Surgical site infection in liver transplant recipients: impact of the type of perioperative prophylaxis. Transplantation. 2008;85:1849-1854. [PMID: 18580480 DOI: 10.1097/tp.0b013e3181735407]

Low rate of surgical site infections after liver transplantation: A 5-year retrospective cohort study

BACKGROUND

Surgical site infection (SSI) after liver transplant (LT) is common, but no studies have been conducted in Australia. The purpose of this study was to determine the proportion of patients who developed an SSI post-LT in Australia's largest LT unit.

METHODS

This was a single-center retrospective cohort study. We included all LT recipients who were aged 18 years or more and received their transplant between March 1, 2018 and April 1, 2023. The primary outcome was to determine the proportion of LT recipients who developed an SSI within 30 days of transplantation.

RESULTS

There were 404 LTs performed during the study period, and 375 met inclusion criteria. Of these, 8% (n = 31/375) developed an SSI and were classified as superficial (3%, n = 12/375) or deep/organ space (5%, n = 19/375). The most common antibiotics used for prophylaxis were amoxicillin/clavulanate (75%, n = 281/375), followed by piperacillin/tazobactam (17%, n = 62/375). Independent risk factors associated with the development of SSI were Roux-en-Y hepaticojejunostomy (aOR 3.16, 95% CI 1.17-8.28, p = .02), operative time (per 60-min increment) (aOR 1.23, 95% CI 1.02-1.48), and re-operation (aOR 4.16, 95% CI 1.81-9.58, p < .01). Type of antibiotic received perioperatively was not significantly associated with SSI.

CONCLUSION

SSI occurred in 8% of LT recipients and was predominantly related to operation-related factors rather than patient- or antibiotic-related factors.

Comparative Effectiveness of Perioperative Antibiotic Regimens to Prevent Surgical Site Infections in Pediatric Liver Transplant Recipients

BACKGROUND

Surgical site infections (SSIs) are a common complication in liver transplant (LT) recipients. Lack of pediatric prophylaxis guidelines results in variation in preventative antibiotic regimens.

METHODS

We performed a retrospective observational study of LT recipients <18 years old using a merged data set that included data from the Pediatric Health Information System and the United Network for Organ Sharing between 2006 and 2017. The exposure was defined as the antibiotic(s) received within 24 hours of LT, with 6 categories, ranging from narrow (category 1: cefazolin), to broad). The primary outcome was presence or absence of SSI in the index admission. Mixed-effects logistic regression compared the effectiveness of each category in preventing SSI, relative to category 1.

RESULTS

Of the 2586 LT, 284 (11%) met SSI criteria. The SSI rate was higher in the younger subcohort (16.2%) than in the older (8.6%), necessitating a stratified analysis. Antibiotics from category 5 were most commonly used. In the younger subcohort, the adjusted risk was increased in all categories compared with the reference, most notably in category 3 (odds ratio [OR], 2.58 [95% confidence interval: .69-9.59]) and category 6 (2.76 [.66-11.56]). In the older subcohort, estimated ORs were also increased for each category, most notably in category 4 (2.49 [95% confidence interval: .99-6.27]). None of the ORs suggested benefit from broader-spectrum prophylaxis. Our E-value assessment suggests that it's unlikely there is unmeasured confounding by indication to the degree necessary to revert ORs to protective.

CONCLUSIONS

There was wide variation in antibiotic prophylaxis. Adjusted analyses did not reveal a protective benefit of broader-spectrum prophylaxis in either subcohort, suggesting that narrower regimens may be adequate.

Risk Factors for Surgical-site Infections After Liver Transplant: Does Perioperative Antibiotic Regimen Matter?

BACKGROUND

Surgical-site infections (SSIs) are common in liver transplant recipients. The optimal SSI antimicrobial prophylaxis agent and duration are not established. We aimed to explore risk factors for SSIs after transplant, with a particular interest in the impact of perioperative antibiotic regimen on the development of SSIs.

METHODS

Retrospective study of adults undergoing liver transplant across 3 transplant programs between January 1, 2020, and June 01, 2021.

RESULTS

Of 557 patients included in the study, 32 (5.7%) were infected or colonized with a multidrug-resistant organism (MDRO) within 1 y before liver transplant. Narrow-spectrum SSI prophylaxis with ceftriaxone or cefazolin alone was administered in 488 of 577 patients (87.6%); the remaining 69 patients (12.4%) received broad-spectrum prophylaxis with vancomycin and aztreonam (n = 40), piperacillin-tazobactam (n = 11), carbapenems (n = 8), ceftriaxone and another antibiotic (n = 7), and others. Patients with pretransplant MDRO were more likely to receive broad-spectrum coverage than those without pretransplant MDROs (28.1% versus 11.4%, P  = 0.005). SSIs were identified in 40 patients (7.2%); 25 (62.5%) were organ-space infections, 3 (7.5%) were deep incisional infections, and 12 (30.0%) were superficial incisional infections. The median time from liver transplant to SSIs was 14 d (interquartile range, 10-20.2). MDROs were identified in 12 SSIs (30%). Multivariable analysis revealed no significant association between antimicrobial spectrum and risk of SSIs ( P  = 0.5), whereas surgical leak ( P <0.001) and reoperation ( P  = 0.017) were independently associated with increased risk of SSIs. SSIs were not significantly associated with composite risk of death or liver allograft failure.

CONCLUSIONS

The spectrum of antimicrobial prophylaxis did not impact the development of SSIs in liver transplant recipients.

Early Intra-Abdominal Bacterial Infections after Orthotopic Liver Transplantation: A Narrative Review for Clinicians

Despite recent advances in the transplant field, infectious complications after orthotopic liver transplantation (OLT) are major causes of morbidity and mortality. Bacterial intra-abdominal infections (IAIs) are predominant during the first month post-transplantation and affect patient and graft survival. Recently, the emergence of multidrug resistant bacteria has generated great concern in OLT patients. We performed this narrative review of the literature in order to propose a "ready-to-use" flowchart for reasoned empirical antibiotic therapy in the case of suspected post-OLT IAIs. The review was ultimately organized into four sections: "Epidemiology and predisposing factors for IAI"; "Surgical-site infections and perioperative prophylaxis"; "MDRO colonization and infections"; and "Reasoned-empirical antibiotic therapy in early intra-abdominal infections post OLT and source control". Multidisciplinary teamwork is warranted to individualize strategies for the prevention and treatment of IAIs in OLT recipients, taking into account each patient's risk factors, the surgical characteristics, and the local bacterial epidemiology.

Epidemiology and Prevention of Early Infections by Multi-Drug-Resistant Organisms in Adults Undergoing Liver Transplant: A Narrative Review

Invasive bacterial infections are a leading cause of morbidity and mortality after liver transplant (LT), especially during the first months after LT, and infections due to multi-drug-resistant organisms (MDRO) are increasing in this setting. Most of the infections in patients in intensive care unit arise from the endogenous microflora and, for this reason, pre-LT MDRO rectal colonization is a risk factor for developing MDRO infections in the post-LT. Moreover, the transplanted liver may carry an increased risk of MDRO infections due to organ transportation and preservation, to donor intensive care unit stay and previous antibiotic exposure. To date, little evidence is available about how MDRO pre-LT colonization in donors and recipients should address LT preventive and antibiotic prophylactic strategies, in order to reduce MDRO infections in the post-LT period. The present review provided an extensive overview of the recent literature on these topics, with the aim to offer a comprehensive insight about the epidemiology of MDRO colonization and infections in adult LT recipients, donor-derived MDRO infections, possible surveillance, and prophylactic strategies to reduce post-LT MDRO infections.

