Perioperative bacterial infections in deceased donor and living donor liver transplant recipients

Concurrent Change in Serum Cholinesterase Activity and Midregional-Proadrennomedullin Level Could Predict Patient Outcome following Liver Transplantation

Background: After liver transplantation (LTX), patients are susceptible to opportunistic infections resulting in reduced outcomes within the early post-transplantation period. The postoperative monitoring of LTX patients has gained much importance in recent years. However, reliable plasmatic markers predicting 90-day outcomes are still lacking. Methods: In the post hoc analysis of a prospective, observational study, butyrylcholinesterase (BChE), mid-regional proadrenomedullin (MR-proADM), as well as conventional inflammatory markers (procalcitonin, C-reactive protein) were evaluated in 93 patients at seven consecutive timepoints within the first 28 days following LTX. Results: Persistently reduced activity of BChE and elevated MR-proADM levels indicated reduced 90-day survival following LTX. Furthermore, reduced BChE and increased MR-proADM activity could indicate early post-transplantation bacterial infections, whereas conventional inflammatory biomarkers showed no diagnostic efficacy within the observation period. Conclusion: Concurrent assessment of BChE and MR-proADM activity might serve as a bedside diagnostic tool for early bacterial infections following liver transplantation. Thus, a combined utilization of the two biomarkers may be a useful tool in the risk evaluation of patients following liver transplantation.

Incidence, Clinicomicrobiological Characteristics, Risk Factors, and Treatment ‎Outcomes of Bacterial Infections Following Liver Transplantation in Pediatrics: A ‎Retrospective Cohort Study

Background: Liver transplantation (LT) is the definitive treatment for patients with advanced liver failure. Bacterial infections are common consequences of organ transplantation resulting from immune suppression and prolonged hospitalization. Methods: This retrospective cohort study examined the records of all liver transplant pediatrics under 18 years of age in Abu-Ali Sina hospital, Shiraz, Fars province, Iran, from April 2019 to February 2020. Demographic, laboratory, and clinical data were extracted along with the administered therapeutic approach for the patient. Results: Of 80 enrolled patients, 52 were male, and 28 were female, with a median age of 60 months. An incidence of 67.9% of bacterial infections was recorded. Gram-negative and Gram-positive pathogens accounted for 64.06% and 35.93% of infections, respectively. Surgical site infections were the most common ones. The length of ICU stay, hospitalization, mechanical ventilation duration, and re-hospitalization were significantly higher in the infected group than in non-infected pediatrics (P-value < 0.05). Multivariate regression analysis showed that the only risk factor for bacterial infections after LT was the length of ICU stay. The mortality rate was 22%, which was significantly higher among the infection group (P = 0.008). Conclusions: A high rate of bacterial infections and an increasing prevalence of nosocomial and antibiotic-resistant pathogens were detected in the early period after LT.

The potential liver donor with tuberculosis: A fresh look at international recommendations based on a survey of practice in Indian liver transplant centres

Background The western recommendations for the use of organs from liver donors with tuberculosis (TB) come from an environment where the burden of disease is low and cadaveric organ donation rates are high-in complete contrast to the Indian scenario, where these recommendations may be too restrictive. Methods A questionnaire relating to current practice on the use of organs from liver donors with TB was sent to all liver transplant centres in India. Results Responses were obtained from 94% of centres. Two-thirds accepted organs from deceased donors with TB in the elective setting, especially for recipients with a high MELD (Model for end-stage liver disease) score. The proportion rose by 1.5 times in the setting of acute liver failure. Two-thirds advised anti-TB treatment (ATT) for corresponding recipients, and the remaining advised isonicotinic acid hydrazide (INH) prophylaxis. Untreated living donors with TB were not accepted. Half the respondents accepted living donors after completion of ATT, and did not treat recipients postoperatively. The remainder accepted them after 8 weeks of treatment and advised INH prophylaxis or ATT for recipients. Conclusions That this practice has not impacted recipient outcomes suggests that the guidelines for management of liver donors and recipients may need to be altered for populations endemic for TB.

Treatment of MRSA infections in India: Clinical insights from a Delphi analysis

PURPOSE

International and Indian guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections are available, but the local guidelines are not MRSA-specific. This study aimed to provide clinical insights for the treatment of MRSA infections in India.

METHODS

We used a three-step modified Delphi method to obtain insights. Ten experts comprising infectious disease specialists, microbiologists, pulmonologists, and critical care experts agreed to participate in the analysis. In round 1, a total of 161 statements were circulated to the panel and the experts were asked to 'agree' or 'disagree' by responding 'yes' or 'no' to each statement and provide comments. The same process was used for 73 statements in round 2. Direct interaction with the experts was carried out in round 3 wherein 35 statements were discussed. At least 80% of the experts had to agree for a statement to reach concordance.

