Surgical site infection in the Liver Transplant Program in Uruguay
High incidence of multiresistant and extremely resistant gram-negative bacilli
Keywords:
LIVER TRANSPLANTATION, SURGICAL WOUND INFECTION, PROPHYLAXIS
Abstract
Introduction: surgical site infection in liver transplant results in high morbimortality for these patients.
Objective: to learn about the incidence of surgical site infection, identify the microorganisms involved and the factors that favor it with the purpose of optimizing our prophylactic strategies.
Method: cohort study where patients with liver transplant were prospectively included in our national database. Period of study: July 14, 2009 through May 31, 2013. Statistical analysis: we used chi squared test. If the value in the contingency table was lower than or equal to 5 we used the exact Fisher test. Values p < 0,05 were considered significant.
Results: sixty-five patients underwent transplant during this period. Relative frequency accumulated for surgical site infection was 12 patients (18.46%); temporal distribution evidences incidence grew in the last 12 months during which seven episodes took place (58%) out of all surgical site infection episodes. Median time for episodes to appear was 17 days. Out of all patients with surgical site infection, 7 evidenced risk factors for multiresistant micro-organisms before transplant. Sixteen micro-organisms were isolated, 12 of them corresponded to gram-negative bacilli: (Klebsiella spp, n = 6), (Acinetobacter baumannii, n = 2), (Enterobacter cloacae, n = 1), (Aeromonas spp, n = 1), (Pseudomonas aeruginosa, n = 1), (E. coli, n = 1). In terms of their resistance profile: ten patients showed a multiresistant and extremely resistant profile.
Conclusions: one out of five patients presented surgical site infection in our center, and the incidence of gram-negative, multiresistant and extremely resistant bacilli was high.
References
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(21) Shi SH, Kong HS, Xu J, Zhang WJ, Jia CK, Wang WL, et al. Multidrug resistant gram-negative bacilli as predominant bacteremic pathogens in liver transplant recipients. Transpl Infect Dis 2009; 11(5):405-12.
(22) Patel G, Huprikar S, Factor SH, Jenkins SG, Calfee DP. Outcomes of carbapenem-resistant Klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies. Infect Control Hosp Epidemiol 2008; 29(12): 1099-106.
(23) Bergamasco MD, Barroso Barbosa M, de Oliveira Garcia D, Cipullo R, Moreira JC, Baia C, et al. Infection with Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae in solid organ transplantation. Transpl Infect Dis 2012; 14(2):198-205.
(24) Wiesmayr S, Stelzmueller I, Mark W, Muehlmann G, Tabarelli W, Tabarelli D, et al. Experience with the use of piperacillin-tazobactam in pediatric non-renal solid organ transplantation. Pediatr Transplant 2007; 11(1):38-48.
(25) Tanaka K, Arakawa S, Miura T, Shigemura K, Nakano Y, Takahashi S, et al. Analysis of isolated bacteria and short-term antimicrobial prophylaxis with tazobactam-piperacillin (1:4 ratio) for prevention of postoperative infections after radical cystectomy. J Infect Chemother 2012; 18(2):175-9.
(26) Bulitta JB, Duffull SB, Kinzig-Schippers M, Holzgrabe U, Stephan U, Drusano GL, et al. Systematic comparison of the population pharmacokinetics and pharmacodynamics of piperacillin in cystic fibrosis patients and healthy volunteers. Antimicrob Agents Chemother 2007; 51(7):2497-507.
(27) Roberts JA, Roberts MS, Robertson TA, Dalley AJ, Lipman J. Piperacillin penetration into tissue of critically ill patients with sepsis—bolus versus continuous administration? Crit Care Med 2009; 37(3):926-33.
(28) Dulhunty JM, Roberts JA, Davis JS, Webb SA, Bellomo R, Gomersall C, et al. Continuous infusion of beta-lactam antibiotics in severe sepsis: a multicenter double-blind, randomized controlled trial. Clin Infect Dis 2013; 56(2):236-44.
(29) Acosta García H, Gil-Navarro MV, Cotrina Luque J, Cisneros Herreros JM, Lepe Jiménez JA, Paloma JB. Piperacilina-tazobactam en perfusión continua o expandida frente a perfusión intermitente. Farm Hosp 2012; 36(5):424-9.