Postoperative negative-pressure incision therapy after liver transplant (PONILITRANS study): A randomized controlled trial

BACKGROUND

Postoperative complications of surgical incisions are frequent in liver transplantation. However, evidence justifying the use of incisional negative pressure wound therapy to improve surgical wound outcomes remains limited.

METHODS

Participating patients were randomly assigned to receive incisional negative pressure wound therapy or standard surgical dressing on the closed surgical incision of the liver transplantation. The primary endpoint was surgical site infection incidence 30 days postoperatively. The secondary endpoints included surgical site events (ie, surgical site infection, dehiscence, hematoma, and seroma) and wound quality of life.

RESULTS

Between December 2018 and September 2021, 108 patients (54 in the incisional negative pressure wound therapy group and 54 in the control group) were enrolled in this study. The incidence of surgical site infection at 30 days postoperatively was 7.4% in the treatment group and 13% in the control group (P = .34). The rate of surgical site events was similar in the treatment in the and control group (27.8% vs 29.6%, P = .83). In relation to wound quality of life, the mean score was 75.20 ± 7.27 in the incisional negative pressure wound therapy group and 72.82 ± 10.57 in the control group (P = .23).

CONCLUSION

The prophylactic use of negative pressure wound therapy on primarily closed incisions did not significantly reduce incisional surgical site infection and surgical site event rates after liver transplantation compared with standard surgical dressings.

Epidemiology and outcomes of surgical site infections among pediatric liver transplant recipients

INTRODUCTION

Surgical site infections (SSI) are a significant cause of morbidity in liver transplant recipients, and the current data in the pediatric population are limited. The goal of this study was to identify the incidence, classification, risk factors, and outcomes of SSIs among children undergoing liver transplantation (LT).

METHODS

A single-center, retrospective descriptive analysis was performed of patients age ≤18 years undergoing LT between September 2007 and April 2017. SSI identified within the first 30 days were analyzed. Primary endpoints included incidence, classification, risk factors, and outcomes associated with SSIs.

RESULTS

We included 86 patients, eight patients (9.3%) developed SSIs. Among segmental grafts (SG) recipients, 7/61 (11.4%) developed SSI. Among whole grafts recipients, 1/25 (4%) developed SSI. SSIs were associated with the presence of biliary complications (35% vs. 3%, p < .01; odds ratios 24, 95% CI: 3.41-487.37, p<.01). There were no differences in long term graft or patient survival associated with SSI. Patients who developed SSI were more likely to undergo reoperation (50% vs. 16.7%, p = .045) and had an increased total number of hospital days in the first 60 days post-transplant (30.5 vs. 12.5 days, p = .001).

CONCLUSIONS

SSIs after pediatric LT was less frequent than what has been previously reported in literature. SSIs were associated with the presence of biliary complications without an increase in mortality. SG had an increased rate of biliary complications without an association to SSIs but, considering its positive impact on organ shortage barriers, should not be a deterrent to the utilization of SGs.

Epidemiology of surgical site infections after solid organ transplants in the period 2015-2019: A single-center retrospective cohort study

Surgical site infections (SSI) are severe complications of solid organ transplant (SOT). This retrospective study assessed the epidemiology of and outcomes associated with invasive primary SSI (IP-SSI) occurring within 3 months of transplantation in adult SOT recipients at Duke University over a 5-year period (2015-2019). Among 2073 consecutive SOT recipients, 198 IP-SSI were identified. The IP-SSI rate declined over the period (14.4% in 2015 vs. 8.3% in 2019) and was higher among multi-organ compared with single-organ transplants (33.9% vs. 8.1%, p < .01). SOT recipients with IP-SSI had longer hospital stays than patients without SSI (30.0 vs. 17.0 days, p < .01). Transplant hospitalization (9.6% vs. 2.2%, p < .01), 6-month (11.6% vs. 3.3%, p < .01), and 1-year mortality (15.7% vs. 5.8%, p < .01) were higher in SOT recipients with IP-SSI than in those without. While Gram-positive bacteria were the most common pathogens, urogenital Mollicute and atypical Mycobacteria were identified as an unexpected cause of IP-SSI, particularly among lung transplant recipients. The median time to IP-SSI was 24.0 (IQR 13.8-48.3) days, although the time to IP-SSI varied based on organ transplanted and the causative pathogen. IP-SSI is an important and potentially modifiable complication of SOT, associated with prolonged hospitalizations and reduced survival, particularly in the lung transplant population.

What is the optimal antimicrobial prophylaxis to prevent postoperative infectious complications after liver transplantation? A systematic review of the literature and expert panel recommendations

BACKGROUND

Antimicrobial prophylaxis is well-accepted in the liver transplant (LT) setting. Nevertheless, optimal regimens to prevent bacterial, viral, and fungal infections are not defined.

OBJECTIVES

To identify the optimal antimicrobial prophylaxis to prevent post-LT bacterial, fungal, and cytomegalovirus (CMV) infections, to improve short-term outcomes, and to provide international expert panel recommendations.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel.

PROSPERO ID

CRD42021244976.

RESULTS

Of 1853 studies screened, 34 were included for this review. Bacterial, CMV, and fungal antimicrobial prophylaxis were evaluated separately. Pneumocystis jiroveccii pneumonia (PJP) antimicrobial prophylaxis was analyzed separately from other fungal infections. Overall, eight randomized controlled trials, 21 comparative studies, and five observational noncomparative studies were included.

CONCLUSIONS

Antimicrobial prophylaxis is recommended to prevent bacterial, CMV, and fungal infection to improve outcomes after LT. Universal antibiotic prophylaxis is recommended to prevent postoperative bacterial infections. The choice of antibiotics should be individualized and length of therapy should not exceed 24 hours (Quality of Evidence; Low | Grade of Recommendation; Strong). Both universal prophylaxis and preemptive therapy are strongly recommended for CMV prevention following LT. The choice of one or the other strategy will depend on individual program resources and experiences, as well as donor and recipient serostatus. (Quality of Evidence; Low | Grade of Recommendation; Strong). Antifungal prophylaxis is strongly recommended for LT recipients at high risk of developing invasive fungal infections. The drug of choice remains controversial. (Quality of Evidence; High | Grade of Recommendation; Strong). PJP prophylaxis is strongly recommended. Length of prophylaxis remains controversial. (Quality of Evidence; Very Low | Grade of Recommendation; Strong).

Carbapenems versus Cephalosporin or Piperacillin-Tazobactam as Perioperative Antibiotic Prophylaxis in Liver Transplant Recipients with Model for End-Stage Liver Disease Scores of ≥30: A Retrospective Study in a Chinese Population

Objective

Perioperative prophylaxis, commonly with a third-generation cephalosporin plus ampicillin or piperacillin-tazobactam, is usually employed to prevent infections in liver transplantation (LT) recipients. Patients with a high Model for End-Stage Liver Disease (MELD) score have an increased infection risk after LT. However, whether carbapenems could be used as surgical prophylaxis in these high-risk patients remains unclear. Therefore, this study aimed at comparing the effectiveness of carbapenems with that of cephalosporin or piperacillin-tazobactam for surgical prophylaxis in high-risk LT recipients with a MELD score ≥30.

Design or Methods

This retrospective study included adult patients with a MELD score ≥30 who underwent LT between May 2018 and September 2020. We comparatively analyzed the infection rate and outcome between patients using cefoperazone-sulbactam or piperacillin-tazobactam and those using carbapenems as surgical prophylaxis.

