Colonization with methicillin-resistant Staphylococcus aureus after liver transplantation

The History of Methicillin-Resistant Staphylococcus aureus in Brazil

Since the emergence of MRSA in the 1960s, a gradual increase in infections by resistant bacteria has been observed. Clinical manifestations may vary from brand to critical condition due to host risk factors, as well as pathogen virulence and resistance. The high adaptability and pathogenic profile of MRSA clones contributed to its spread in hospital and community settings. In Brazil, the first MRSA isolates were reported in the late 1980s, and since then different genetic profiles, such as the Brazilian epidemic clone (BEC) and other clones considered a pandemic, became endemic in the Brazilian population. Additionally, Brazil's MRSA clones were shown to be able to transfer genes involved in multidrug resistance and enhanced pathogenic properties. These events contributed to the rise of highly resistant and pathogenic MRSA. In this review, we present the main events which compose the history of MRSA in Brazil, including numbers and locations of isolation, as well as types of staphylococcal cassette chromosome mec (SCCmec) found in the Brazilian territory.

Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions

Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early post-transplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa (P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.

Virulence and resistance profiles of MRSA isolates in pre- and post-liver transplantation patients using microarray

Methicillin-resistant Staphylococcus aureus (MRSA) screening plays a great role in preventing infections in surgical patients. This study aims to evaluate clonality, virulence and resistance of MRSA in pre- and post-liver transplantation (LT) patients. Nasal and groin swabs of 190 patients were collected. PCR for virulence genes and staphylococcal cassette chromosome mec (SCCmec) types, microarray, PFGE, multilocus sequence typing and MIC were performed. MRSA carriers were detected in 20.5 % (39/190) of the patients. However, only three colonized patients developed infections post-LT. Sixty-nine MRSA isolates were identified, and the most frequent SCCmec type was type II (29/69; 42.0 %). Most isolates (57/69; 82.6 %) were susceptible to trimethoprim-sulfamethoxazole (TMP/SMX) and harboured the lukD, lukE, clf and fnbA genes as determined by PCR. Five sequence types (ST) were identified among nine clones; 36.2 % (25/69) isolates belonged to a predominant clone (ST105 and SCCmec type II) that was susceptible to TMP/SMX, mupirocin and chlorhexidine, which had 87.9 % similarity with the New York/Japan clone. The array showed virulence difference in isolates of the same clone and patients and that colonized isolates (pre-LT patients) were less virulent than those post-LT and those infected. Therefore, despite the high frequency of MRSA colonization, infection due to MRSA was uncommon in our LT unit. MRSA isolates presented great diversity. Isolates of the same clone expressed different virulence factors by array. Colonizing isolates pre-LT expressed less virulent factors than post-LT and infecting isolates.

Methicillin Resistant Staphylococcus aureus among HIV Infected Pediatric Patients in Northwest Ethiopia: Carriage Rates and Antibiotic Co-Resistance Profiles

Background

MRSA infections are becoming more prevalent throughout the HIV community. MRSA infections are a challenge to both physicians and patients due to limited choice of therapeutic options and increased cost of care.

Objectives

This study was aimed to determine the prevalence of colonization and co-resistance patterns of MRSA species among HIV positive pediatric patients in the Amhara National Regional State, Northwest Ethiopia.

Methods

Culture swabs were collected from the anterior nares, the skin and the perineum of 400 participants. In vitro antimicrobial susceptibility testing was done on Muller Hinton Agar by the Kirby-Bauer disk diffusion method, using 30 μg cefoxitin (OXOID, ENGLAND) according to the recommendations of the Clinical and Laboratory Standards Institute. Methicillin sensitivity/resistance was tested using cefoxitin. Data was analyzed by descriptive statistics and logistic regression model using Epi Info 7.

Results

S. aureus was detected in 206 participants (51.5%). The prevalence of MRSA colonization in this study was 16.8%. Colonization by S. aureus was associated with male gender (OR = 0.5869; 95% CI: 0.3812–0.9036; p-value = 0.0155), history of antibiotic use over the previous 3 months (OR = 2.3126; 95% CI: 1.0707–4.9948; p-value = 0.0329) and having CD₄ T-cell counts of more than 350 x 10⁶ cells / L (OR = 0.5739; 95% CI = 0.3343–0.9851; p-value = 0.0440). Colonization by MRSA was not associated with any one of the variables. Concomitant resistance of the MRSA to clindamycin, chloramphenicol, co-trimoxazole, ceftriaxone, erythromycin and tetracycline was 7.6%, 6%, 5.25%, 20.9%, 23.9% and 72.1%, respectively.

