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Abstract

Background
Invasive primary surgical site infections (IP-SSI) are a severe complication of liver transplant. Identification of risks for IP-SSI is critical to IP-SSI prevention.
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Methods
All adult single liver transplants performed at Duke University Hospital in 2015-2019 were reviewed for IP-SSI occurring within 3 months of transplant. Antimicrobial prophylaxis regimens are noted in Table 1. Risks for IP-SSI were identified via backward stepwise multiple logistic regression using an entry cut-off of 0.01. Repeat transplantation, split liver, transplant surgery >8 hrs, Roux-en-Y biliary anastomosis, anastomotic leak, and repeat abdominal surgery within 3 months were entered into the initial model. Prior hepato-biliary surgery, pre-transplant immunosuppressive therapy, and living donor status were excluded due to potential collinearity with “repeat transplantation” and “split liver”. A two-sided p-value of < 0.05 was considered statistically significant.
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Results
Among 380 single adult liver transplants performed, 25 (6.6%) IP-SSI were identified. IP-SSI were associated with longer hospital stay (25.0 vs. 9.0 days, p < 0.01). Among IP-SSI, 13 (52.0%) were polymicrobial and 12 (48.0%) monomicrobial. IP-SSI microbiology is detailed in Table 2. Fluconazole resistance occurred in 5 (45.5%) Candida isolates among which 3 (60.0%) broke through individualized echinocandin prophylaxis. Baseline recipient characteristics are shown in Table 3. Per Table 4, repeat transplantation, Roux-en-Y biliary anastomosis, anastomotic leak, and repeat abdominal surgery were significantly associated with IP-SSI risk.
Baseline characteristics of adult patients who underwent a single liver transplant at Duke University Hospital in the period 1 Jan 2015 - 31 Dec 2019 stratified by the diagnosis of invasive primary surgical site infection (IP-SSI) within 90 days of transplant surgery. BMI, body mass index; HBV, hepatitis b virus; HCV, hepatitis c virus; MELD, model for end-stage liver disease; NASH, non-alcoholic steatohepatitis; PRBC, packed red blood cells
Table 3.

Baseline characteristics of adult patients who underwent a single liver transplant at Duke University Hospital in the period 1 Jan 2015 - 31 Dec 2019 stratified by the diagnosis of invasive primary surgical site infection (IP-SSI) within 90 days of transplant surgery. BMI, body mass index; HBV, hepatitis b virus; HCV, hepatitis c virus; MELD, model for end-stage liver disease; NASH, non-alcoholic steatohepatitis; PRBC, packed red blood cells

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Conclusion

The overall IP-SSI rate in our cohort is low compared to published literature supporting effectiveness of current antimicrobial prophylaxis. In this setting, factors that portend risk for IP-SSI are related to the surgical procedures, thus are not easily modifiable. Patients with repeat transplantation, Roux-en-Y biliary anastomosis, anastomotic leak, and repeat abdominal surgery within 3 months of transplantation must be monitored closely for development of IP-SSI. However, the appropriateness of current prophylaxis regimens should be further evaluated given the high prevalence of drug-resistant pathogens causing breakthrough IP-SSI.

Disclosures

Matt Harris, PharmD, MHS, wolters kluer: Advisor/Consultant Barbara D. Alexander, MD, F2G Pharmaceuticals: Advisor/Consultant|HealthTrackRx: Advisor/Consultant|HealthTrackRx: Board Member|Leadiaint: Grant/Research Support|Merck: Advisor/Consultant|Scynexis: Grant/Research Support|Thermofisher: Advisor/Consultant

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Author notes

Session: 145. HAI: Surgical Site Infections

Friday, October 13, 2023: 12:15 PM

© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
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