RESULTS

Eighty-eight statements in round 1, thirty-eight statements in round 2, and eight statements in round 3 reached concordance and were accepted without modification. The final document comprised 152 statements on the management of various syndromes associated with MRSA such as skin and soft tissue infections, bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system infections.

CONCLUSIONS

This analysis will assist clinicians in India to choose an appropriate course of action for MRSA infections.

Meta-analysis and meta-regression of outcomes for adult living donor liver transplantation versus deceased donor liver transplantation

Prior single center or registry studies have shown that living donor liver transplantation (LDLT) decreases waitlist mortality and offers superior patient survival over deceased donor liver transplantation (DDLT). The aim of this study was to compare outcomes for adult LDLT and DDLT via systematic review. A meta-analysis was conducted to examine patient survival and graft survival, MELD, waiting time, technical complications, and postoperative infections. Out of 8600 abstracts, 19 international studies comparing adult LDLT and DDLT published between 1/2005 and 12/2017 were included. U.S. outcomes were analyzed using registry data. Overall, 4571 LDLT and 66,826 DDLT patients were examined. LDLT was associated with lower mortality at 1, 3, and 5 years posttransplant (5-year HR 0.87 [95% CI 0.81-0.93], p < .0001), similar graft survival, lower MELD at transplant (p < .04), shorter waiting time (p < .0001), and lower risk of rejection (p = .02), with a higher risk of biliary complications (OR 2.14, p < .0001). No differences were observed in rates of hepatic artery thrombosis. In meta-regression analysis, MELD difference was significantly associated with posttransplant survival (R2 0.56, p = .02). In conclusion, LDLT is associated with improved patient survival, less waiting time, and lower MELD at LT, despite posing a higher risk of biliary complications that did not affect survival posttransplant.

High mortality associated with gram-negative bacterial bloodstream infection in liver transplant recipients undergoing immunosuppression reduction

BACKGROUND

Immunosuppression is an important factor in the incidence of infections in transplant recipient. Few studies are available on the management of immunosuppression (IS) treatment in the liver transplant (LT) recipients complicated with infection. The aim of this study is to describe our experience in the management of IS treatment during bacterial bloodstream infection (BSI) in LT recipients and assess the effect of temporary IS withdrawal on 30 d mortality of recipients presenting with severe infection.

AIM

To assess the effect of temporary IS withdrawal on 30 d mortality of LT recipients presenting with severe infection.

METHODS

A retrospective study was conducted with patients diagnosed with BSI after LT in the Department of Liver Surgery, Renji Hospital from January 1, 2016 through December 31, 2017. All recipients diagnosed with BSI after LT were included. Univariate and multivariate Cox regression analysis of risk factors for 30 d mortality was conducted in the LT recipients with Gram-negative bacterial (GNB) infection.

RESULTS

Seventy-four episodes of BSI were identified in 70 LT recipients, including 45 episodes of Gram-positive bacterial (GPB) infections in 42 patients and 29 episodes of GNB infections in 28 patients. Overall, IS reduction (at least 50% dose reduction or cessation of one or more immunosuppressive agent) was made in 28 (41.2%) cases, specifically, in 5 (11.9%) cases with GPB infections and 23 (82.1%) cases with GNB infections. The 180 d all-cause mortality rate was 18.5% (13/70). The mortality rate in GNB group (39.3%, 11/28) was significantly higher than that in GPB group (4.8%, 2/42) (P = 0.001). All the deaths in GNB group were attributed to worsening infection secondary to IS withdrawal, but the deaths in GPB group were all due to graft-versus-host disease. GNB group was associated with significantly higher incidence of intra-abdominal infection, IS reduction, and complete IS withdrawal than GPB group (P < 0.05). Cox regression showed that rejection (adjusted hazard ratio 7.021, P = 0.001) and complete IS withdrawal (adjusted hazard ratio 12.65, P = 0.019) were independent risk factors for 30 d mortality in patients with GNB infections after LT.

CONCLUSION

IS reduction is more frequently associated with GNB infection than GPB infection in LT recipients. Complete IS withdrawal should be cautious due to increased risk of mortality in LT recipients complicated with BSI.

IS

Pre- and post-transplant bacterial infections in liver transplant recipients

BACKGROUND

Early (<1 month) bacterial infection after liver transplant is a major cause of morbidity and mortality among liver transplant recipients. We investigated the impact of pre-transplant bacterial infection on early post-transplant bacterial infection incidence and outcomes.

METHODS

A retrospective cohort study identified all patients who underwent liver transplantation between January 1, 2011, and December 31, 2012, at a single tertiary center in the United States. Infections occurring within the 30 days prior to transplant and within the 30 following transplant were identified. Information regarding pre-transplant morbidity and post-transplant outcomes was collected.

