance to <20ml/min in <2weeks;

¶ HRS type 2 or chronic HRS is defined as moderate renal failure that progressed gradually over weeks to months with a serum creatinine of 133–220μmol/l (1.5–2.5mg/dl).

† Modification of diet in renal disease MDRD 6 equation (MDRD6) = 198 × [serum creatinine(mg/dL)]−0.858 × [age]−0.167 × [0.822 if patient is female] × [1.178 if patient is black] × [serum urea nitrogen concentration (mg/dL)]−0.293 × [urine urea nitrogen excretion (g/d)]0.249