1
|
Liu AJ, Dennis ASM, Fariha Z, Pai Mangalore R, Macesic N. Multidrug-resistant organism bloodstream infections in solid organ transplant recipients and impact on mortality: a systematic review. JAC Antimicrob Resist 2024; 6:dlae152. [PMID: 39386374 PMCID: PMC11463335 DOI: 10.1093/jacamr/dlae152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Accepted: 09/13/2024] [Indexed: 10/12/2024] Open
Abstract
Background Bloodstream infections (BSIs) cause significant morbidity and mortality in solid organ transplant (SOT) recipients. There are few data regarding the contribution of MDR organisms (MDROs) to these infections. We evaluated the resistance percentage of MDRO BSIs in SOT recipients and the associated mortality. Methods A systematic review of MEDLINE and Embase databases up to January 2024, for studies of adult SOT recipients that quantified MDRO BSI resistance percentage and/or associated crude mortality. MDROs studied were carbapenem-resistant Enterobacterales (CRE), Acinetobacter baumannii (CRAB) and Pseudomonas aeruginosa (CRPA), third-generation cephalosporin-resistant Enterobacterales (3GCR-E), MRSA and VRE. Resistance percentage and mortality outcomes were reported as median (IQR) and crude mortality (%), respectively. Results Of 945 studies identified, 52 were included. Most were retrospective (41/52) and/or single centre (37/52), and liver transplantation was the most frequently studied SOT type (22/52). High resistance percentages of BSIs were noted, ranging from 13.6% CRE for Enterobacterales to 59.2% CRAB for A. baumannii. Resistance percentage trends decreased over time, but these changes were not statistically significant. Asia had the highest resistance percentages for MRSA [86.2% (IQR 77.3%-94.6%)], 3GCR-E [59.5% (IQR 40.5%-66.7%)] and CRE [35.7% (IQR 8.3%-63.1%)]. North America had the highest VRE resistance percentages [77.7% (IQR 54.6%-94.7%)]. Crude mortality was 15.4%-82.4% and was consistently higher than for non-MDRO BSIs. Conclusions MDRO BSI resistance percentages were high for all pathogens studied (IQR 24.6%-69.4%) but there was geographical and temporal heterogeneity. MDRO BSIs were associated with high mortality in SOT recipients. Microbiological and clinical data in this vulnerable population were incomplete, highlighting the need for robust international multicentre studies.
Collapse
Affiliation(s)
- Alice J Liu
- Department of Infectious Diseases, The Alfred Hospital and School of Translational Medicine, Monash University, Melbourne, Australia
| | - Adelaide S M Dennis
- Department of Infectious Diseases, The Alfred Hospital and School of Translational Medicine, Monash University, Melbourne, Australia
| | - Zarin Fariha
- Department of Infectious Diseases, The Alfred Hospital and School of Translational Medicine, Monash University, Melbourne, Australia
| | - Rekha Pai Mangalore
- Department of Infectious Diseases, The Alfred Hospital and School of Translational Medicine, Monash University, Melbourne, Australia
| | - Nenad Macesic
- Department of Infectious Diseases, The Alfred Hospital and School of Translational Medicine, Monash University, Melbourne, Australia
- Centre to Impact AMR, Monash University, Clayton, Australia
- Infection Prevention & Healthcare Epidemiology, Alfred Health, Melbourne, Australia
| |
Collapse
|
2
|
Kara S, Ozturk G, Demir Yetis Z, Korkut E, Aksungur N, Altundas N, Dogan N, Ozden K. The Effect of Enhanced Recovery After Surgery Protocol on Surgical Site Infections in Liver Transplantation. Surg Infect (Larchmt) 2024. [PMID: 38959241 DOI: 10.1089/sur.2024.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
Background: Liver surgeries are treatment modalities that require careful pre- and postoperative follow-up for both the surgeon and the patient. Infections are the leading causes of morbidity and mortality after liver transplantation. Infections are the most frequent cause of death between 30 and 180 days after liver transplantation. We aimed to investigate the effect of the Enhanced Recovery After Surgery (ERAS) protocol on the prevention of infections in liver transplant patients. Patients and Methods: The study included patients who underwent liver transplantation in Ataturk University Organ Transplantation Center between 2017 and 2022. Two patient groups with and without ERAS were formed. Blood and urine cultures were collected retrospectively, and those with positive blood cultures for bacteremia were recorded as infection development. The development of infection between the two groups was statistically compared. Also, all patients' length of intensive care stay, length of hospital stay, and duration of antibiotic use were recorded. These parameters were compared between both groups. Results: There was a statistically significant difference between the two groups in terms of infection development (p: 0.01). There was a statistically significant difference between the two groups in terms of duration of antibiotic use and length of hospital stay (Mann-Whitney U test; p: 0.00, p: 0.04, respectively). There was no statistically significant difference between the two groups in terms of length of intensive care stay. Conclusion: We concluded that the introduction of an ERAS protocol was associated with fewer infections, thus shortening the duration of antibiotic therapy and length of hospital stay, although the standardization of the protocols is difficult, especially in liver transplants.
