Association between gut colonization of vancomycin‐resistant enterococci and liver transplant outcomes

Abstract

Background: Vancomycin-resistant enterococci (VRE) colonization is common in liver transplant recipients and has been associated with worse posttransplant outcomes. Methods:We conducted a retrospective cohort study at the University of Alberta Hospital including patients who underwent a liver transplant between September 2014 and December 2017.Results: Of 343 patients, 68 (19.8%) had pretransplant VRE colonization and 27 (27/275, 9.8%) acquired VRE posttransplant, 67% were males and the median age was 56.5 years. VRE colonized patients at baseline had higher MELD scores and required longer posttransplant hospitalization. VRE colonization was associated with increased risk of early acute kidney injury (AKI) (64% vs. 52%, p = .044), clinically significant bacterial/fungal infection (29% vs. 17%, p = .012) and invasive VRE infection (5% vs. 1%, p = .017). Mortality at 2 years was 13% in VRE-colonized versus 7% in noncolonized (p = .085). On multivariate analysis, VRE colonization increased the risk of posttransplant AKI (HR 1.504, 95% CI: 1.077-2.100, p = .017) and clinically significant bacterial or fungal infection at 6 months (HR 2.038, 95% CI: 1.222-3.399, p = .006), and was associated with nonsignificant trend toward increased risk of mortality at 2 years posttransplant (HR 1.974 95% CI 0.890-4.378; p = .094).Conclusions: VRE colonization in liver transplant patients is associated with increased risk of early AKI, clinically significant infections, and a trend toward increased mortality at 2 years.

Pre‐transplant multidrug‐resistant infections in liver transplant recipients‐epidemiology and impact on transplantation outcome

“…27 Additionally, a recent study failed to identify differences between VRE-colonized and non-colonized patients regarding post-LT survival. 20,28 An interesting finding in our cohort was the high post-LT mortality rate among patients who had ESBL-producing Enterobacterales infection before LT (51%), which was higher than other pre-LT MDRO infections (39%) and higher than the mortality of patients with pre-…”

“…Regarding VRE colonization, Russell et al reported that VRE colonization increased the risk of death in LT recipients and candidates by more than two‐fold, this was a cross‐section study in ICU and there is no information about the follow up of LT candidates after transplantation 27 . Additionally, a recent study failed to identify differences between VRE‐colonized and non‐colonized patients regarding post‐LT survival 20,28 …”

Microbiome compositions and fecal metabolite concentrations predict post-operative infection in liver transplant recipients

“…The clinical impact of these infections is compounded by rising rates of antibiotic resistance, with vancomycin resistant Enterococcus faecium (VRE) and multiple drug resistant Enterobacterales making outsized contributions to morbidity and mortality. (12,13) Enterococcus and Enterobacterales species are normal inhabitants of the human gut microbiota. (14,15) In healthy individuals, these facultative anaerobes compose a small fraction of the microbiota but are capable of markedly expanding following loss of microbiota diversity.…”

“…The clinical impact of these infections is compounded by rising rates of antibiotic resistance, with vancomycin resistant Enterococcus faecium (VRE) and multiple drug resistant Enterobacterales making outsized contributions to morbidity and mortality. (12, 13)…”

“…Despite advances in antibiotic prophylaxis, patient selection, donor screening, organ preservation, and surgical technique, infection remains a leading cause of morbidity and mortality. (11)(12)(13) Enterococcus species and members of the order Enterobacterales, such as Escherichia coli and Klebsiella pneumonia, remain among the most common causes of infection in the post-transplant period. The clinical impact of these infections is compounded by rising rates of antibiotic resistance, with vancomycin resistant Enterococcus faecium (VRE) and multiple drug resistant Enterobacterales making outsized contributions to morbidity and mortality.…”