Conclusion

High rates of colonization by pathogenic MRSA strains is observed among HIV positive pediatric patients in the Amhara National Regional state.

Clinical significance of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci colonization in liver transplant recipients

BACKGROUND/AIMS

Liver transplant patients are at high risk for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) colonization. We evaluated patients before and after liver transplant using active surveillance culture (ASC) to assess the prevalence of MRSA and VRE and to determine the effect of bacterial colonization on patient outcome.

METHODS

We performed ASC on 162 liver transplant recipients at the time of transplantation and 7 days posttransplantation to monitor the prevalence of MRSA and VRE.

RESULTS

A total of 142 patients had both nasal and rectal ASCs. Of these patients, MRSA was isolated from 12 (7.4%) at the time of transplantation (group 1a), 9 (6.9%) acquired MRSA posttransplantation (group 2a), and 121 did not test positive for MRSA at either time (group 3a). Among the three groups, group 1a patients had the highest frequency of developing a MRSA infection (p < 0.01); however, group 2a patients had the highest mortality rate associated with MRSA infection (p = 0.05). Of the 142 patients, VRE colonization was detected in 37 patients (22.8%) at the time of transplantation (group 1b), 21 patients (20%) acquired VRE posttransplantation (group 2b), and 84 patients did not test positive for VRE at either time (group 3b). Among these three groups, group 2b patients had the highest frequency of VRE infections (p < 0.01) and mortality (p = 0.04).

CONCLUSIONS

Patients that acquired VRE or MRSA posttransplantation had higher mortality rates than did those who were colonized pre-transplantation or those who never acquired the pathogens. Our findings highlight the importance of preventing the acquisition of MRSA and VRE posttransplantation to reduce infections and mortality among liver transplant recipients.

MRSA and VRE colonization in solid organ transplantation: a meta-analysis of published studies

The burden of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) colonization among the increasing number of solid organ transplant patients has not been systematically explored. We searched PubMed and EMBASE for pertinent articles, performed a meta-analysis of prevalence across eligible studies and estimated the risk of ensuing MRSA or VRE infections relative to colonization status. We stratified effects in the pretransplant and posttransplant period. Twenty-three studies were considered eligible. Seventeen out of 23 (74%) referred to liver transplants. Before transplantation, the pooled prevalence estimate for MRSA and VRE was 8.5% (95% confidence interval [CI] 3.2–15.8) and 11.9% (95% CI 6.8–18.2), respectively. MRSA estimate was influenced by small studies and was lower (4.0%; 95% CI 0.4–10.2) across large studies (>200 patients). After transplantation, the prevalence estimates were 9.4% (95% CI 3.0–18.5) for MRSA and 16.2% (95% CI 10.7–22.6) for VRE. Pretransplant as well as posttransplant MRSA colonization significantly increased the risk for MRSA infections (pooled risk ratio [RR] 5.51; 95% CI 2.36–12.90 and RR 10.56; 95% CI 5.58–19.95, respectively). Pretransplant and posttransplant VRE colonization were also associated with significant risk of VRE infection (RR 6.65; 95% CI 2.54–17.41 and RR 7.93; 95% CI 2.36–26.67, respectively). Solid organ transplantation is a high-risk setting for MRSA and VRE colonization, and carrier state is associated with infection. Upgraded focus in prevention and eradication strategies is warranted.

[Nosocomial infection in patients receiving a solid organ transplant or haematopoietic stem cell transplant]

Bacterial infections are the most common infections in solid organ transplant recipients. These infections occur mainly in the first month after transplantation and are hospital-acquired. Nosocomial infections cause significant morbidity and are the most common cause of mortality in this early period of transplantation. These infections are caused by multi-drug resistant (MDR) microorganisms, mainly Gram-negative enterobacteria, non-fermentative Gram-negative bacilli, enterococci, and staphylococci. The patients at risk of developing nosocomial bacterial infections are those previously colonized with MDR bacteria while on the transplant waiting list. Intravascular catheters, the urinary tract, the lungs, and surgical wounds are the most frequent sources of infection. Preventive measures are the same as those applied in non-immunocompromised, hospitalized patients except in patients at high risk for developing fungal infection. These patients need antifungal therapy during their hospitalization, and for preventing some bacterial infections in the early transplant period, patients need vaccinations on the waiting list according to the current recommendations. Although morbidity and mortality related to infectious diseases have decreased during the last few years in haematopoietic stem cell transplant recipients, they are still one of the most important complications in this population. Furthermore, as occurs in the general population, the incidence of nosocomial infections has increased during the different phases of transplantation. It is difficult to establish general preventive measures in these patients, as there are many risk factors conditioning these infections. Firstly, they undergo multiple antibiotic treatments and interventions; secondly, there is a wide variability in the degree of neutropenia and immunosuppression among patients, and finally they combine hospital and home stay during the transplant process. However, some simple measures could be implemented to improve the current situation.