Collapse
Affiliation(s)
- S Kara
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - G Ozturk
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - Z Demir Yetis
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - E Korkut
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - N Aksungur
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - N Altundas
- Faculty of Medicine, Department of Transplantation Center, Ataturk University, Erzurum, Turkey
| | - N Dogan
- Faculty of Medicine, Department of Anesthesiology, Ataturk University, Erzurum, Turkey
| | - K Ozden
- Faculty of Medicine, Department of Infectious Diseases, Ataturk University, Erzurum, Turkey
| |
Collapse
|
3
|
Freire MP, Pouch S, Manesh A, Giannella M. Burden and Management of Multi-Drug Resistant Organism Infections in Solid Organ Transplant Recipients Across the World: A Narrative Review. Transpl Int 2024; 37:12469. [PMID: 38952482 PMCID: PMC11215024 DOI: 10.3389/ti.2024.12469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/07/2024] [Indexed: 07/03/2024]
Abstract
Solid organ transplant (SOT) recipients are particularly susceptible to infections caused by multidrug-resistant organisms (MDRO) and are often the first to be affected by an emerging resistant pathogen. Unfortunately, their prevalence and impact on morbidity and mortality according to the type of graft is not systematically reported from high-as well as from low and middle-income countries (HIC and LMIC). Thus, epidemiology on MDRO in SOT recipients could be subjected to reporting bias. In addition, screening practices and diagnostic resources may vary between countries, as well as the availability of new drugs. In this review, we aimed to depict the burden of main Gram-negative MDRO in SOT patients across HIC and LMIC and to provide an overview of current diagnostic and therapeutic resources.
Collapse
Affiliation(s)
- Maristela Pinheiro Freire
- Department of Infectious Diseases, Hospital das Clínicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Stephanie Pouch
- Transplant Infectious Diseases, Emory University School of Medicine, Atlanta, GA, United States
| | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| |
Collapse
|
4
|
Adelman MW, Connor AA, Hsu E, Saharia A, Mobley CM, Victor DW, Hobeika MJ, Lin J, Grimes KA, Ramos E, Pedroza C, Brombosz EW, Ghobrial RM, Arias CA. Bloodstream infections after solid organ transplantation: clinical epidemiology and antimicrobial resistance (2016-21). JAC Antimicrob Resist 2024; 6:dlad158. [PMID: 38213312 PMCID: PMC10783261 DOI: 10.1093/jacamr/dlad158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/21/2023] [Indexed: 01/13/2024] Open
Abstract
Background Solid organ transplant (SOT) recipients are at risk of bloodstream infections (BSIs) with MDR organisms (MDROs). Objectives To describe the epidemiology of BSI in the year after several types of SOT, as well as the prevalence of MDRO infections in this population. Methods We conducted a single-centre, retrospective study of kidney, liver, heart, and multi-organ transplantation patients. We examined BSIs ≤1 year from SOT and classified MDRO phenotypes for Staphylococcus aureus, enterococci, Enterobacterales, Pseudomonas aeruginosa and Candida spp. We compared BSI characteristics between SOT types and determined risk factors for 90 day mortality. Results We included 2293 patients [1251 (54.6%) kidney, 663 (28.9%) liver, 219 (9.6%) heart and 160 (7.0%) multi-organ transplant]. Overall, 8.5% of patients developed a BSI. BSIs were most common after multi-organ (23.1%) and liver (11.3%) transplantation (P < 0.001). Among 196 patients with BSI, 323 unique isolates were recovered, 147 (45.5%) of which were MDROs. MDROs were most common after liver transplant (53.4%). The most frequent MDROs were VRE (69.8% of enterococci) and ESBL-producing and carbapenem-resistant Enterobacterales (29.2% and 27.2% of Enterobacterales, respectively). Mortality after BSI was 9.7%; VRE was independently associated with mortality (adjusted OR 6.0, 95% CI 1.7-21.3). Conclusions BSI incidence after SOT was 8.5%, with a high proportion of MDROs (45.5%), especially after liver transplantation. These data, in conjunction with local antimicrobial resistance patterns and prescribing practices, may help guide empirical antimicrobial selection and stewardship practices after SOT.
