Infection Complications and Pattern of Bacterial Resistance in Living-Donor Liver Transplantation: A Multicenter Epidemiologic Study in Egypt A. Mukhtara,*, A. Abdelaalb, M. Husseinc, H. Dabousd, I. Fawzyd, G. Obayaha, A. Hasanina, N. Adele, D. Ghaithf, M. Bahaag, A. Abdelaalg, M. Fathyg, and M. El Meteinig From the aDepartment of Anesthesia and Critical Care, Cairo University, Cairo, Egypt; bDepartment of Anesthesia and Critical Care, Beni Suef University, cDepartment of Anesthesia and Critical Care, Theodor Bilharz Research Institute; dDepartment of Hepatology, Ain Shams University; eDepartment of Critical Care, Egypt Air Hospital; fDepartment of Clinical Bacteriology, Cairo University; and the g Department of Surgery, Ain Shams University, Cairo, Egypt
ABSTRACT Introduction. Data on the prevalence and pattern of infection after living-donor liver transplantation (LDLT) are scarce in Egypt. We therefore conducted this study to quantify the incidence, risk factors, and pattern of bacterial resistance post-LDLT in 3 hospitals in Egypt. Patients and Methods. We conducted a retrospective, multicenter study of the medical records of 246 patients who underwent LDLT between January 2006 and April 2011 at 3 transplant centers in Egypt. Results. Of 246 patients enrolled in this study, 127 (52%) developed infectious complications after LDLT, with 416 episodes of infection occurring within 3 months of transplantation. Biliary tract infection was the most common, occurring in 169 (40.6%) patients. The rate of infection with Gram-negative bacteria was higher than that of infection with Gram-positive bacteria (310 [74%] vs 87 [21%]; P < .001). Overall, 75% of Gramnegative isolates were multidrug resistant. Significant independent risk factors for infection were portal vein thrombosis (odds ratio, 2.4; P ¼ .037) and biliary complications (odds ratio, 5.4; P < .001). Conclusions. Our data showed a high-resistance pattern of bacterial infection after LDLT in Egypt. Early biliary complications were an independent risk factor for bacterial infection.
I
NFECTION after liver transplantation is a devastating complication, with an attributable mortality rate of up to 50% [1]. The incidence of infection differs between centers, and the reported incidence ranges from 30% to 70% [2]. Several factors increase the risk of infection posteliver transplantation, including the complexity of the operation, poor general condition of the patient, and use of immunosuppressant drugs [3,4]. These risk factors increase the risk of infection and change the pattern of bacterial resistance. At present, multidrug-resistant (MDR) pathogens are a common cause of nosocomial infection posteliver transplantation [5]. Although there is currently no internationally accepted definition of multiply resistant micro-organisms,
the term MDR is used to denote isolates resistant to all but 1 or 2 classes of antimicrobial agents. The first living-donor liver transplantation (LDLT) in Egypt was performed in 2001 [6]. Since then, many centers have adopted this procedure as the only transplantation modality in patients with end-stage liver disease. Given that data on the prevalence and pattern of infection after LDLT are scarce in Egypt, we conducted the present study to *Address correspondence to Ahmed Mukhtar, 1 Al-Saray Str, Al-Manial, Anesthesia Department, Faculty of Medicine, Cairo University, Cairo 11559, Egypt. E-mail: ahmed.mukhtar@ kasralainy.edu.eg
0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2014.02.022
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1444
Transplantation Proceedings, 46, 1444e1447 (2014)
INFECTION COMPLICATIONS
quantify the incidence of and identify the risk factors for infection post-LDLT in 3 Egyptian hospitals. PATIENTS AND METHODS Patient Population This retrospective, multicenter study was conducted by using the medical records of 246 patients who underwent LDLT between January 2006 and April 2011 at 3 transplant centers in Egypt: the Ain Shams Center for Organ Transplantation, Wady El-Neel Hospital, and Egypt Air Hospital. Ethical approval was obtained from each center, and informed consent was waived because of the retrospective nature of the study.
Standard Posttransplant Management Immunosuppressant Regimen. In the early postoperative period, we used triple-therapy immunosuppression, comprising a steroid, cyclosporine or tacrolimus, and mycophenolate mofetil. In patients with pretransplant renal dysfunction or renal deterioration that occurred intraoperatively or immediately postoperatively, cyclosporine therapy may not be advisable; under these circumstances, induction of immunosuppression with monoclonal antibodies to T cells is appropriate. In patients with hepatocellular cancer, monotherapy with tacrolimus was used to decrease the incidence of recurrence. Antimicrobial Prophylaxis. Piperacillin/tazobactam 4.5 g/d was used for 3 days postoperatively. A polymerase chain reaction assay for cytomegalovirus was performed every 2 weeks until discharge. Pre-emptive therapy with ganciclovir for the prevention of cytomegalovirus disease was initiated if the polymerase chain reaction assay was positive.
Case Identification Postoperative infection was defined as any positive culture result or clinical suspicion within 3 months of transplantation, based on the Centers for Disease Control and Prevention’s definition of a hospitalacquired infection [7]. Bloodstream infection was considered present when micro-organisms were isolated from 1 blood culture. The term MDR was used to refer to pathogens resistant to 3 classes of antibiotics: extended-spectrum penicillins, third-generation cephalosporins, aminoglycosides, carbapenems, and quinolones [8].