(30) Fleischhack G, Schmidt-Niemann M, Wulff B, Havers W, Marklein G, Hasan C, et al. Piperacillin, beta-lactam inhibitor plus gentamicin as empirical therapy of a sequential regimen in febrile neutropenia of pediatric cancer patients. Support Care Cancer 2001; 9(5):372-9.
(31) Zelenitsky SA, Silverman RE, Duckworth H, Harding GK. A prospective, randomized, double-blind studyof single high dose versus multiple standard dose gentamicin both in combination withmetronidazole for colorectal surgicalprophylaxis. J Hosp Infect 2000; 46(2):135-40.
(32) Zelenitsky SA, Ariano RE, Harding GK, Silverman RE. Antibiotic pharmacodynamics in surgical prophylaxis: an association between intraoperative antibiotic concentrations and efficacy. Antimicrob Agents Chemother 2002; 46(9): 3026-30.
(2) Scottish Intercollegiate Guidelines Network. Antibiotic prophylaxis in surgery: a national clinical guideline. SIGN 2008; 104. Disponible en: www.sign.ac.uk/pdf/sign104.pdf. Consulta: octubre 2013.
(3) Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38(12):1706-15.
(4) American Society of Health-System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America;Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70(3):195-283.
(5) Romanelli RM de Castro, Clemente W Trindade, Lima SS Soares, Martinho GH, Furtado S Rodrigues, Menezes TC de Oliveira, et al. Notificação de infecções hospitalares de pacientes submetidos a transplante hepático: casuística de cinco anos do Hospital das Clínicas da UFMG. Rev Méd Minas Gerais 2008; 18(4):243-51.
(6) Freire MP, Soares Oshiro IC, Bonazzi PR, Guimarães T, Ramos Figueira ER, Bacchella T, et al. 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. Liver Transpl 2013; 19(9):1011-9.
(7) Cervera C, Linares L, Bou G, Moreno A. Multidrug-resistant bacterial infection in solid organ transplant recipients. Enferm Infecc Microbiol Clin 2012; 30(Suppl 2):40-8.
(8) Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999; 20(4):250-78.
(9) Centers for Disease Control and Prevention. Surgical Site Infection (SSI) Event: 2014. Atlanta, GA: CDC, 2014. Disponible en: http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. Consulta: febrero 2014.
(10) Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012; 18(3):268-81.
(11) Uruguay. Dirección Nacional de Sanidad de las Fuerzas Armadas. Hospital Central de las Fuerzas Armadas. Servicio de Trasplante Hepático. Prevención en el período perioperatorio de trasplante hepático. Montevideo: DNSFFAA, 2009.
(12) Sociedad Argentina de Infectología. Evaluación infectológica para receptores de trasplante de órganos sólidos: seguimiento inicial post-trasplante. Guía de recomendaciones 2011. Buenos Aires: SADI, 2012. Disponible en: https://www.dropbox.com/s/ysm3cr1tkx975sf/Documento%20Receptor%202011%20V3.pdf. Consulta: octubre 2013.
(13) Kibbler CC. Infections in liver transplantation: risk factors and strategies for prevention. J Hosp Infect 1995; 30 Suppl:209-17.
(14) España. Hospital Universitario 12 de Octubre. Prevención de la infección en los programas de Trasplante de órgano sólido. Madrid: Hospital Universitario 12 de Octubre, 2010.
(15) Soave R. Prophylaxis strategies for solid-organ transplantation. Clin Infect Dis 2001; 33(Suppl 1):S26-31.
(16) García-Prado E, Cordero E, Álamo JM, Gómez MA, Pascasio JM, Sánchez M, et al. Estudio descriptivo de las complicaciones infecciosas en 109 receptores de trasplantes hepáticos consecutivos. Enferm Infecc Microbiol Clin 2009; 27(4):199-205.
(17) de Oliveira AC, Braz NJ, Ribeiro MM. Incidência da infecção do sitio cirúrgico em um hospital universitario. Cienc Cuid Saude 2007; 6(4):486-93.
(18) García Prado ME, Matia EC, Ciuro FP, Díez-Canedo JS, Sousa Martín JM, Porras López FM, et al. Surgical site infection in liver transplant recipients: impact of the type of perioperative prophylaxis. Transplantation 2008; 85(12):1849- 54.