Collapse
Affiliation(s)
- Max W Adelman
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, TX, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Hospital, Houston, TX, USA
- Department of Medicine, Weill Cornell Medical College, NewYork, NY, USA
| | - Ashton A Connor
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- J.C. Walter, Jr. Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Enshuo Hsu
- Center for Health Data Science and Analytics, Houston Methodist Hospital, Houston, TX, USA
| | - Ashish Saharia
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- J.C. Walter, Jr. Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Constance M Mobley
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- J.C. Walter, Jr. Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - David W Victor
- J.C. Walter, Jr. Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Mark J Hobeika
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- J.C. Walter, Jr. Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Jiejian Lin
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
- Department of Medicine, Weill Cornell Medical College, NewYork, NY, USA
| | - Kevin A Grimes
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, TX, USA
- Department of Medicine, Weill Cornell Medical College, NewYork, NY, USA
| | - Elizabeth Ramos
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - R Mark Ghobrial
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- J.C. Walter, Jr. Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Cesar A Arias
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, TX, USA
- Department of Medicine, Weill Cornell Medical College, NewYork, NY, USA
| |
Collapse
|
5
|
Chadha R, Sakai T, Rajakumar A, Shingina A, Yoon U, Patel D, Spiro M, Bhangui P, Sun LY, Humar A, Bezinover D, Findlay J, Saigal S, Singh S, Yi NJ, Rodriguez-Davalos M, Kumar L, Kumaran V, Agarwal S, Berlakovich G, Egawa H, Lerut J, Clemens Broering D, Berenguer M, Cattral M, Clavien PA, Chen CL, Shah S, Zhu ZJ, Ascher N, Bhangui P, Rammohan A, Emond J, Rela M. Anesthesia and Critical Care for the Prediction and Prevention for Small-for-size Syndrome: Guidelines from the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2216-2225. [PMID: 37749811 DOI: 10.1097/tp.0000000000004803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND During the perioperative period of living donor liver transplantation, anesthesiologists and intensivists may encounter patients in receipt of small grafts that puts them at risk of developing small for size syndrome (SFSS). METHODS A scientific committee (106 members from 21 countries) performed an extensive literature review on aspects of SFSS with proposed recommendations. Recommendations underwent a blinded review by an independent expert panel and discussion/voting on the recommendations occurred at a consensus conference organized by the International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplantation Society of India. RESULTS It was determined that centers with experience in living donor liver transplantation should utilize potential small for size grafts. Higher risk recipients with sarcopenia, cardiopulmonary, and renal dysfunction should receive small for size grafts with caution. In the intraoperative phase, a restrictive fluid strategy should be considered along with routine use of cardiac output monitoring, as well as use of pharmacologic portal flow modulation when appropriate. Postoperatively, these patients can be considered for enhanced recovery and should receive proactive monitoring for SFSS, nutrition optimization, infection prevention, and consideration for early renal replacement therapy for avoidance of graft congestion. CONCLUSIONS Our recommendations provide a framework for the optimal anesthetic and critical care management in the perioperative period for patients with grafts that put them at risk of developing SFSS. There is a significant limitation in the level of evidence for most recommendations. This statement aims to provide guidance for future research in the perioperative management of SFSS.
