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Hepatitis B Prophylaxis for Non-Thoracic Solid Organ Transplant – Adult – Inpatient [118]

Hepatitis B Prophylaxis for Non-Thoracic Solid Organ Transplant – Adult – Inpatient [118] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols



Delegation Protocol Number: 118

Delegation Protocol Title:
Hepatitis B Prophylaxis for Non-Thoracic Solid Organ Transplant – Adult – Inpatient

Delegation Protocol Applies To:
All adult inpatients except those with evidence of a lamivudine-resistant HBV genotype

Target Patient Population:
Adult patients who have received a non-thoracic solid organ transplant (kidney, liver, pancreas, or any
combination thereof) with laboratory evidence of chronic hepatitis B infection, recipients of an organ
from a donor with laboratory evidence of previous hepatitis B exposure, or recipients with laboratory
evidence of previous hepatitis B exposure.

Delegation Protocol Champions:
Joshua Mezrich, MD – Department of Surgery, Division of Transplant Surgery
Adnan Said, MD – Department of Medicine, Gastroenterology

Delegation Protocol Reviewers:
David Hager, PharmD – Department of Pharmacy
Jaime Myers, RN – Department of Transplant
Michael Armbrust, RN – Department of Transplant
Joshua Vanderloo, PharmD – Department of Pharmacy

Responsible Department:
Department of Pharmacy

Purpose Statement:
To delegate authority from the attending physician to the inpatient pharmacist to determine and to
order the appropriate hepatitis B antiviral prophylaxis for non-thoracic solid organ transplant patients as
outline in UWHC Hepatitis B Prophylaxis for Non-thoracic Solid Organ Transplant – Adult – Inpatient –
Clinical Practice Guideline.

Who May Carry Out This Delegation Protocol:
Pharmacists who have been trained in the use of this protocol.

Guidelines for Implementation:
1. This protocol is initiated when a pharmacist identifies a patient who is receiving a non-thoracic solid
organ transplant:
1.1. who has laboratory evidence of chronic hepatitis B infection (hepatitis B surface antigen
positivity and/or hepatitis B by polymerase chain reaction detected viremia),
1.2. from a donor who has laboratory evidence of previous hepatitis B exposure (donor hepatitis B
core antibody IgG and/or IgM positivity and hepatitis B surface antigen negativity), or
1.3. who has evidence of previous hepatitis B exposure (hepatitis B core antibody IgG and/or IgM
positivity and hepatitis B surface antigen negativity).
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


2. For new kidney, liver, pancreas, or any combination of these transplants the clinical pharmacist
determines the appropriate antiviral regimen based on the recipient hepatitis B status documented
in the medical record and the donor hepatitis B status.
3. The pharmacist will order appropriate antiviral therapy after transplantation according to the
Hepatitis B Prophylaxis for Non-Thoracic Solid Organ Transplant – Adult – Inpatient – Clinical Practice
Guideline.
4. The pharmacist enters a note in the medical record indicating the antiviral prophylaxis therapy
ordered per protocol. The clinical pharmacist will document the induction agent, the recipient
hepatitis B status (hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B core
antibody, and hepatitis B DNA by polymerase chain reaction, if applicable), donor hepatitis B status
(hepatitis B core antibody and hepatitis B surface antigen), UNOS ID number for the donor, and
appropriate antiviral regimen.
5. This protocol may be overridden at any time by a provider order for antiviral prophylaxis that
indicates “antiviral prophylaxis – dispense as written” or similar designation in the administration
instructions of the order.

Order Mode:
Medications – Protocol/Policy without Cosign

References: N/A

Collateral Documents/Tools:
1. Hepatitis B Prophylaxis for Non-Thoracic Solid Organ Transplant – Adult – Inpatient – Clinical
Practice Guideline
2. Renal Function-based Dose Adjustments – Adult – Inpatient – Clinical Practice Guideline
Approved By:
Antimicrobial Use Sub-Committee: March 2015
Pharmacy and Therapeutics Committee: July 2015
UWHC Medical Board: August 2015

Effective Date: August 2015

Scheduled for Review: August 2017






Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org