Multidrug-resistant bacterial infections after liver transplantation: An ever-growing challenge

Bacterial infections are a leading cause of morbidity and mortality among solid organ transplant recipients. Over the last two decades, various multidrug-resistant (MDR) pathogens have emerged as relevant causes of infection in this population. Although this fact reflects the spread of MDR pathogens in health care facilities worldwide, several factors relating to the care of transplant donor candidates and recipients render these patients particularly prone to the acquisition of MDR bacteria and increase the likelihood of MDR infectious outbreaks in transplant units. The awareness of this high vulnerability of transplant recipients to infection leads to the more frequent use of broad-spectrum empiric antibiotic therapy, which further contributes to the selection of drug resistance. This vicious cycle is difficult to avoid and leads to a scenario of increased complexity and narrowed therapeutic options. Infection by MDR pathogens is more frequently associated with a failure to start appropriate empiric antimicrobial therapy. The lack of appropriate treatment may contribute to the high mortality occurring in transplant recipients with MDR infections. Furthermore, high therapeutic failure rates have been observed in patients infected with extensively-resistant pathogens, such as carbapenem-resistant Enterobacteriaceae, for which optimal treatment remains undefined. In such a context, the careful implementation of preventive strategies is of utmost importance to minimize the negative impact that MDR infections may have on the outcome of liver transplant recipients. This article reviews the current literature regarding the incidence and outcome of MDR infections in liver transplant recipients, and summarizes current preventive and therapeutic recommendations.

Management of infections pre- and post-liver transplantation: report of an AISF consensus conference

The burden of infectious diseases both before and after liver transplantation is clearly attributable to the dysfunction of defensive mechanisms of the host, both as a result of cirrhosis, as well as the use of immunosuppressive agents. The present document represents the recommendations of an expert panel commended by the Italian Association for the Study of the Liver (AISF), on the prevention and management of infectious complications excluding hepatitis B, D, C, and HIV in the setting of liver transplantation. Due to a decreased response to vaccinations in cirrhosis as well as within the first six months after transplantation, the best timing for immunization is likely before transplant and early in the course of disease. Before transplantation, a vaccination panel including inactivated as well as live attenuated vaccines is recommended, while oral polio vaccine, Calmette-Guerin's bacillus, and Smallpox are contraindicated, whereas after transplantation, live attenuated vaccines are contraindicated. Before transplant, screening protocols should be divided into different levels according to the likelihood of infection, in order to reduce costs for the National Health Service. Recommended preoperative and postoperative prophylaxis varies according to the pathologic agent to which it is directed (bacterial vs. viral vs. fungal). Timing after transplantation greatly determines the most likely agent involved in post-transplant infections, and specific high-risk categories of patients have been identified that warrant closer surveillance. Clearly, specifically targeted treatment protocols are needed upon diagnosis of infections in both the pre- as well as the post-transplant scenarios, not without considering local microbiology and resistance patterns.

Effects of blood products on nosocomial infections in liver transplant recipients

OBJECTIVES

Infection is the most severe complication after an organ transplant. Blood cell transfusion is an independent risk factor for adverse events, including infection in the recipient. This study sought to evaluate the effect of blood product transfusions on nosocomial infections in liver transplant patients.

MATERIALS AND METHODS

Patients who underwent a liver transplant at our hospital between 2003 and 2010 were recruited for this study. Exclusion criteria were incomplete records, patients who were hospitalized for more than 48 hours during the 4 weeks before transplant, and pediatric transplants. Incidence of nosocomial infections, which were defined as infections occurring within 30 days after transplant was the primary endpoint.

RESULTS

The incidence of nosocomial infections was 28.7%. The number of transfusions of packed red blood cells and fresh frozen plasma was significantly higher in patients with nosocomial infection compared with patients without nosocomial infection (P = .018 and P = .039). Blood products dose-dependently contributed to nosocomial infections. Transfusions of ≥ 7.5 units of red blood cells (odds ratio: 2.8) or ≥ 12.5 units of fresh frozen plasma (odds ratio: 3.27) were associated with nosocomial infections (P = .042 and P = .015). The infection-related mortality rate was 10.3%.