Results

This study included 105 LT recipients. Seventy-eight and 27 patients used non-carbapenem and carbapenem antibiotics, respectively, as surgical prophylaxis. The corresponding infection incidence rates within 30 days were 38.5% and 66.7% (p = 0.011). Multivariate analysis revealed that reoperation and the Child–Pugh score were independent risk factors for infections within 30 days after LT. The following four risk factors were associated with the 180-day post-LT survival: MELD score, vascular complication, intra-abdominal bleeding, and infection with carbapenem-resistant organisms (CROs). There was no significant difference in CRO infection incidence between the carbapenem and non-carbapenem groups (18.5% vs 11.5%; p = 0.345).

Conclusion

Carbapenem use as surgical prophylaxis was not associated with infection incidence within 30 days after LT, 180-day post-LT survival or CRO infection. Therefore, carbapenems are not superior to cephalosporin or piperacillin-tazobactam for perioperative antibiotic prophylaxis in LT recipients with a MELD score ≥30.

Surgical Site Infections in Post-Living Donor Liver Transplantation: Surveillance and Evaluation of Care Bundle Approach

Background and Aim: Although implantation of a care bundle approach is well established in intensive care units (ICUs), yet its impact on reducing surgical site infections (SSI) among post living-donor-liver transplantation (LDLT) patients has not been established. Our aim is to evaluate the impact of a care bundle in reducing SSI and to detect the pattern of antibiotic resistance in LDLT. Materials and Methods: This before and after comparative study was conducted at Elmanial specialized tertiary hospital, Cairo University over a period of 3 years (January 2016 - December 2018) including 57 LDLT patients. We introduced a care bundle comprised of a group of evidence-based practices implemented together. The study was divided into three phases. All bacterial identification and antibiotic sensitivity testing were done by a Vitek 2 compact system. Results: SSIs rates were reduced significantly by 30.4% from the pre-implementation to the post implementation phase (from 13/24, 54.2% to 5/21, 23.8%, OR 0.21, CI 95%: 1.137- 0.039). This reduction went hand in hand with increase in the hand hygiene compliance from 57.3 % to 78 %, then remained sustained with a median rate of 78% in the last 6 months. Klebsiella pneumoniae 11\25 (44% of SSIs), Acinetobacter baumannii 8\25 (32% of SSIs), Escherichia coli 5\25 (20%), Pseudomonas aeruginosa 5\25 (20%) and MRSA 4\25 (16%). With predominance of XDR phenotype 14/25 (56%), followed by ESBL of gram-negative bacteria 6/25 (24%), then MRSA 4/25 (16%). Conclusion: SSIs in LDLT mandates strict implementation of comprehensive evidence-based care bundles for better patent outcome.

Eliminated routine postorthotopic liver transplant antibiotics in uncomplicated patients leads to equivalent safety outcomes

Objective:

The purpose of this retrospective study was to evaluate safety and efficacy end points of a postoperative antibiotic prophylaxis protocol in liver transplant (LT) patients, which was revised to limit antibiotic use.

Methods:

In the routine antibiotics group (RA), patients routinely received prophylactic antibiotics for around 3 days postoperatively for a variety of rationales, versus the limited antibiotics group (LA), in which patients received antibiotics for the treatment of secondary peritonitis. Patients were included if they were 18 or older and underwent liver transplant between January 2016 and September 2019. In total, 216 patients remained after exclusion: 118 patients in the RA group and 98 patients in the LA group.

Results:

We detected a significant difference in the primary end point of postoperative antibiotic days of therapy. The median days of therapy was 2 for the RA group and 0 for the LA group (P < 0.005). Significantly fewer patients received only intraoperative antibiotics in the RA group versus the LA group: 42 (35.6%) versus 76 (73.5%) respectively (P < .005). There was no significant difference in secondary or safety outcomes, including surgical site infections.

Conclusions:

This study provides evidence that limiting the duration of prophylactic antibiotics postoperatively and treating most patients with only intraoperative antibiotics is safe.

Effect of Blood Product Resuscitation on the Pharmacokinetics of Ampicillin-Sulbactam during Orthotopic Liver Transplantation

Background: Ampicillin-sulbactam is a piperacillin-tazobactam-sparing alternative antibiotic administered as surgical prophylaxis during orthotopic liver transplant (OLT), but limited data are available describing its pharmacokinetics and impact of blood product resuscitation. The purpose of this study was to determine the intra-operative pharmacokinetics of ampicillin-sulbactam in patients during OLT and evaluate the effects of blood resuscitation on exposure. Patients and Methods: This was a pharmacokinetic study in 10 OLT patients receiving ampicillin-sulbactam surgical prophylaxis. A 5,000-patient Monte Carlo simulation was conducted to identify optimal ampicillin-sulbactam regimens. Linear regression assessed association between blood product administration and ampicillin exposures. Results: Ampicillin and sulbactam concentrations best fitted two-compartment models. Mean ampicillin pharmacokinetic parameters were central compartment volume (V_c): 6.9 ± 2.0 L, clearance (CL): 26.6 ± 18.4 L/h, and inter-compartmental rate constants (k₁₂ and k₂₁): 4.8 ± 2.6 and 2.3 ± 1.4 h^-1. Sulbactam pharmacokinetic parameters were V_c: 8.1 ± 2.7 L, CL: 26.1 ± 7.4 L/h, k₁₂ and k₂₁: 4.9 ± 1.0 and 2.8 ± 1.1 h^-1. Participants received between 500 and 23,642 mL of total blood product. No statistical relations were observed between blood product administration and exposures (R² 0.00-0.26). Ampicillin-sulbactam 2/1 g every two hours and 2/1 g bolus followed by 6/3 g continuous infusion provided acceptable probability of target attainment up to minimum inhibitory concentrations (MICs) of 16 and 32 mcg/mL, respectively. Conclusions: High and frequent ampicillin-sulbactam doses are required to maintain 100% fT > MIC at relevant MICs during OLT and no impact of blood product resuscitation was observed on ampicillin exposure. These are the first data available to guide ampicillin-sulbactam dosing in patients undergoing OLT.

Surgical site infection prevention and management in immunocompromised patients: a systematic review of the literature

BACKGROUND

Immunocompromised patients are at higher risk of surgical site infection and wound complications. However, optimal management in the perioperative period is not well established. Present systematic review aims to analyse existing strategies and interventions to prevent and manage surgical site infections and other wound complications in immunocompromised patients.

METHODS

A systematic review of the literature was conducted.

RESULTS

Literature review shows that partial skin closure is effective to reduce SSI in this population. There is not sufficient evidence to definitively suggest in favour of prophylactic negative pressure wound therapy. The use of mammalian target of rapamycin (mTOR) and calcineurin inhibitors (CNI) in transplanted patient needing ad emergent or undeferrable abdominal surgical procedure must be carefully and multidisciplinary evaluated. The role of antibiotic prophylaxis in transplanted patients needs to be assessed.

CONCLUSION

Strict adherence to SSI infection preventing bundles must be implemented worldwide especially in immunocompromised patients. Lastly, it is necessary to elaborate a more widely approved definition of immunocompromised state. Without such shared definition, it will be hard to elaborate the needed methodologically correct studies for this fragile population.