Statistical Analysis Categorical variables were analyzed by using the c2 or the Fisher exact test as appropriate. For continuous variables, data are presented as the median (range) and were analyzed by using the Mann-Whitney U test. Risk factors independently associated with infectious complications were identified by using univariate analysis. Differences were considered statistically significant when P values were
ABSTRACT Introduction. Data on the prevalence and pattern of infection after living-donor liver transplantation (LDLT) are scarce in Egypt. We therefore conducted this study to quantify the incidence, risk factors, and pattern of bacterial resistance post-LDLT in 3 hospitals in Egypt. Patients and Methods. We conducted a retrospective, multicenter study of the medical records of 246 patients who underwent LDLT between January 2006 and April 2011 at 3 transplant centers in Egypt. Results. Of 246 patients enrolled in this study, 127 (52%) developed infectious complications after LDLT, with 416 episodes of infection occurring within 3 months of transplantation. Biliary tract infection was the most common, occurring in 169 (40.6%) patients. The rate of infection with Gram-negative bacteria was higher than that of infection with Gram-positive bacteria (310 [74%] vs 87 [21%]; P < .001). Overall, 75% of Gramnegative isolates were multidrug resistant. Significant independent risk factors for infection were portal vein thrombosis (odds ratio, 2.4; P ¼ .037) and biliary complications (odds ratio, 5.4; P < .001). Conclusions. Our data showed a high-resistance pattern of bacterial infection after LDLT in Egypt. Early biliary complications were an independent risk factor for bacterial infection.
I
NFECTION after liver transplantation is a devastating complication, with an attributable mortality rate of up to 50% [1]. The incidence of infection differs between centers, and the reported incidence ranges from 30% to 70% [2]. Several factors increase the risk of infection posteliver transplantation, including the complexity of the operation, poor general condition of the patient, and use of immunosuppressant drugs [3,4]. These risk factors increase the risk of infection and change the pattern of bacterial resistance. At present, multidrug-resistant (MDR) pathogens are a common cause of nosocomial infection posteliver transplantation [5]. Although there is currently no internationally accepted definition of multiply resistant micro-organisms,
the term MDR is used to denote isolates resistant to all but 1 or 2 classes of antimicrobial agents. The first living-donor liver transplantation (LDLT) in Egypt was performed in 2001 [6]. Since then, many centers have adopted this procedure as the only transplantation modality in patients with end-stage liver disease. Given that data on the prevalence and pattern of infection after LDLT are scarce in Egypt, we conducted the present study to *Address correspondence to Ahmed Mukhtar, 1 Al-Saray Str, Al-Manial, Anesthesia Department, Faculty of Medicine, Cairo University, Cairo 11559, Egypt. E-mail: ahmed.mukhtar@ kasralainy.edu.eg
0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2014.02.022
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1444
Transplantation Proceedings, 46, 1444e1447 (2014)
INFECTION COMPLICATIONS
quantify the incidence of and identify the risk factors for infection post-LDLT in 3 Egyptian hospitals. PATIENTS AND METHODS Patient Population This retrospective, multicenter study was conducted by using the medical records of 246 patients who underwent LDLT between January 2006 and April 2011 at 3 transplant centers in Egypt: the Ain Shams Center for Organ Transplantation, Wady El-Neel Hospital, and Egypt Air Hospital. Ethical approval was obtained from each center, and informed consent was waived because of the retrospective nature of the study.
Standard Posttransplant Management Immunosuppressant Regimen. In the early postoperative period, we used triple-therapy immunosuppression, comprising a steroid, cyclosporine or tacrolimus, and mycophenolate mofetil. In patients with pretransplant renal dysfunction or renal deterioration that occurred intraoperatively or immediately postoperatively, cyclosporine therapy may not be advisable; under these circumstances, induction of immunosuppression with monoclonal antibodies to T cells is appropriate. In patients with hepatocellular cancer, monotherapy with tacrolimus was used to decrease the incidence of recurrence. Antimicrobial Prophylaxis. Piperacillin/tazobactam 4.5 g/d was used for 3 days postoperatively. A polymerase chain reaction assay for cytomegalovirus was performed every 2 weeks until discharge. Pre-emptive therapy with ganciclovir for the prevention of cytomegalovirus disease was initiated if the polymerase chain reaction assay was positive.
Case Identification Postoperative infection was defined as any positive culture result or clinical suspicion within 3 months of transplantation, based on the Centers for Disease Control and Prevention’s definition of a hospitalacquired infection [7]. Bloodstream infection was considered present when micro-organisms were isolated from 1 blood culture. The term MDR was used to refer to pathogens resistant to 3 classes of antibiotics: extended-spectrum penicillins, third-generation cephalosporins, aminoglycosides, carbapenems, and quinolones [8].
Statistical Analysis Categorical variables were analyzed by using the c2 or the Fisher exact test as appropriate. For continuous variables, data are presented as the median (range) and were analyzed by using the Mann-Whitney U test. Risk factors independently associated with infectious complications were identified by using univariate analysis. Differences were considered statistically significant when P values were