CONCLUSIONS

Blood product transfusions are associated with an increased rate of nosocomial infections, which contributes to higher morbidity and mortality.

Multidrug-resistant bacterial infection in solid organ transplant recipients

The most frequent complication from infection after solid organ transplantation is bacterial infection. This complication is more frequent in organ transplantation involving the abdominal cavity, such as liver or pancreas transplantation, and less frequent in heart transplant recipients. The sources, clinical characteristics, antibiotic resistance and clinical outcomes vary according to the time of onset after transplantation. Most bacterial infections during the first month post-transplantation are hospital acquired, and there is usually a high incidence of multidrug-resistant bacterial infections. The higher incidence of complications from bacterial infection in the first month post-transplantation may be associated with high morbidity. Of special interest due to their frequency are infections by S. aureus, enterococci, Gram-negative enteric and non-fermentative bacilli. Opportunistic bacterial infections may occur at any time on the posttransplant timeline, but are more frequent between months two and six, the period in which immunosuppression is higher. The most frequent bacterial species causing opportunistic infections in organ transplant recipients are Listeria monocytogenes and Nocardia spp. After month six, posttransplantation solid organ transplant patients usually develop conventional community-acquired bacterial infections, especially urinary tract infections by E. coli and S. pneumoniae pneumonia. In this article we review the clinical characteristics, epidemiology, diagnosis and prognosis of bacterial infections in solid organ transplant patients.

Length of exposure to the hospital environment is more important than antibiotic exposure in healthcare associated infections by methicillin-resistant Staphylococcus aureus: a comparative study

OBJECTIVES

Both total antimicrobial use and specific antimicrobials have been implicated as risk factors for healthcare-associated methicillin-resistant Staphylococcus aureus (HCA-MRSA) infection. The aims of this study were: (I) to explore predictors of a new HCA-MRSA infection in comparison with a new healthcare-associated methicillin-sensitive Staphylococcus aureus (HCA-MSSA); (II) to thoroughly assess the role of recent antibiotic use qualitatively and quantitatively.

METHODS

The time-period for our study was from October 1997 through September 2001. Through applying strict criteria, we identified two groups of inpatients, one with a new HCA-MRSA infection and one with a new HCA-MSSA infection. We recorded demographic, clinical and antibiotic use-related data up to 30 days before the positive culture date.

RESULTS

We identified 127 and 70 patients for each group, respectively. Two logistic regression models were carried out to assess the role of antimicrobial use (qualitatively and quantitatively). In model I, duration of hospital stay, presence of chronic wounds, aminoglycoside and fluoroquinolone use retained statistical significance. In model II, duration of hospital stay and history of intubation during the last month stood out as the only significant predictors of a subsequent HCA-MRSA infection. No significant differences in outcome were noted.

CONCLUSIONS

The length of exposure to the hospital environment may be the best predictor of a new HCA-MRSA infection. Use of aminoglycosides and fluoroquinolones may also stand independently along with presence of chronic ulcers and surgical procedures. No independent association between quantitative antibiotic use and subsequent HCA-MRSA infection was documented.

[Daptomycin in Gram-positive bacterial infections in oncohematological patients and transplant recipients]

Gram-positive infections are a major cause of morbidity and mortality in oncohematological patients and transplant recipients. The most frequently isolated Gram-positive organisms are the coagulase-negative staphylococci, Staphylococcus aureus and Enterococcus spp., and viridans group streptococci. Antibiotic resistance in these organisms is increasing and poses a challenge to clinicians. Daptomycin is rapidly bactericidal against a broad spectrum of gram-positive bacteria, including strains resistant to other drugs. The present article reviews some aspects of Gram-positive infections in these immunocompromised patients and provides a detailed analysis of experience with daptomycin in the treatment of these infections.

