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Liver Transplant Invasive Fungal Infection Prophylaxis – Adult – Inpatient [123]

Liver Transplant Invasive Fungal Infection Prophylaxis – Adult – Inpatient [123] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols


Delegation Protocol Number: 123

Delegation Protocol Title:
Liver Transplant Invasive Fungal Infection Prophylaxis – Adult – Inpatient

Delegation Protocol Applies To:
All adult admitted patients who have undergone a liver transplantation within the past five days and are
not receiving antifungals for a suspected or confirmed fungal disease.

Target Patient Population:
Adult patients who have received a liver transplant within the past five days and are at high-risk of
developing an invasive fungal infection post-operatively.

Delegation Protocol Champions:
Barry Fox, MD – Department of Medicine – Infectious Disease
Luis Fernandez, MD – Department of Surgery – Transplantation
Jeannina Smith, MD – Department of Medicine – Infectious Disease

Delegation Protocol Reviewers:
David Hager, PharmD, BCPS - Pharmacy
Margaret Jorgenson, PharmD, BCPS - Pharmacy
Sara Koth, PharmD - Pharmacy
Lucas Schulz, PharmD, BCPS AQ-ID – Pharmacy

Responsible Department:
Department of Pharmacy

Purpose Statement:
To delegate from the attending physician to the inpatient pharmacist the authority to screen patients for
risk factors for invasive fungal infections post-operatively and to initiate appropriate antifungal
prophylaxis.

Who May Carry Out This Delegation Protocol:
Pharmacists that have been trained in this delegation protocol.

Guidelines for Implementation:
1. This protocol is initiated when the pharmacist identifies a patient with a new liver transplant during the
current hospitalization.
2. Inclusion criteria
2.1. Eighteen years of age or older AND
2.2. Patient receiving new liver transplant in the during the current hospitalization
3. Exclusion criteria: If the patient meets any of the exclusion criteria the protocol does not apply and a
provider will be consulted prior to placing any orders.
3.1. Patient younger than eighteen years of age
3.2. Administration instructions with the wording “Do not adjust per protocol” or other language
conveying this intent
4. Pharmacist determines if the patient is high-risk or low-risk for invasive fungal infection post-
transplant based on criteria outlined in the Antifungal Prophylaxis in Liver Transplant Recipients –
Adult – Inpatient Clinical Practice Guideline.
5. If a patient is high risk, the pharmacist initiates appropriate antifungal prophylaxis following transplant
surgery according to Table 1. If a patient is low risk, no antifungal prophylaxis is initiated.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

6. Pharmacist discontinues any antifungal prophylactic therapy that is not in accordance with the
Antifungal Prophylaxis in Liver Transplant Recipients – Adult – Inpatient Clinical Practice Guideline
and initiates the appropriate antifungal therapy.
7. Pharmacist enters a note in the medical record indicating patient has been screened antifungal
infection prophylaxis, the results of the screening (high risk or low risk), and the antifungal selected
for prophylaxis if the patient is high risk. If the patient is low risk, pharmacist indicates in the note that
no antifungal therapy is initiated.

Table 1. Antifungal prophylaxis for patients at high-risk of invasive fungal infection following liver
transplant
Risk for developing
invasive fungal infection
Allergies, intolerances,
contraindications
Antifungal agent
High risk
No fluconazole allergy,
intolerance, or contraindication
Fluconazole 400 mg by mouth daily
for 14 days
History of fluconazole allergy,
intolerance, or contraindication
OR
Patients with prior isolation of
a fluconazole-resistant
Candida isolate
OR
Patients who have received
triazole treatment dosing
within the previous 90 days
Micafungin 100 mg IV daily for 14
days
Low Risk Not applicable No antifungal prophylaxis

Order Mode:
Medications – Protocol/Policy, Without Cosign

References:
1. Evans JD, Morris PJ, Knight SR. Antifungal prophylaxis in liver transplantation: a systematic review
and network meta-analysis. Am J Transplant. 2014;14(12):2765-2776.
2. Eschenauer GA, Kwak EJ, Humar A, et al. Targeted versus universal antifungal prophylaxis among
liver transplant recipients. Am J Transplant. 2015;15(1):180-189.
3. Hadley S, Huckabee C, Pappas PG, et al. Outcomes of antifungal prophylaxis in high-risk liver
transplant recipients. Transpl Infect Dis. 2009;11(1):40-48.
4. Perrella A, Esposito C, Pisaniello D, et al. Role of liposomal amphotericin B prophylaxis after liver
transplantation compared with fluconazole for high-risk patients. impact on infections and mortality
within one year. Transplant Proc. 2012;44(7):1977-1981.
5. Saliba F, Pascher A, Cointault O, et al. Randomized trial of micafungin for the prevention of invasive
fungal infection in high-risk liver transplant recipients. Clin Infect Dis. 2015;60(7):997-1006.
6. Sun HY, Cacciarelli TV, Singh N. Micafungin versus amphotericin B lipid complex for the prevention
of invasive fungal infections in high-risk liver transplant recipients. Transplantation. 2013;96(6):573-
578.
7. Winston DJ, Limaye AP, Pelletier S, et al. Randomized, double-blind trial of anidulafungin versus
fluconazole for prophylaxis of invasive fungal infections in high-risk liver transplant recipients. Am J
Transplant. 2014;14(12):2758-2764.
8. Winston DJ, Busuttil RW. Randomized controlled trial of oral itraconazole solution versus
intravenous/oral fluconazole for prevention of fungal infections in liver transplant recipients.
Transplantation. 2002;74(5):688-695.
9. Winston DJ, Pakrasi A, Busuttil RW. Prophylactic fluconazole in liver transplant recipients. A
randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1999;131(10):729-737.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


Collateral Documents/Tools:
Antifungal Prophylaxis in Liver Transplant Recipients – Adult – Inpatient Clinical Practice Guideline

Approved By:
Antimicrobial Use Subcommittee: July 2015; November 2015; *July 2016
Pharmacy and Therapeutics Committee: September 2015; *July 2016
UWHC Medical Board: October 2015; *July 2016

Effective Date: October 2015

Scheduled for Review: October 2017

*July 2016 – revision of high risk patient category (addition triazole)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org