Rates and causative pathogens of surgical site infections attributed to liver transplant procedures and other hepatic, biliary, or pancreatic procedures, 2015-2018

Liver transplant recipients are at high risk for surgical site infections (SSIs). Limited data are available on SSI epidemiology following liver transplant procedures (LTPs). We analyzed data on SSIs from 2015 to 2018 reported to CDC's National Healthcare Safety Network to determine rates, pathogen distribution, and antimicrobial resistance after LTPs and other hepatic, biliary, or pancreatic procedures (BILIs). LTP and BILI SSI rates were 5.7% and 5.9%, respectively. The odds of SSI after LTP were lower than after BILI (adjusted odds ratio = 0.70, 95% confidence interval 0.57-0.85). Among LTP SSIs, 43.1% were caused by Enterococcus spp., 17.2% by Candida spp., and 15.0% by coagulase-negative Staphylococcus spp. (CNS). Percentages of SSIs caused by Enterococcus faecium or CNS were higher after LTPs than BILIs, whereas percentages of SSIs caused by Enterobacteriaceae, Enterococcus faecalis, or viridans streptococci were higher after BILIs. Antimicrobial resistance was common in LTP SSI pathogens, including E. faecium (69.4% vancomycin resistant); Escherichia coli (68.8% fluoroquinolone non-susceptible and 44.7% extended spectrum cephalosporin [ESC] non-susceptible); and Klebsiella pneumoniae and K. oxytoca (39.4% fluoroquinolone non-susceptible and 54.5% ESC non-susceptible). National LTP SSI pathogen and resistance data can help prioritize studies to determine effective interventions to prevent SSIs and reduce antimicrobial resistance in liver transplant recipients.

Standardization of post-operative antimicrobials reduced exposure while maintaining good outcomes in pediatric liver transplant recipients

Infections following orthotopic liver transplant (OLT) result in significant morbidity and mortality, warranting careful consideration of risks associated with antibiotic overuse and benefits of infection prevention. In the absence of specific guidelines for antimicrobial prophylaxis in pediatric OLT, we developed a standardized approach to post-operative (post-op) antimicrobial therapy including 48 hours of antibiotics, no vancomycin for post-op fever within the first 48 hours, and caspofungin only for certain situations. The goal was to reduce antimicrobial utilization and adverse outcomes associated with longer duration of and broader treatment while maintaining good outcomes. The impact of this standardization on antimicrobial utilization and clinical outcomes at the largest pediatric liver transplant center in the United States is described. All individuals receiving an OLT from 1/1/17-9/30/17 (N = 38) and 3/14/18-12/13/18 (N = 27) were included in the pre-intervention (PreI) and post-intervention (PostI) groups, respectively. The intervention resulted in a significant reduction in individuals receiving post-op broad-spectrum gram-negative antibiotics for >48 hours (76% PreI vs 44% PostI OLT recipients, P = .01) and post-op vancomycin use (50% PreI, vs 7.4% PostI, P < .001). There were no statistically significant differences between groups for post-op fever, positive pre-/post-operative cultures, receipt of massive transfusion, or hospital length of stay. In conclusion, following the implementation of a standardized approach to post-op prophylaxis, antimicrobial exposure was significantly reduced without affecting OLT recipient outcomes.

The economic impact of increased length of stay associated with surgical site infections in liver transplantation on Canadian healthcare costs

BACKGROUND

Complications after liver transplantation cause additional healthcare costs. The objective of this study was to contrast the length of stay (LOS) costs for recipients with and without surgical site infections (SSIs).

METHODS

This retrospective observational cohort study was conducted at a transplant center in Canada, between February 2011 and August 2014. The difference in the LOS costs was assessed by the Mann-Whitney U test, while multiple linear regression analysis was used to identify the variables that may have impacted on the costs.

RESULTS

Two hundred and twenty-nine liver transplant recipients were enrolled. Thirty-six recipients developed SSIs (36/229, 15.7%). The median LOS costs in recipients with and without SSIs were $39,456 Canadian dollars (interquartile range $25,696- 59,722) and $31,084 Canadian dollars (interquartile range $22,712-49 610), respectively (p = .072). There was a trend that the costs were higher for those recipients with versus those without SSIs (p = .088). Transfusion of ≥ 5 units of red cells and dialysis before transplantation impacted on cost.

CONCLUSION

There was a trend for higher healthcare facility costs for recipients with SSIs. Red cell transfusions and greater dialysis use before transplant were factors associated with the cost. Implementation of cost reduction strategies targeting high-cost recipients is necessary.

Surgical site infection after liver transplantation in the era of multidrug-resistant bacteria: what new risks should be considered?

Surgical site infection (SSI) is a frequent infection site after liver transplantation (LT), and multidrug-resistant bacteria are common agents of those infections. This study aimed to analyze risk factors for SSI, including SSI caused by a multidrug-resistant microorganism (MDRO) after LT. We performed a cohort study of patients who underwent an LT from 2010 to 2018. The outcomes were SSI and SSI caused by MDRO. We analyzed features related to surgical procedure, patients' characteristics, and post-LT intercurrence. Surveillance for carbapenem-resistant Enterobacteriaceae (CRE), vancomycin-resistant Enterococcus (VRE), and carbapenem-resistant Acinetobacter baumannii (CRAB) was performed through rectal swab at the LT admission and weekly until hospital discharge during all study periods. SSI was identified in 30.1% (229/762) of LTs. We observed a decline in the SSI rate from 37.5% in 2014 to 16.7% in 2018 (P 0.02). SSI caused by MDRO occurred in 109 (14.3%) patients. Klebsiella pneumoniae was the most common agent of both SSI and SSI caused by MDRO. The pre-LT colonization was 98 (12.9%) by CRE, 73 (9.6%) by VRE, and 28 (3.7%) by CRAB. Risk factors for SSI caused by MDRO identified were dialysis after LT (P 0.01), CRAB acquisition before LT (0.03), and CRE acquisition before LT (P 0.004); use of adjusted prophylaxis by MDRO risk was the only protective factor identified (P 0.01). MDROs were frequent agents of SSI after LT, and the carbapenem-resistant Gram-negative colonization before LT increased the risk of SSI by these agents.

Surgical Site Infections in Liver Transplant Patients: A Single-Center Experience

AIM

The aim of the study was a single-center assessment of occurrence of surgical site infections (SSI) in patients after liver transplantation and an attempt to determine factors that may contribute to this complication.

PATIENTS AND METHODS

Analysis of medical records of 60 adult patients, who underwent first transplantation in 2016 and 2017 was conducted. Selected pre-, intra-, and postoperative factors were assessed. Statistical analysis was performed with StatSoft Statistica 13.1 PL package.

RESULTS

SSI occurred in 25% of liver recipients, with average timing of diagnosis on the 14th day after surgery. Mean duration of hospitalization was significantly longer in patients who experienced SSI than in patients without this complication (35.8 ± 8.9 days vs 25.2 ± 6 days, P < .0001). SSI occurred a little more frequently in men and older recipients, as well as in overweight and underweight patients (not significant). An indication for transplantation did not have an impact on SSI occurrence. The complication was more likely in patients with diabetes and renal failure prior to transplantation (P > .05). Duration of the procedure, blood loss and prolonged drainage did not have any impact on SSIs. SSI was significantly more common in recipients with lower total protein value (P < .0002) and anemia (P < .0002) in early postoperative period.

CONCLUSION

Among the studied population, a high incidence of SSI was noted, and that some of the identified risk factors differ from those described in the literature.

Daptomycin perioperative prophylaxis for the prevention of vancomycin-resistant Enterococcus infection in colonized liver transplant recipients

BACKGROUND

Vancomycin-resistant Enterococcus (VRE)-colonized liver transplantation (LT) recipients have increased post-LT morbidity, mortality, and higher rates of VRE infections compared with their non-colonized counterparts. Pre-LT screening for VRE colonization and inclusion of daptomycin in the perioperative antibiotic prophylaxis regimen may mitigate this risk.