RESULTS

One-hundred seventy-four patients were included in the study. Forty patients (23%) experienced a total of 50 pre-transplant infections. Fifty-two (30%) developed a total of 62 post-transplant infections. Patients with a pre-transplant infection were more likely to develop a post-transplant infection compared to patients without a pre-transplant infection (48% [19 of 40] vs. 25% [33 of 134], respectively, P = .006). Patients with a pre-transplant infection had a longer mean post-transplant length of stay compared to those without a pre-transplant infection (16.3 days vs. 10.4 days, respectively, P < .001), but survival at 30 days was similar in both groups (95% [38 of 40] vs. 97% [130 of 134, respectively, P = .56).

CONCLUSIONS

Among liver transplant recipients, pre-transplant infection is an important risk factor for early post-transplant bacterial infections. Pre-transplant infection is associated with increased early morbidity but not mortality after transplant.

Predictors of postoperative infectious complications in liver transplant recipients: experience of 185 consecutive cases

BACKGROUND/AIMS

Infections following liver transplant (LT) remain a major cause of mortality. This study was conducted to evaluate risk factors for infection and to review clinical characteristics.

METHODS

Medical records of patients who underwent LT from 2010 to 2014 were retrospectively analyzed. Binary logistic regression analysis was used to investigate risk factors of infection. Kaplan-Meier analysis was used to predict prognosis of infected and non-infected groups.

RESULTS

Of 185 recipients, 89 patients experienced infectious complications. The median follow-up period was 911 days (range, 9 to 2,031). The infected group had higher 1-year mortality (n = 22 [24.7%] vs. n = 8, [8.3%], p = 0.002), and longer postoperative admission days (mean: 53.7 ± 35.8 days vs. 28.3 ± 13.0 days, p &lt; 0.001), compared to the non-infected group. High preoperative Model for End-Stage Liver Disease (MELD) score (odds ratio [OR], 1.057; 95% confidence interval [CI], 1.010 to 1.105; p = 0.016), deceased-donor type (OR, 5.475; 95% CI, 2.442 to 12.279; p &lt; 0.001), and acute rejection (OR, 3.042; 95% CI, 1.241 to 7.454; p = 0.015) were independent risk factors associated with infection. Intra-abdominal infection (n = 35, 20.8%) was the major infectious complication. Among identified bacteria, Enterococcus species (28.4%) were major pathogens, followed by Escherichia coli and Klebsiella species.

CONCLUSIONS

High preoperative MELD score, deceased-donor type, and acute rejection were risk factors associated with infection. To prevent infections following surgery, it is important to determine the appropriate time of operation before the recipient has a high MELD score.

Infections in live donor liver transplant recipients: A study of timeline, aetiology and antimicrobial resistance of bacterial and fungal infections from the developing world

Infections are the leading cause of morbidity and mortality in liver transplant (LT) recipients. We studied timeline, spectrum of infection, system involved, and antimicrobial resistance in 64 patients undergoing live donor LT with 6-month follow-up. Of 64 patients, 38 (59.5%) patients had 103 infectious episodes, 10 patients had single infectious episode and 28 patients had two or more infectious episodes. 96 (93.2%) were bacterial and Candida infections were in 7 (6.8%). Early phase had 30 (29.1%) episodes; intermediate phase 25 (24.2%) and late phase 48 (46.6%). Mortality was 11/64 (17.1%). Knowledge of timeline, aetiological agent and antimicrobial resistance is useful to guide empirical therapy and infection prevention.

Use of organs from donors with bloodstream infection, pneumonia, and influenza: Results of a survey of infectious diseases practitioners

BACKGROUND

Potential organ donors may be admitted with an infection to an intensive care unit, or contract a nosocomial infection during their stay, increasing the risk of potential transmission to the recipient. Because of a lack of practice guidelines and large-scale data on this topic, we undertook a survey to assess the willingness of transplant infectious diseases (ID) physicians to accept such organs.

METHODS

We performed a 10-question survey of ID providers from the American Society of Transplantation Infectious Disease Community of Practice to determine the scope of practice regarding acceptance of organs from donors with bloodstream infection, pneumonia, and influenza prior to organ procurement, as well as management of such infections following transplantation.

RESULTS

Among 60 respondents to our survey, a majority indicated that organs would be accepted from donors bacteremic with streptococci (76%) or Enterobacteriaceae (73%) without evidence of drug resistance. Acceptance rates varied based on infecting organism, type of organ, and center size. Ten percent of respondents would accept an organ from a donor bacteremic with a carbapenem-resistant organism. Over 90% of respondents would accept an organ other than a lung from a donor with influenza on treatment, compared with 52% that would accept a lung in the same setting.