Collapse
Affiliation(s)
- Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Akila Rajakumar
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Alexandra Shingina
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | - Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Dhupal Patel
- Department of Anesthesia and Intensive Care Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Michael Spiro
- Department of Anaesthesia, Royal Devon and Exeter and Department of Anaesthesia and Intensive Care Medicine, The Royal Free Hospital, London, United Kingdom
| | - Pooja Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Li-Ying Sun
- Department of Critical Liver Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Abhinav Humar
- Division of Transplantation, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - James Findlay
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Sanjiv Saigal
- Centre of Liver and Biliary Sciences, Centre of Gastroenterology, Hepatology and Endoscopy, Max Super Specialty Hospital, New Delhi, India
| | - Shweta Singh
- Department of Anesthesiology and Critical Care, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Nam-Joon Yi
- Division of HBP Surgery, Department of Surgery, Seoul National University, College of Medicine, Seoul, Korea
| | - Manuel Rodriguez-Davalos
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Lakshmi Kumar
- Department of Anesthesiology, Amrita Hospital, Kochi, India
| | - Vinay Kumaran
- Division of Transplant Surgery, Department of Surgery, VCU Medical Center, Richmond, VA
| | - Shaleen Agarwal
- Centre of Liver and Biliary Sciences, Centre of Gastroenterology, Hepatology and Endoscopy, Max Super Specialty Hospital, New Delhi, India
| | | | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jan Lerut
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Dieter Clemens Broering
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Liver Transplantation and Hepatology Unit, La Fe University Hospital and IISLaFe and Ciberehd, Valencia, Spain
| | - Mark Cattral
- Ajmera Transplant Center, University of Toronto, Toronto, ON, Canada
| | | | - Chao-Long Chen
- Liver Transplantation Centre, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Jean Emond
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, NY
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| |
Collapse
|
6
|
Enterococcal Infections the First Year after Liver Transplantation-A Prospective Cohort Study. Microorganisms 2021; 9:microorganisms9081740. [PMID: 34442818 PMCID: PMC8400967 DOI: 10.3390/microorganisms9081740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 11/17/2022] Open
Abstract
This study aimed to investigate the incidence of enterococcal infections and determine risk factors associated with enterococcal bloodstream infection (BSI) within the first year post-liver transplantation (LTx). We included 321 adult liver transplant recipients transplanted from 2011 to 2019 in a prospective cohort study. Cumulative incidence of enterococcal infections and risk factors associated with BSI were investigated in a competing risk model and time-updated Cox models, respectively. A total of 223 enterococcal infections were identified in 89 recipients. The cumulative incidences of first enterococcal infection and first enterococcal BSI were 28% (95% CI (23-33)) and 11% (CI (7-14)), respectively. Risk factors associated with enterococcal BSI were previous infections in the biliary tract (HR, 33; CI (15-74); p < 0.001), peritoneum (HR, 8.1; CI (3-23); p < 0.001) or surgical site (HR, 5.5; CI (1.4-22); p = 0.02), recipient age (HR per 10 years increase, 1.2; CI (1.03-1.6); p = 0.03), and cold ischemia time (HR per one hour increase, 1.2; CI (1.1-1.3); p < 0.01). Enterococcal infections are highly prevalent the first year post-LTx, and recipients with enterococcal infections in the biliary tract, peritoneum, or surgical site are at increased risk of BSI. These findings may have implications for the choice of empiric antibiotics early post-LTx.
Collapse
|