METHODS

We performed a retrospective chart review of liver transplant recipients aged ≥ 18 years between 2013 and August 2019 to identify pre-LT VRE-colonized recipients and whether they received daptomycin perioperative prophylaxis (DPP). Demographic and clinical characteristics, including risk factors for VRE infection, were collected. Outcomes measured were VRE-related infection and all-cause mortality within 90 days of LT.

RESULTS

Of the 27 VRE-colonized liver transplant recipients within the study period, 25 received DPP. All recipients were admitted to the intensive care unit postoperatively, six (24%) required reoperation, fifteen (60%) required renal replacement therapy, and eight (32%) experienced postoperative hemorrhage within 90 days post-transplant. Two recipients (8%) experienced acute cellular rejection, but no primary graft failure was seen within 90 days. Among those who received DPP, no infections related to VRE or death was seen within 90 days of LT. The two VRE-colonized recipients who did not receive DPP both developed VRE bacteremia in the early post-LT period.

CONCLUSION

Despite having multiple risk factors for post-LT VRE infection, VRE-colonized recipients who received DPP did not develop VRE-related infections in the first 90 days post-LT. Our experience demonstrates that pre-LT VRE screening and DPP may be associated with a reduction in VRE infection in the early post-LT period, but this strategy warrants further evaluation in prospective studies.

Comparison of Ceftizoxime Plus Ampicillin-Sulbactam versus Gentamicin Plus Ampicillin-Sulbactam in the Prevention of Post-Transplant Early Bacterial Infections in Liver Transplant Recipients: A Randomized Controlled Trial

Purpose

In this study, we aimed to compare the efficacy of combined ceftizoxime with ampicillin-sulbactam versus combined gentamicin with ampicillin-sulbactam as prophylactic antibiotic regimen in preventing early bacterial PTIs in liver TX recipients at a referral center.

Patients and methods

All patients older than 18 years who had undergone liver TX at Abu-Ali Sina transplantation center in Shiraz, Iran from July 2018 to April 2019 were included in this study. In a single-blinded manner, the participants randomly received either combined intravenous ceftizoxime plus ampicillin-sulbactam (ceftizoxime group) or gentamicin plus ampicillin-sulbactam (gentamicin group) as prophylactic antibiotic regimen before the incision of the surgery, which was continued for 48 hrs after liver Tx. The rate and type of bacterial infections, length of hospital and intensive care unit (ICU) stay, mortality rate, and kidney function were assessed during 1 month following liver TX in the two groups.

Results

Two hundred and thirty patients were divided into two groups. One patient in the gentamicin group and five in the ceftizoxime group were excluded due to emergency exploratory laparotomy within the first 3 days after transplantation. The rate of bacterial infections during the first month after transplantation was 25.4%. This rate was significantly lower in the gentamicin group (13.16%) in comparison to the ceftizoxime group (38.18%) (P value<0.01), based on the univariate logistic regression analysis. Length of ICU and hospital stay and also mortality rate were significantly lower in the gentamicin group (P value <0.01). There was no significant difference regarding kidney function between the two groups (P value = 0.16).

Conclusion

Our results suggested that gentamicin can be considered as a promising agent in prophylactic antibiotic regimen for patients undergoing liver TX.

Trial registration

The study was registered at the Iranian Registry of Clinical Trials (IRCT20120731010453N2; http://www.irct.ir/).

Bacterial infections in children after liver transplantation: A single-center surveillance study of 345 consecutive transplantations

BACKGROUND

Infectious complications after pediatric liver transplantation frequently occur and are potentially serious. Data concerning strictly defined bacterial infections and their associated risk factors are lacking.

METHODS

For the pediatric liver transplant postoperative period, we analyzed data from the nosocomial infection surveillance (2006-2015).

RESULTS

A total of 235 bacterial infections in 162 transplantations (47%) occurred, including 32 bacterial pneumonia cases, 104 surgical site infections, 27 urinary tract infections, and 40 bloodstream infections. Sepsis was diagnosed in 127 cases (54%), severe sepsis in 22 (9%) cases, and septic shock in 41 (17%) cases. Thirty patients (9%) died, and septic shock was the leading cause of death. The carrier status of multi-drug resistant bacteria and a tacrolimus level >20 ng/mL were independent risk factors for surgical site infections and the occurrence of severe sepsis or septic shock. The length of mechanical ventilation was an independent risk factor for pneumonia and surgical site infection.

CONCLUSION

Bacterial infections in the early postoperative period after pediatric liver transplantation are associated with high morbidity and mortality. Physicians involved in the medical care of these patients should be aware of the specific risk factors, and further development of prevention programs is highly recommended.

Surgical site infection and risk factors following right lobe living donor liver transplantation in adults: A single-center prospective cohort study

INTRODUCTION

Surgical site infection (SSI) is an important cause of decreased graft survival, prolonged hospital stay, and higher costs following living donor liver transplantation. There are several risk factors for SSI. In this cohort study, we aimed to investigate the incidence of SSI at our center and the associated risk factors.

MATERIALS AND METHODS

Adult right lobe living donor liver transplantations were included in this prospective cohort. Patients who died postoperatively within 3 days; patients with infected ascites or open abdomen, cadaveric, or pediatric transplants; and patients with biologic or cryopreserved vascular grafts were excluded. Patients' demographic characteristics and perioperative surgical findings were recorded. SSI follow-up was continued for 90 days. CDC-2017 criteria were used to diagnose SSI. In the presence of superficial, deep, and organ/space SSI, only the organ in the poorest condition was included in SSI evaluation. The patients were administered similar to antibiotic prophylaxes and immunosuppressive protocols.

RESULTS

A total of 101 patients were enrolled in this study, of which 30 (29.7%) were diagnosed with SSI. Organ/space, only deep, and only superficial SSI were noted in 90% (27/30), 6.7% (2/30), and 3.3% (1/30) of the patients, respectively. Twenty-five of 30 patients with SSI had a remote site infection. One or more bacteria observed in cultures were obtained from 28 patients. A donor-recipient age difference of >10 years, cold ischemia lasting for ≥150 minutes, surgical duration of ≥600 minutes, intraoperative hemorrhage of ≥1000 mL, intraoperative blood transfusion, biliary leak or stricture, prolonged mechanical ventilation, prolonged intensive care unit and hospital stay, remote site infection, and the need for reoperation were associated with increased SSI incidence. Preoperative and intraoperative levels of blood glucose, albumin, and hemoglobin were not associated with SSI. A donor-recipient age difference of >10 years, remote site infection, and biliary leak were found to be independent risk factors for SSI. Hospital mortality with and without SSIs was 6.7% vs 4.4%, P = .61.

DISCUSSION

Organ/space SSIs were the essential part of SSIs following right lobe living donor liver transplantations. Donor-recipient age gap, prolonged cold ischemia time, complicated surgery, and postoperative biliary complications were the main causes of SSIs. Although they did not increase the perioperative mortality, they promote increased rate of reoperations, remote infections, prolonged intensive care unit, and hospital stays.

Perioperative prophylaxis with single-dose cefazolin for liver transplantation: a retrospective study

BACKGROUND

Early infections are common during the first month after liver transplantation (LT), whereas no consensus exists on the optimal prophylactic antimicrobial therapy. We aimed to evaluate the effectiveness of cefazolin perioperative prophylaxis in LT.