(19) Medina JC, Antelo V, Nin M, Arteta Z, González F, Bazet C, et al. Infecciones bacterianas en pacientes receptores de trasplante renal y reno-páncreas: alta incidencia de microorganismos multirresistentes. Rev Méd Urug 2012; 28(3): 190-8.
(20) Kim YJ, Yoon JH, Kim SI, Hong KW, Kim JI, Choi JY, et al. High mortality associated with Acinetobacter species infection in liver transplant patients. Transplant Proc 2011; 43(6):2397-9.
(21) Shi SH, Kong HS, Xu J, Zhang WJ, Jia CK, Wang WL, et al. Multidrug resistant gram-negative bacilli as predominant bacteremic pathogens in liver transplant recipients. Transpl Infect Dis 2009; 11(5):405-12.
(22) Patel G, Huprikar S, Factor SH, Jenkins SG, Calfee DP. Outcomes of carbapenem-resistant Klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies. Infect Control Hosp Epidemiol 2008; 29(12): 1099-106.
(23) Bergamasco MD, Barroso Barbosa M, de Oliveira Garcia D, Cipullo R, Moreira JC, Baia C, et al. Infection with Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae in solid organ transplantation. Transpl Infect Dis 2012; 14(2):198-205.
(24) Wiesmayr S, Stelzmueller I, Mark W, Muehlmann G, Tabarelli W, Tabarelli D, et al. Experience with the use of piperacillin-tazobactam in pediatric non-renal solid organ transplantation. Pediatr Transplant 2007; 11(1):38-48.
(25) Tanaka K, Arakawa S, Miura T, Shigemura K, Nakano Y, Takahashi S, et al. Analysis of isolated bacteria and short-term antimicrobial prophylaxis with tazobactam-piperacillin (1:4 ratio) for prevention of postoperative infections after radical cystectomy. J Infect Chemother 2012; 18(2):175-9.
(26) Bulitta JB, Duffull SB, Kinzig-Schippers M, Holzgrabe U, Stephan U, Drusano GL, et al. Systematic comparison of the population pharmacokinetics and pharmacodynamics of piperacillin in cystic fibrosis patients and healthy volunteers. Antimicrob Agents Chemother 2007; 51(7):2497-507.
(27) Roberts JA, Roberts MS, Robertson TA, Dalley AJ, Lipman J. Piperacillin penetration into tissue of critically ill patients with sepsis—bolus versus continuous administration? Crit Care Med 2009; 37(3):926-33.
(28) Dulhunty JM, Roberts JA, Davis JS, Webb SA, Bellomo R, Gomersall C, et al. Continuous infusion of beta-lactam antibiotics in severe sepsis: a multicenter double-blind, randomized controlled trial. Clin Infect Dis 2013; 56(2):236-44.
(29) Acosta García H, Gil-Navarro MV, Cotrina Luque J, Cisneros Herreros JM, Lepe Jiménez JA, Paloma JB. Piperacilina-tazobactam en perfusión continua o expandida frente a perfusión intermitente. Farm Hosp 2012; 36(5):424-9.
(30) Fleischhack G, Schmidt-Niemann M, Wulff B, Havers W, Marklein G, Hasan C, et al. Piperacillin, beta-lactam inhibitor plus gentamicin as empirical therapy of a sequential regimen in febrile neutropenia of pediatric cancer patients. Support Care Cancer 2001; 9(5):372-9.
(31) Zelenitsky SA, Silverman RE, Duckworth H, Harding GK. A prospective, randomized, double-blind studyof single high dose versus multiple standard dose gentamicin both in combination withmetronidazole for colorectal surgicalprophylaxis. J Hosp Infect 2000; 46(2):135-40.
(32) Zelenitsky SA, Ariano RE, Harding GK, Silverman RE. Antibiotic pharmacodynamics in surgical prophylaxis: an association between intraoperative antibiotic concentrations and efficacy. Antimicrob Agents Chemother 2002; 46(9): 3026-30.
Published
2014-06-30
How to Cite
1.
Prieto J, Medina Presentado JC, López Cáceres M, Scalone P, Harguindeguy M, Leites A, Etlin A, Menéndez J, Valverde M, Castelli J, Rando K, Grecco G, Abelleira M, González S, Gerona S. Surgical site infection in the Liver Transplant Program in Uruguay. Rev. Méd. Urug. [Internet]. 2014Jun.30 [cited 2024Nov.8];30(2):112-2. Available from: http://www2.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/250
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