Quality of Surgical Care in Liver and Small-Bowel Transplant: Approach to Risk Assessment and Antibiotic Prophylaxis

Abstract

In August 2002, The Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention implemented the National Surgical Infection Prevention project. The goal of the project was to decrease the morbidity and mortality associated with postoperative surgical site infections through appropriate selection and timing of administration and discontinuation of prophylactic antimicrobials. The National Surgical Infection Prevention project, however, excluded transplant surgeries from its focus because of the lack of randomized clinical trials comparing antimicrobial agents. The goals of this article are to (1) provide a framework for risk factors associated with surgical site infections in liver, small-bowel, and multivisceral transplants; (2) review general principles of the appropriate antimicrobial prophylaxis; (3) provide a framework for developing a triage of liver, small-bowel, and multivisceral transplant candidates for appropriate antibiotic prophylaxis; and (4) develop an approach to further quality improvements in transplant surgical care. A multidisciplinary team produced recommendations for antibacterial prophylaxis and monitoring.

Duration of Perioperative Antimicrobial Prophylaxis in Orthotopic Liver Transplantation Patients

“…1,2 The incidence of posttransplant infections range from 10% to 37% in this patient population. 1 –6 The first 4 weeks posttransplant are the most crucial, as the risk of infection is the highest. 1 –6 Surgical site infections (SSIs) are concerning given that 1 in 3 patients develop an infection posttransplant.…”

Intraoperative Versus Extended Antibiotic Prophylaxis in Liver Transplant Surgery: A Randomized Controlled Pilot Trial

“…(1) Historically, liver transplant recipients have a marked increase in rates of SSIs compared with other solid organ transplant patients, with rates ranging from 9% to 79% for all liver transplants and 18% to 38% in first-time transplant recipients. (1)(2)(3)(4)(5)(6)(7) This is also notably higher than general surgical cases, reported to be approximately 4%. (8) SSI is the most costly health care-associated infection, totaling US $3.3 billion in 2009.…”

“…Surgical site infections (SSIs) are a significant cause of morbidity and mortality in postsurgical patients, specifically following liver transplantation . Historically, liver transplant recipients have a marked increase in rates of SSIs compared with other solid organ transplant patients, with rates ranging from 9% to 79% for all liver transplants and 18% to 38% in first‐time transplant recipients . This is also notably higher than general surgical cases, reported to be approximately 4% .…”

“…In 1999, the Centers for Disease Control and Prevention (CDC) issued guidelines specifically addressing SSI risk factors and prevention as a way to methodically reduce SSI rates, but they do not specifically address transplant patients, who are a unique, medically complicated population due to the use of immunosuppression . Updated 2017 CDC guidelines and 2016 World Health Organization (WHO) Guidelines for Prevention of Surgical Site Infection also do not address this unique population .…”

“…(9) In 1999, the Centers for Disease Control and Prevention (CDC) issued guidelines specifically addressing SSI risk factors and prevention as a way to methodically reduce SSI rates, but they do not specifically address transplant patients, who are a unique, medically complicated population due to the use of immunosuppression. (2,10) Updated 2017 CDC guidelines and 2016 World Health Organization (WHO) Guidelines for Prevention of Surgical Site Infection also do not address this unique population. (11,12) Orthotopic liver transplantation (OLT) patients have a prolonged duration of anesthesia, (1) extensive operative times, surgical complexity, biliary disruption, potential need for multiple blood products, and mandatory postoperative immunosuppression.…”