PATIENTS AND METHODS

We documented our experience with single-dose cefazolin as prophylaxis for LT. Infections occurring within 30 days following LT during 2006-2015 were documented retrospectively. Univariate and multivariate analyses of risk factors for infection were carried out.

RESULTS

Among 113 LT recipients receiving cefazolin as prophylaxis, infections occurred in 50 (44%) patients, including surgical site infections (n=24, 21%) and bacteremia (n=14, 12%). Bacteria resistant to cefazolin were documented in 59/72 (82%) isolates. Enterococcal infections were documented in 6% (7/113). Almost half of the infections (44%) occurred in the first week following LT and the vast majority within 2 weeks. The 30-day mortality rate (7%, 8/113) was significantly higher among infected patients (7/50, 14% vs. 1/63, 1.6%, P=0.011). Model for End-stage Liver Disease score, age, and requirement for at least 5 U of packed red cells during transplantation were predictive for postoperative infections.

CONCLUSION

In our center, cefazolin was insufficient as perioperative prophylaxis in LT. We suggest that all LT recipients should receive antibiotic prophylaxis targeting microorganisms on the basis of local bacterial ecology and patterns of resistance irrespective of preoperative or intraoperative risk assessment.

Intraoperative Versus Extended Antibiotic Prophylaxis in Liver Transplant Surgery: A Randomized Controlled Pilot Trial

The appropriate duration of surgical antibiotic prophylaxis in orthotopic liver transplantation (OLT) in the presence of significant iatrogenic immunosuppression is unclear. We hypothesized that 72 hours of perioperative antibiotic prophylaxis would decrease rates of surgical site infection (SSI) in OLT patients when compared with intraoperative antibiotic prophylaxis alone. OLT recipients were randomized to receive either intraoperative antibiotics only (short antibiotics [SAs]) or 72 hours of perioperative antibiotics (extended antibiotics [EAs]). A total of 102 patients were randomized: 51 to the EA group and 51 to the SA group. Rates of SSI and nosocomial infection (NI) in the SA group were 19% and 17%, respectively, compared with 27% (SSI; P = 0.36) and 22% (NI; P = 0.47) in the EA group, although these differences were not statistically significant. Intensive care unit (ICU) length of stay (LOS), hospital LOS, 30-day mortality, and time to infection were also similar between the 2 groups. Patients developing infections had longer ICU LOS and hospital LOS and a higher association with reoperation, endoscopic retrograde cholangiopancreatography, and 30-day readmission. In conclusion, extending perioperative antibiotics to 72 hours from intraoperative dosing alone in OLT patients does not appear to decrease the incidence of SSI or NI. The results from this pilot trial with 60% power suggest that it is acceptable for OLT recipients to receive intraoperative antibiotic prophylaxis alone.

Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.

Early Use of Etanercept for Graft-Versus-Host Disease After Liver Transplant: the Importance of Broad Spectrum Infective Prophylaxis

Graft-versus-host-disease after orthotopic liver transplant is a rare and life-threatening complication. The diagnosis is challenging and usually confirmed by chimerism and skin biopsies. The most common cause of death is sepsis (60%), and broad-spectrum antibiotics and antifungal prophylaxis are strongly recommended. We present a case of a 61-year-old man with hepatocellular carcinoma and a previous history of metabolic and alcoholic cirrhosis who underwent orthotopic liver transplant. The immunosuppression regimen consisted of corticosteroids, calcineurin inhibitor, and mammalian target of rapamycin complex 1 inhibitor. Nine days after surgery, the patient developed leukopenia and skin rash. After confirmation of graft-versus-host disease by chimerism and skin biopsy, etanercept, a novel anti-tumor necrosis factor-alpha drug used for patients with hematologic and rheumatologic disease, was administrated. Unfortunately, no clinical improvements or bone marrow recovery were noted, and the patient had subsequent fatal sepsis due to Enterococcus faecium, Aspergillus fumigatus, and viral superinfection. There are no US Food and Drug Administration-approved treatments for graft-versus-host disease after orthotopic liver transplant. The main risk factors are recipients > 50 years old, patients with glucose intolerance, patients transplanted due to hepatocellular carcinoma, donor-recipient age difference of > 20 years, and any HLA-class I match. In accordance with the literature, we suggest early use of broad-spectrum antibiotics and antifungal drugs during etanercept treatment. In addition, because of substantially higher risk for severe sepsis, we strongly recommend adding an antiviral prophylaxis to prevent Cytomegalovirus reactivation or unexpected superinfection.

Risk factors for development of surgical site infections among liver transplantation recipients: An integrative literature review

BACKGROUND

Surgical site infection (SSI) is an important complication in the postoperative period of recipients of liver transplantation. The purpose of this integrative literature review is to summarize the knowledge available about the risk factors contributing to the development SSI among adults undergoing liver transplantation.

METHODS

We reviewed the Medical Literature Analysis and Retrieval System Online/PubMed, the Cumulative Index to Nursing and Allied Health Literature, the Latin American and Caribbean Health Sciences Literature, Scopus, and Web of Science databases.

RESULTS

Two hundred sixteen articles were identified and the final sample of 9 articles was analyzed in full length. The SSI rate found in the investigations ranged between 9.6% and 35.5%. Risk factors for SSI were grouped into categories related to the preoperative period, such as Model for End-Stage Renal Disease score > 35 and ventilated support on day of transplant; to the intraoperative period activity, such as transfusion of packed red blood cells, extended surgical time, hyperglycemia >200 mg/dL, use of vasopressor drugs, and ascites flow >1 L; and to the donor/recipient relationship, such as age differences >10 years, ratio of donor liver mass to recipient body mass < 0.01. Additionally, centers that annually perform <50 transplants appear to have higher rates of SSI.

CONCLUSIONS

Few studies have addressed the subject of SSI in relation to liver transplantation in the scientific literature. Risk factors for SSI in patients who underwent liver transplantation vary between institutions.

Surgical Site Infections After Liver Transplantation: Prospective Surveillance and Evaluation of 250 Transplant Recipients in Canada

OBJECTIVE

To evaluate the incidence of surgical-site infections (SSIs) in a cohort of liver transplant recipients and to assess risk factors predisposing patients to these infections.

DESIGN

Prospective observational cohort study.

SETTING

Single transplant center in Canada.

PATIENTS

Patients who underwent liver transplantation between February 2011 and August 2014.

METHODS

Multivariate logistic regression was used to identify independent risk factors for SSIs in liver transplant patients.

RESULTS

We enrolled 250 liver transplant recipients. The recipients’ median age at the time of transplantation was 56 years (range, 19–70 years), and 166 patients (66.4%) were male. Moreover, 47 SSIs were documented in 43 patients (17.2%). Organ-space, superficial, and deep SSIs were noted in 29, 7, and 3 patients, respectively. In addition, 2 patients developed superficial and organ-space SSIs, and another 2 patients were found to have deep as well as organ-space infections. In total, we identified 33 organ-space SSIs (70.2%), 9 superficial SSIs (19.1%), and 5 deep SSIs (10.6%). Factors predictive of SSIs by multivariate analysis were duct-to-duct anastomosis (odds ratio [OR], 3.88; 95% CI, 1.85–8.13; P<.001) and dialysis (OR, 3.57; 95% CI, 1.02–12.50; P=.046). Of the 66 organisms isolated in both deep and organ-space SSIs, 55 (83%) were resistant to cefazolin.

