Evaluation of antiviral prophylaxis of cytomegalovirus in patients receiving liver, kidney or pancreas transplantation

Abstract

Abstract

Background– All solid organ transplanted patients are treated with immuno suppression medications to keep the immune system from rejecting the transplanted organ. Unfortunately the suppressed immune system makes the body more exposed for cancer and opportunistic infections. Among the most important viruses that causes one of these opportunistic infections is cytomegalovirus (CMV). A local project showed that not all transplanted patients on CMV prophylaxis get the right dose according to creatinine clearance (CrCl), and that the patients who had not been prescribed the recommended dose according to CrCl had a higher incident of CMV disease than those adjusted as recommended. The Quality improvement team for the transplant unit therefore suggested that a project could further investigate these issues.

Aim and objectives – The aim of this project was to critically review and evaluate the processes in the prescribing and administration of valganciclovir for cytomegalovirus prophylaxis in liver, kidney or pancreas transplantation.

Methods – Semi-structured one-to-one interviews with 2 nurses and 6 prescribers were conducted to establish current practice in prescribing, administration and monitoring of valganciclovir. A review of the local protocols at the transplant unit was conducted. To assess the harm a database analysis on the incident reporting system and a retrospective review of clinical records of 4 patients was undertaken. A questionnaire was developed for staff to self-assess the risk of harm of the whole process of CMV prophylaxis treatment. Pharmaceutical care issues relevant to CMV prophylaxis were recorded prospectively by clinical pharmacists over a two month period.

Results – The semi-structured interviews with prescribers indicated that: 1) Prescribers often fail to recognise that the valganciclovir dose should be adjusted with changing CrCl. 2) That the laboratory test results taken at the clinic do not come back until the evening and are therefore not available at the time of prescribing, 3) There are gaps of knowledge, especially in the junior doctors. Reviews of local protocols suggested a need for update of the protocols and inclusion of detailed dosing guidance. The one incident reported in the database in terms of valganciclovir involved a missed dose. Case note reviews of four patients identified that dose adjustments are appropriate in 2 cases, 1 case was borderline and the other was a complex case but was judged to be appropriate. The questionnaire identified that there was agreement among healthcare professionals that there is a risk of errors that might lead to harm associated with all stages of valganciclovir use. Two clinical pharmacists recommended adjustment of valganciclovir 12 times in 7 patients in a time period of approximately two months.

Conclusion – the outcomes from the interviews and pharmaceutical care issues analysis confirm the previous observation that the dose of valganciclovir is not always adjusted according to CrCl. Recommendations for improvement are to ensure modified guidelines are implemented to ensure all prescribers are aware of need for dose adjustment. Further work can be undertaken to measure the benefit after implement of the recommendations to assess improvement.