Recommendations for the assessment and reporting of multivariable logistic regression in transplantation literature

Multivariable logistic regression is an important method to evaluate risk factors and prognosis in solid organ transplant literature. We aimed to assess the quality of this method in six major transplantation journals. Eleven analytical criteria and four documentation criteria were analyzed for each selected article that used logistic regression. A total of 106 studies (6%) out of 1,701 original articles used logistic regression analyses from January 1, 2005 to January 1, 2006. The analytical criteria and their respective reporting percentage among the six journals were: Linearity (25%); Beta coefficient (48%); Interaction tests (19%); Main estimates (98%); Ovefitting prevention (84%); Goodness-of-fit (3.8%); Multicolinearity (4.7%); Internal validation (3.8%); External validation (8.5%). The documentation criteria were reported as follows: Selection of independent variables (73%); Coding of variables (9%); Fitting procedures (49%); Statistical program (65%). No significant differences were found among different journals or between general versus subspecialty journals with respect to reporting quality. We found that the report of logistic regression is unsatisfactory in transplantation journals. Because our findings may have major consequences for the care of transplant patients and for the design of transplant clinical trials, we recommend a practical solution for the use and reporting of logistic regression in transplantation journals.

Acquisition of methicillin-resistant Staphylococcus aureus after living donor liver transplantation: a retrospective cohort study

BACKGROUND

The incidence and risk factors of methicillin-resistant Staphylococcus aureus (MRSA) acquisition after living donor liver transplantation (LDLT) are unclear. The aim of the present study was to assess the incidence and to analyze the risk factors for the acquisition of MRSA after LDLT in adults by multivariate analysis.

METHODS

We retrospectively reviewed the data from 158 adult patients that underwent LDLT at the Tokyo University Hospital. The microbiologic and medical records of the patients from admission to 3 months after LDLT were reviewed. Uni- and multivariate analyses were performed to identify the risk factors for postoperative acquisition of MRSA.

RESULTS

Postoperative MRSA acquisition was detected in 35 of 158 patients by median postoperative day 18. Age (>or= 60 y) and perioperative dialysis and/or apheresis predicted postoperative MRSA acquisition by multivariate analysis. In contrast, postoperative use of fluoroquinolone was negatively associated with acquisition of MRSA.

CONCLUSION

MRSA arose early after LDLT in adults with a high incidence (35 of 158 patients). Surveillance culture should be checked periodically after LDLT to identify and prevent the transmission of MRSA.

Bloodstream infection after living donor liver transplantation

There are no detailed studies on the prevalence or clinical magnitude of bloodstream infection (BSI) following living donor liver transplantation (LDLT). The study aimed to assess the incidence and analyze the risk factors for BSI after LDLT. Univariate and multivariate analyses were performed to identify the independent risk factors for postoperative BSI. Postoperatively, 26 episodes of BSI occurred in 21 of 242 studied adult patients by median postoperative d 35. Five patients had primary BSI. The source was unknown in 3 patients and an intravascular catheter in 2. The other 16 patients had secondary BSI. Secondary BSI was caused by surgical site infection in 8 patients, followed by intra-abdominal infection in 5, pneumonia in 2, and both surgical site infection and intra-abdominal infection in 1. The most frequent pathogen isolated was MRSA, which was detected in 4 patients. Surveillance culture detected the same isolates prior to BSI in 14 of 26 (50%) episodes. Diabetes mellitus and serum albumin level less than 2.4 g/dl independently predicted postoperative BSI. Perioperatively, screening for and taking actions against pathogen including MRSA should be performed in LDLT patients.

Outcomes of colonization with MRSA and VRE among liver transplant candidates and recipients

Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) infections cause significant morbidity and mortality among liver transplant candidates and recipients. To assess rates of MRSA and VRE colonization, we obtained active surveillance cultures from 706 liver transplant candidates and recipients within 24 h of admission to an 11-bed liver transplant ICU from October 2000 to December 2005. Patients were followed prospectively to determine the cumulative risk of MRSA or VRE infection or death by colonization status. Outcomes were assessed by Kaplan-Meier survival analysis and Cox regression and multivariate logistic regression adjusting for covariates. The prevalence of newly detected MRSA nasal and VRE rectal colonization was 6.7% and 14.6%, respectively. Liver transplant candidates and recipients with MRSA colonization had an increased risk of MRSA infection (adjusted OR = 15.64, 95% CI 6.63-36.89) but not of death (adjusted OR = 1.00, 95% CI 0.43-2.30), whereas those with VRE colonization had an increased risk both of VRE infection (adjusted OR = 3.61, 95% CI 2.01-6.47) and of death (adjusted OR = 2.12, 95% CI 1.27-3.54) compared with noncolonized patients. Prevention and control strategies, including use of active surveillance cultures, should be implemented to reduce the rates of both MRSA and VRE colonization in this high-risk patient population.