CONCLUSIONS

Organ-space SSIs are a common complication after liver transplantation. Duct-to-duct anastomosis and dialysis were independent risk factors associated with SSIs. Appropriate perioperative prophylaxis targeting patients with duct-to-duct anastomosis and dialysis while simultaneously providing optimum coverage for the potential pathogens causing SSIs is warranted.

Infect Control Hosp Epidemiol 2017;38:1084–1090

Surgical Site Infections After Liver Transplantation: Emergence of Multidrug-Resistant Bacteria and Implications for Prophylaxis and Treatment Strategies

BACKGROUND

Perioperative antimicrobial prophylaxis is administered to liver transplant (LTx) recipients to prevent surgical site infections (SSIs), but regimens are not standardized, and there are limited effectiveness data. Prevention and treatment of SSIs have been complicated by the emergence of multidrug-resistant (MDR) pathogens.

METHODS

We retrospectively reviewed SSIs among 331 LTx recipients at our center in 2010 to 2014.

RESULTS

Culture-proven superficial and deep SSIs occurred in 3% and 15% of patients, respectively, at median 12.5 and 13.5 days post-LTx. Recipients with superficial SSIs and those without SSIs were similar in demographics, clinical characteristics, length of hospital stay, and mortality. Deep SSIs included abscesses (58%), peritonitis (28%), deep incisional infections (8%), and cholangitis (6%). Rates of deep SSIs were comparable among patients receiving prophylaxis with ampicillin-sulbactam, aztreonam and vancomycin, or tigecycline (P = 0.61). Independent risk factors for deep SSIs were bile leak (P < 0.001) and operative time (P < 0.001). Enterobacteriaceae (42%), Enterococcus spp. (24%), and Candida spp. (15%) were predominant pathogens. Fifty-three percent of bacteria were MDR, including 95% of Enterococcus faecium and 55% of Enterobacteriaceae; 82% of deep SSIs were caused by bacteria resistant to antimicrobials used for prophylaxis, and 58% of patients were treated with an inactive empiric regimen. Deep SSIs were associated with longer lengths of stay (P < 0.001), and higher 90-day and long-term mortality rates (P < 0.001).

CONCLUSIONS

Deep SSIs, including those caused by MDR bacteria, were common after LTx despite prophylaxis with broad-spectrum antimicrobials. Rather than altering prophylaxis regimens, programs should devise empiric treatment regimens that are directed against the most common local pathogens.

Carbapenem-Resistant Enterobacteriaceae Acquired Before Liver Transplantation: Impact on Recipient Outcomes

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) is an emergent microorganism of infections after liver transplant (LT). The aim of this study was to analyze the risk factors for CRE acquisition and infection after LT.

METHODS

This was a prospective cohort study involving patients who underwent LT in the 2010 to 2014 period. Surveillance cultures for CRE were collected immediately before LT and weekly thereafter until hospital discharge.

RESULTS

We analyzed 386 patients undergoing a total of 407 LTs. Before LT, 68 (17.6%) patients tested positive for CRE, 11 (16.2%) of those patients having CRE infection, whereas 119 (30.8%) patients acquired CRE after LT. Post-LT CRE infection was identified in 59 (15.7%) patients: Klebsiella pneumoniae was isolated in 83.2%; surgical site infection was the most common type of infection (46.7%). Multivariate analysis showed that post-LT dialysis was the only risk factor for post-LT CRE acquisition. Eighty-two percent of patients who underwent 3 or more post-LT dialysis sessions and acquired CRE before LT evolved with post-LT CRE infection. Other risk factors for CRE infection were acquisition of CRE post-LT, Model for End-Stage Liver Disease score greater than 32, combined transplantation, and reoperation. Patients who acquired CRE before LT had a high risk of developing CRE infection (P < 0.001).

CONCLUSIONS

Measures for minimizing that risk, including altering the antibiotic prophylaxis, should be investigated and implemented.

Antibiotic prophylaxis for surgical site infection in people undergoing liver transplantation

BACKGROUND

Surgical site infection is more frequent in liver transplantation than in other types of solid organ transplantation with different antibiotics. Studies have shown that the rate of surgical site infection varies from 8.8% to 37.5% after liver transplantation. Therefore, antimicrobial prophylaxis is likely an essential tool for reducing these infections. However, the literature lacks evidence indicating the best prophylactic antibiotic regimen that can be used for liver transplantation.

OBJECTIVES

To assess the benefits and harms of antibiotic prophylactic regimens for surgical site infection in people undergoing liver transplantation.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded and Latin American Caribbean Health Sciences Literature (LILACS). The most recent search was performed on 11 September 2015.

SELECTION CRITERIA

All eligible randomised clinical trials comparing any antibiotic regimen versus placebo, versus no intervention or versus another antibiotic regimen for surgical site infection in liver transplant recipients, regardless of age, sex and reason for transplantation. Quasi-randomised studies and other observational studies were considered for data on harm if retrieved with search results for randomised clinical trials.

DATA COLLECTION AND ANALYSIS

Two review authors selected relevant trials, assessed risk of bias of studies and extracted data.

MAIN RESULTS

The electronic search identified 786 publications after removal of duplicates. From this search, only one seemingly randomised clinical trial, published in abstract form, fulfilled the inclusion criteria of this review. This trial was conducted at Shiraz Transplant Centre, Shiraz, Iran, where investigators randomly assigned a total of 180 consecutive liver transplant recipients. We judged the overall risk of bias of the trial published in abstract form as high. Researchers reported no numerical data but mentioned that 163 participants met the inclusion criteria after randomisation, and hence were included in the analyses. Most probably, the 17 excluded participants were high-risk liver transplant recipients. Trial authors concluded that they could find no differences between the two antibiotic regimens - ceftriaxone plus metronidazole versus ampicillin-sulbactam plus ceftizoxime - when given to liver transplant recipients. Review authors could not reconfirm the analyses because, as it has been mentioned, trial authors provided no trial data for analyses.

AUTHORS' CONCLUSIONS

Benefits and harms of antibiotic prophylactic regimens for surgical site infection in liver transplantation remain unclear. Additional well-conducted randomised clinical trials adhering to SPIRIT (Spirit Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) guidelines are needed to determine the exact role of antibiotic prophylactic regimens in patients undergoing liver transplantation.

Changes in Surgical Site Infections after Living Donor Liver Transplantation

Surgical site infections (SSIs) are a major threat for liver transplant recipients. We prospectively studied SSIs after living donor liver transplantation (LDLT) at Kyoto University Hospital from April 2001 to March 2002 (1st period) and from January 2011 to June 2012 (2nd period). We investigated the epidemiology of SSIs after LDLT and determined the differences between the two periods. A total of 129 adult recipients (66 during the 1st period and 63 during the 2nd period) and 72 pediatric recipients (39 and 33) were included in this study. The SSI rates for each period were 30.3% (1st period) and 41.3% (2nd period) among the adult recipients and 25.6% and 30.3% among the pediatric recipients. The overall rates of 30-day mortality among adult transplant recipients with SSIs were 10.0% (1st period) and 3.9% (2nd period). No pediatric recipient died from SSIs after LDLT in either period. The incidence of Enterococcus faecium increased from 5.0% to 26.9% in the adults and from 10.0% to 40.0% in the pediatric patients. Extended-spectrum β-lactamase-producing Enterobacteriaceae were emerging important isolates during the 2nd period. For this period, a univariate analysis showed that ABO incompatibility (P = 0.02), total operation duration (P = 0.01), graft-to-recipient body weight ratio (GRWR [P = 0.04]), and Roux-en-Y biliary reconstruction (P<0.01) in the adults and age (P = 0.01) and NHSN risk index (P = 0.02) in the children were associated with SSI development. In a multivariate analysis, lower GRWR (P = 0.02) and Roux-en-Y biliary reconstruction (P<0.01) in the adults and older age (P = 0.01) in the children were independent risk factors for SSIs during the 2nd period. In conclusion, SSIs caused by antibiotic resistant bacteria may become a major concern. Lower GRWR and Roux-en-Y biliary reconstruction among adult LDLT recipients and older age among pediatric LDLT recipients increased the risk of developing SSIs after LDLT.

