Antibiotic Stewardship Based on Colonization with Multi-Drug-Resistant Bacteria in Liver Transplantation: A Narrative Review
Abstract
1. Introduction
2. Materials and Methods
3. Multi-Drug-Resistant Infections in Liver Transplant Recipients—Epidemiology
4. Risk Factors for Acquisition of Multi-Drug-Resistant Organisms Among Liver Transplant Recipients
5. Liver Transplant Recipients’ Prophylaxis
6. Expert Opinion
- Close monitoring for signs indicative of peritonitis, ascites superinfections, cholangitis, and hepatic abscesses by employing radiological evaluation using abdominal ultrasound and/or CT scans.
- The surveillance of inflammatory signs at the surgical site.
- Monitoring invasive devices such as central venous lines, drainage sites, and bladder catheters.
- For patients with severe clinical conditions but negative MDRO screening results, we suggest managing the infection on the basis of the local epidemiology. Antibiotics targeting MDROs should be chosen if the MDRO prevalence is greater than or equal to 20%, assuming none of the previously mentioned risk factors are present. If at least one of these risk factors is identified, MDRO coverage may be considered, even when the local prevalence is below 20%.
- For patients with positive MDRO screening results but uncomplicated infections (as assessed on the basis of clinical scoring systems like the NEWS—National Early Warning Score—or MEWS—Modified Early Warning Score [43]), overtreatment is a common risk, and so we recommend initiating antimicrobial therapy based on the suspected source of infection and local microbiological epidemiology, without necessarily considering the patient’s MDRO carrier status. In our opinion, a history of MDRO bacteremia constitutes an exception, as in this case antibiotic use should be based on that previous occurrence. Close monitoring of the patient is crucial in this instance, and it requires careful clinical and laboratory monitoring every 24 h. This ensures, on one hand, the proper implementation of antimicrobial stewardship practices (such as de-escalation therapy); on the other hand, it allows for ongoing reassessment and, if necessary, the broadening of the antimicrobial spectrum.
Author Contributions
Funding
Conflicts of Interest
References
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Pre-Transplant Factors | Perioperative Factors | Post-Transplant Factors |
---|---|---|
Age (>45 yo) | Duration of surgery | ICU stay > 48 h |
Diabetes | Intraoperative blood loss ≥1500 mL | Long hospital stay |
Renal failure and dyalisis | Prolonged cold ischemia time | Indwelling devices |
Malnutrition | Biliary complications | Early allograft dysfunction |
High MELD score | Surgical re-exploration | Rejection |
Pre-transplant infections |
Risk Factors for MDRO Infections |
---|
MDRO colonization |
High MELD score (>25) |
Long ICU stay and hospitalization |
Post-transplant renal failure requiring CRRT |
Broad-spectrum antimicrobials use |
Invasive procedures |
Indwelling devices |
Blood loss during surgery greater than 1.5 L |
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Zuccaro, V.; Giordani, P.; Binda, F.; Asperges, E.; Farina, E.; Viganò, M.; Gervasi, E.; Pagani, E.; Fagiuoli, S.; Bruno, R. Antibiotic Stewardship Based on Colonization with Multi-Drug-Resistant Bacteria in Liver Transplantation: A Narrative Review. Microorganisms 2024, 12, 2493. https://doi.org/10.3390/microorganisms12122493
Zuccaro V, Giordani P, Binda F, Asperges E, Farina E, Viganò M, Gervasi E, Pagani E, Fagiuoli S, Bruno R. Antibiotic Stewardship Based on Colonization with Multi-Drug-Resistant Bacteria in Liver Transplantation: A Narrative Review. Microorganisms. 2024; 12(12):2493. https://doi.org/10.3390/microorganisms12122493
Chicago/Turabian StyleZuccaro, Valentina, Paola Giordani, Francesca Binda, Erika Asperges, Elisa Farina, Mauro Viganò, Elena Gervasi, Elisabetta Pagani, Stefano Fagiuoli, and Raffaele Bruno. 2024. "Antibiotic Stewardship Based on Colonization with Multi-Drug-Resistant Bacteria in Liver Transplantation: A Narrative Review" Microorganisms 12, no. 12: 2493. https://doi.org/10.3390/microorganisms12122493
APA StyleZuccaro, V., Giordani, P., Binda, F., Asperges, E., Farina, E., Viganò, M., Gervasi, E., Pagani, E., Fagiuoli, S., & Bruno, R. (2024). Antibiotic Stewardship Based on Colonization with Multi-Drug-Resistant Bacteria in Liver Transplantation: A Narrative Review. Microorganisms, 12(12), 2493. https://doi.org/10.3390/microorganisms12122493