CONCLUSIONS

This study is the first to our knowledge to survey transplant ID providers regarding acceptance of organs based on specific infections in the donor. These decisions are often based on limited published data and experience. Better characterization of the outcomes from donors with specific types of infection could lead to liberalization of organ acceptance practices across centers.

Liver transplantation in India

Liver transplantation as an established form of treatment for end-stage liver disease has gained acceptance in India over the last 10 years. Liver transplantation in India has unique features that have contributed to the growth of both deceased donor and living donor transplantations of which living donor currently dominates the picture. Living donor contributes to 80% and deceased donor to 20% of the liver transplants currently performed in India. The majority of these transplants are performed within the private sector with public sector hospitals lagging behind significantly. This article gives an overview of the evolution of liver transplantation in India and the potential future challenges. Liver Transplantation 22 1019-1024 2016 AASLD.

Liver Transplantation in India: At the Crossroads

As the liver transplant journey in India reaches substantial numbers and suggests quality technical expertise, it is time to dispassionately look at the big picture, identify problems, and consider corrective measures for the future. Several features characterize the current scenario. Although the proportion of deceased donor liver transplants is increasing, besides major regional imbalances, the activity is heavily loaded in favor of the private sector and live donor transplants. The high costs of the procedure, the poor participation of public hospitals, the lack of a national registry, and outcomes reporting are issues of concern. Organ sharing protocols currently based on chronology or institutional rotation need to move to a more justiciable severity-based system. Several measures can expand the deceased donor pool. The safety of the living donor continues to need close scrutiny and focus. Multiple medical challenges unique to the Indian situation are also being thrown up. Although many of the deficits demand state intervention and policy changes the transplant community needs to take notice and highlight them. The future of liver transplantation in India should move toward a more accountable, equitable, and accessible form. We owe this to our citizens who have shown tremendous faith in us by volunteering to be living donors as well as consenting for deceased donation.

Bacterial infection after liver transplantation

Infectious complications are major causes of morbidity and mortality after liver transplantation, despite recent advances in the transplant field. Bacteria, fungi, viruses and parasites can cause infection before and after transplantation. Among them, bacterial infections are predominant during the first two months post-transplantation and affect patient and graft survival. They might cause surgical site infections, including deep intra-abdominal infections, bacteremia, pneumonia, catheter-related infections and urinary tract infections. The risk factors for bacterial infections differ between the periods after transplant, and between centers. Recently, the emergence of multi-drug resistant bacteria is great concern in liver transplant (LT) patients. The instructive data about effects of infections with extended-spectrum beta lactamase producing bacteria, carbapenem-resistant gram-negative bacteria, and glycopeptide-resistant gram-positive bacteria were reported on a center-by-center basis. To prevent post-transplant bacterial infections, proper strategies need to be established based upon center-specific data and evidence from well-controlled studies. This article reviewed the recent epidemiological data, risk factors for each type of infections and important clinical issues in bacterial infection after LT.

Impacts of pretransplant infections on clinical outcomes of patients with acute-on-chronic liver failure who received living-donor liver transplantation

Background

Liver transplantation is the only therapeutic modality for patients with acute-on chronic liver failure (ACLF). These patients are at high risk for bacterial infections while awaiting transplantation. The aim of this study was to elucidate whether an adequately treated bacterial infection influences the outcomes after transplantation in this patient population.

Methodology/Principal Findings

54 recipients (median age, 49.5 years [range, 22–60]) of adult-to-adult living donor liver transplant (LDLT) for ACLF were categorized as those with pretransplant infection (Group 1, n = 34) or without pretransplant infection (Group 2, n = 20) for retrospective analyses. With the exception of a higher male-female ratio (P = 0.046) and longer length of pretransplant hospital stay (P = 0.026) in Group 1, similar demographic, laboratory and clinical features were found in both groups. Patients in Group 1 (totally 42 pretransplant infection episodes) were adequately treated with effective antibiotic(s) before receiving LDLT. All included patients were followed up until one year after transplantation or death. Sixty-one posttransplant infection episodes were found in an overall of 44 ACLF patients (27 in Group 1 vs. 15 in Group 2; P = 0.352). Frequently encountered posttransplant infections were intraabdominal infection, pneumonia, bloodstream infection and urinary tract infection. Two patients died in each group (P = 0.622). No significant difference was found in the length of posttransplant ICU stay, and in one-year survival, graft rejection, and posttransplant infection rate between both groups. The longer overall hospital stay (mean day, 89.0 vs. 65.5, P = 0.024) found in Group 1 resulted from a longer pretransplant hospital stay receiving treatment for pretransplant infection(s) and/or awaiting transplantation.

Conclusions

These data suggested that an adequately treated pretransplant infection do not pose a significant risk for clinical outcomes including posttransplant fatality in recipients in adult-to-adult LDLT for ACLF.