Hepatic iron content and the risk of Staphylococcus aureus bacteremia in liver transplant recipients

Iron is a critical nutrient source and contributes to staphylococcal pathogenesis. We assessed the role of hepatic explant iron overload as a risk factor for Staphylococcus aureus bacteremia in liver transplant recipients. Seven of 13 cases with S aureus bacteremia (53.8%) had hepatic explant iron concentrations that exceeded normal limits (grade > or = 2). Length of posttransplant intensive care unit stay (P= .013) and hepatocellular carcinoma as underlying liver disease (P = .04), but not hepatic explant iron concentration, correlated with a higher risk of S aureus bacteremia after transplantation. However, noncarriers (patients without S aureus nasal carriage) who developed S aureus bacteremia were more likely to have high hepatic iron content; 4 of 7 (57%) noncarriers with high-grade iron content developed S aureus bacteremia but no noncarriers with low-grade iron content did (P = .07). All noncarriers who became infected had high iron content (grade > or = 2) of the hepatic explant. A readily quantifiable assessment of hepatic iron at the time of transplantation can potentially identify patients without carriage who may be at risk for early S aureus bacteremia.

Impact of new methicillin-resistant Staphylococcus aureus carriage postoperatively after living donor liver transplantation

BACKGROUND

Preoperative carriage of methicillin-resistant Staphylococcus aureus (MRSA) is associated with an increased risk of MRSA infection after liver transplantation. It is not known, however, whether new MRSA carriage postoperatively also increases the risk of MRSA infection after liver transplantation.

METHODS

We retrospectively reviewed the data from 242 adult patients who underwent living donor liver transplantation (LDLT) including microbiological and medical records from admission to 3 months after LDLT. Uni and multivariate analyses were performed to identify independent risk factors for postoperative MRSA infection among preoperative noncarriers of MRSA.

RESULTS

Postoperative MRSA infection occurred in 18 of 219 preoperative noncarriers of MRSA by median postoperative day 26. Operation time of at least 16 hours and postoperative colonization with MRSA independently predicted postoperative MRSA infection.

CONCLUSION

Postoperative surveillance cultures should be performed periodically after liver transplantation to identify high-risk candidates for postoperative MRSA infection, even among preoperative noncarriers of MRSA.

Skin infections in organ transplant recipients

In contrast to the well-described high risk of skin cancer in organ transplant recipients, skin infections in these patients are not as well explored. Skin infections caused by viruses, bacteria or fungi represent a growing diagnostic and therapeutic challenge in the dermatological aftercare of organ transplant recipients. Differing immunosuppressive drugs and their variable dosage in chronologic sequence after transplantation probably influence the type and appearance of skin infections. The typical chronology of skin infections are wound infections, pyoderma or the reactivation of herpes viruses in the first month post-transplant; the main problems in months 2-5 are opportunistic infections and reactivation of varicella-zoster virus. After 6 months as immunosuppression is reduced, the spectrum of causative organisms approaches that of the general population; mycoses and human papilloma virus (HPV) infections dominate. A causal connection exists between infection with oncogenic viruses such as HPV, Epstein-Barr virus and human herpesvirus 8 and specific skin cancers (squamous cell carcinoma, Kaposi sarcoma and post-transplant lymphoproliferative disorders). Dermatological care of organ transplant recipients using appropriate diagnostic methods adapted to the modified clinical pattern may lead to early adequate treatment.

Methicillin-resistant Staphylococcus aureus infection after living-donor liver transplantation in adults

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) infection frequently complicates the postoperative course in deceased-donor liver transplantation. The incidence and risk factors of MRSA infection after Living-donor Liver transplantation (LDLT), however, are unclear.

METHODS

We retrospectively reviewed the data from 242 adult patients who underwent LDLT at the University of Tokyo Hospital. The microbiologic and medical records of the patients from admission to 3 months after LDLT were reviewed. Uni- and multivariate analyses were performed to identify the independent risk factors for postoperative MRSA infection.

RESULTS

Postoperative MRSA infection occurred in 25 of 242 patients by median postoperative day 23. Preoperative MRSA colonization, preoperative use of antimicrobials, operation time (> or =16 h), and postoperative apheresis independently predicted postoperative MRSA infection.

CONCLUSION

Surveillance culture should be checked periodically after admission to identify patients at high risk for MRSA infection and to administer appropriate antimicrobials for perioperative infection. Postoperative apheresis, suggesting postoperative liver dysfunction, predisposed patients to MRSA infection.