Surgical site infections after liver retransplantation: incidence and risk factors

Surgical site infections (SSIs) after liver transplantation (LT) are associated with an increased risk of graft loss and death. The incidence of SSIs after LT and their risk factors have been determined for first LT but not for second LT. The importance of reporting the incidence of SSIs risk-stratified by first LT versus second LT is not known. All patients undergoing second LT at a single institution between 2003 and 2011 (n = 152) were reviewed. The Kaplan-Meier method was used to estimate the cumulative SSI incidence. Relative risks (RRs) and 95% confidence intervals (CIs) from Cox proportional hazards regression models were used to evaluate associations of potential risk factors with SSIs after second LT. Thirty-one patients developed SSIs (6 superficial SSIs, 1 deep SSI, and 24 organ/space SSIs). The cumulative incidence of SSIs 30 days after LT was 20.8% (95% CI = 14%-27%), which was slightly but not significantly higher than the previously reported incidence of SSIs after first LT at our institution between 2003 and 2008 (16%, RR = 1.32, 95% CI = 0.90-1.93, P = .16). Units of transfused red blood cells [RR (doubling) = 1.38, 95% CI = 1.02-1.86, P = .04] and hepaticojejunostomy (RR = 2.22, 95% CI = 1.05-4.72, P = .04) were the only factors associated with SSIs after second LT in single-variable analysis. The associations weakened in a multivariate analysis (P = .07 and P = .07, respectively), potentially because of the correlation of red blood cell transfusions and hepaticojejunostomy (P = .08). In conclusion, the incidence of SSIs after second LT was slightly higher but not significantly different than the published incidence of SSIs (16%) after first LT at the same institution. Significant independent risk factors for SSIs after second LT were not identified. Risk stratification for retransplantation may not be necessary when the incidence of SSIs after LT is being reported.

A meta-analysis of complications following deceased donor liver transplant

BACKGROUND

Liver transplantation is a complex surgery associated with high rates of postoperative complications. While national outcomes data are available, national rates of most complications are unknown.

DATA SOURCES

A systematic review of the literature reporting rates of postoperative complications between 2002 and 2012 was performed. A cohort of 29,227 deceased donor liver transplant recipients from 74 studies was used to calculate pooled incidences for 17 major postoperative complications.

CONCLUSIONS

This is the first comprehensive review of postoperative complications after liver transplantation and can serve as a guide for transplant and nontransplant clinicians. Efforts to collect national data on complications, such as through the National Surgical Quality Improvement Program, would improve the ability to provide patients with informed consent, serve as a tool for individual center performance monitoring, and provide a central source against which to measure interventions aimed at improving patient care.

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.

Donor risk index predicts graft failure reliably but not post-transplant infections

BACKGROUND

The Donor Risk Index (DRI) is used to predict graft survival following liver transplantation, but has not been used to predict post-operative infections in graft recipients. We hypothesized that lower-quality grafts would result in more frequent infectious complications.

METHODS

Using a prospectively collected infection data set, we matched liver transplant recipients (and the respective allograft DRI scores) with their specific post-transplant infectious complications. All transplant recipients were organized by DRI score and divided into groups with low-DRI and high-DRI scores.

RESULTS

We identified 378 liver transplants, with 189 recipients each in the low-DRI and high-DRI groups. The mean DRI scores for the low- and high-DRI-score groups were 1.14±0.01 and 1.74±0.02, respectively (p<0.0001 for the difference). The mean Model for End-Stage Liver Disease (MELD) scores were 26.25±0.53 and 24.76±0.55, respectively (p=0.052), and the mean number of infectious complications per patient were 1.60±0.19 and 1.94±0.24, respectively (p=0.26). Logistic regression showed only length of hospital stay and a history of vascular disease as being associated independently with infection, with a trend toward significance for MELD score (p=0.13).

CONCLUSION

We conclude that although DRI score predicts graft-liver survival, infectious complications depend more heavily on recipient factors.

Nosocomial infections within the first month of solid organ transplantation

Infections remain a common complication of solid organ transplantation. Early postoperative infections remain a significant cause of morbidity and mortality in solid organ transplant (SOT) recipients. Although significant effort has been made to understand the epidemiology and risk factors for early nosocomial infections in other surgical populations, data in SOT recipients are limited. A literature review was performed to summarize the current understanding of pneumonia, urinary tract infection, surgical-site infection, bloodstream infection, and Clostridium difficult colitis, occurring within the first 30 days after transplantation.

Surgical site infections in liver transplant recipients in the model for end-stage liver disease era: an analysis of the epidemiology, risk factors, and outcomes

In recipients of liver transplantation (LT), surgical site infection (SSIs) are among the most common types of infection occurring in the first 60 days after LT. In 2007, the Model for End-Stage Liver Disease (MELD) scoring system was adopted as the basis for prioritizing organ allocation. Patients with higher MELD scores are at higher risk for developing SSIs as well as other health care-associated infections. However, there have been no studies comparing the incidence of SSIs in the pre-MELD era with the incidence in the period since its adoption. Therefore, the objectives of this study were to evaluate the incidence, etiology, epidemiology, and outcomes of post-LT SSIs in those 2 periods and to identify risk factors for SSIs. We evaluated all patients who underwent LT over a 10-year period (2002-2011). SSI cases were identified through active surveillance. The primary outcome measure was an SSI during the first 60 days after LT. Risk factors were analyzed via logistic regression, and 60-day survival rates were evaluated via Cox regression. We evaluated 543 patients who underwent LT 597 times. The SSI rates in the 2002-2006 and 2007-2011 periods were 30% and 24%, respectively (P = 0.21). We identified the following risk factors for SSIs: retransplantation, the transfusion of more than 2 U of blood during LT, dialysis, cold ischemia for >400 minutes, and a cytomegalovirus infection. The overall 60-day survival rate was 79%. Risk factors for 60-day mortality were retransplantation, dialysis, and a longer surgical time. The use of the MELD score modified the incidence and epidemiology of SSIs only during the first year after its adoption. Risks for SSIs were related more to intraoperative conditions and intercurrences after LT than to a patient's status before LT.

Infections after orthotopic liver transplantation in the intensive care unit

PURPOSE

The purpose of the study was to assess the characteristics and risk factors of infections in the early period after orthopic liver transplantation (OLT) among adult patients.

MATERIAL AND METHODS

We studied 75 patients who underwent OLT over 3 years from 2008 to 2010. We recorded all infections that developed during hospitalization in the intensive care unit (ICU) their outcomes, and the possible risk factors.

RESULTS

During the study period in 80 OLT we recorded 19 bloodstream infections (47.5%), 7 ventilator-associated pneumonias (VAP; 17.5%), and 14 intra-abdominal infections (35%). Among the 40 isolated microbes, 72.5% were Gram negative, 25% were Gram positive, and 2.5% were fungi. The median time to developing the infection was 4.95 days (range 2-10). Patients with infections showed longer durations of mechanical ventilation, longer lengths of ICU stay, and lower 1-year survivals.