Daptomycin perioperative prophylaxis for the prevention of vancomycin‐resistant Enterococcus infection in colonized liver transplant recipients

Abstract

Background: Vancomycin-resistant Enterococcus (VRE)-colonized liver transplantation (LT) recipients have increased post-LT morbidity, mortality, and higher rates of VRE infections compared with their non-colonized counterparts. Pre-LT screening for VRE colonization and inclusion of daptomycin in the perioperative antibiotic prophylaxis regimen may mitigate this risk. Methods: We performed a retrospective chart review of liver transplant recipients aged ≥ 18 years between 2013 and August 2019 to identify pre-LT VRE-colonized recipients and whether they received daptomycin perioperative prophylaxis (DPP). Demographic and clinical characteristics, including risk factors for VRE infection, were collected. Outcomes measured were VRE-related infection and all-cause mortality within 90 days of LT. Results: Of the 27 VRE-colonized liver transplant recipients within the study period, 25 received DPP. All recipients were admitted to the intensive care unit postoperatively, six (24%) required reoperation, fifteen (60%) required renal replacement therapy, and eight (32%) experienced postoperative hemorrhage within 90 days posttransplant. Two recipients (8%) experienced acute cellular rejection, but no primary graft failure was seen within 90 days. Among those who received DPP, no infections related to VRE or death was seen within 90 days of LT. The two VRE-colonized recipients who did not receive DPP both developed VRE bacteremia in the early post-LT period. Conclusion: Despite having multiple risk factors for post-LT VRE infection, VREcolonized recipients who received DPP did not develop VRE-related infections in the first 90 days post-LT. Our experience demonstrates that pre-LT VRE screening and DPP may be associated with a reduction in VRE infection in the early post-LT period, but this strategy warrants further evaluation in prospective studies. K E Y W O R D S daptomycin, perioperative prophylaxis, vancomycin-resistant Enterococcus

Rectal screening for azole non‐susceptible Candida species in patients undergoing liver transplantation

“…Nonetheless, tailored antimicrobial prophylaxis protocols based on peri-transplant screening for multidrug-resistant organisms have the potential to reduce post-transplant infections in LT recipients, as was suggested by a study at our transplant center evaluating the use of daptomycin perioperative prophylaxis for the prevention of vancomycinresistant Enterococcus (VRE) infection in colonized LT recipients who underwent VRE screening prior to transplant. 14 Similarly, there is evidence supporting the use of prophylactic vancomycin in LT recipients with methicillin-resistant Staphylococcus aureus colonization or prior infection. 15,16 Therefore, the efficacy of tailored prophylaxis for ANSC based on peri-transplant screening among LT merits further evaluation.…”

Rates and causative pathogens of surgical site infections attributed to liver transplant procedures and other hepatic, biliary, or pancreatic procedures, 2015‐2018

“…[35][36][37][38][39] Some centers screen patients pre-transplant to detect colonization with resistant organisms and tailor perioperative prophylaxis. 40 Other approaches to prevent colonization and infection of patients before and after transplantation are needed. These include antimicrobial stewardship and infection control interventions in the peritransplant period 41 ; increased focus on improving antimicrobial use among patients with liver disease who are expected to require transplantation in the future may also be warranted.…”

Outpatient and peri‐operative antibiotic stewardship in solid organ transplantation

“…One study evaluating patients undergoing liver transplantation in the setting of known vancomycin‐resistant enterococci (VRE) colonization suggests that there may be benefit in broadening prophylaxis to include the addition of daptomycin. 10 Expert opinion suggests benefit in expansion of coverage to include activity against resistant Gram‐negative pathogens when there is known colonization identified prior to transplantation but this has not been substantiated with robust randomized clinical trials. 5 Pre‐surgical colonization with methicillin‐resistant Staphylococcus aureus has been tied to increased risk of surgical site infection in other procedure types and may benefit from the addition of the targeted therapy such as vancomycin.…”