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

Freire, Maristela Pinheiro MSc; Oshiro, Isabel C. V. S. MSc; Pierrotti, Ligia C. PhD; Bonazzi, Patricia R. PhD; de Oliveira, Larissa M. PhD; Song, Alice T. W. PhD; Camargo, Carlos H. PhD; van der Heijden, Inneke M. PhD; Rossi, Flavia PhD; Costa, Silvia F.; D'Albuquerque, Luiz A. C. PhD; Abdala, Edson PhD

doi: 10.1097/TP.0000000000001620
Original Clinical Science-Liver

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.

The authors of this prospective study establish risk factors for carbapenem-resistant Enterobacteriaceae, an emergent microorganism of infections after liver transplantation, highlighting that colonization before transplantation is one of the main risk factors that could potentially be targetted with adequate antibiotic prophylaxis.

1 Infection Control Team, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.

2 Department of Infectious Diseases, University of São Paulo School of Medicine, São Paulo, Brazil.

3 Liver and Intestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

4 Microbiology Research Laboratory-LIM54, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.

5 Centro de Bacteriologia, Instituto Adolfo Lutz, São Paulo, Brazil.

6 Microbiology Laboratory, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.

Received 9 August 2016. Revision received 11 October 2016.

Accepted 7 November 2016.

This study received financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP, São Paulo Research Foundation; Grant no. 2010/02267-6).

The authors declare no conflicts of interest.

M.P.F. participated in the performance of the research, in the writing of the article and in data analysis. I.C.V.SO participated in the performance of the research and in the data collection. L.C.P. participated in the performance of the research and in the writing of the article. P.R.B. participated in the performance of the research. L.M.D.O. participated in the performance of the research. A.W.S. participated in the performance of the research. C.H.C participated in the performance of the research. I.M.v.d.H. participated in the performance of the research. F.R. participated in the performance of the research. S.F. C. participated in the performance of the research and in the revised the article. L.A.C.D'A. participated as general supervision of transplant unit and in the performance of the research. E.A. participated in research design, in the performance of the research and in the writing of the article.

Correspondence: Maristela Pinheiro Freire, Infection Control Team, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil. (maristelapf@uol.com.br).

Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.transplantjournal.com).

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