Carbapenem-resistant<i>Klebsiella pneumoniae</i>colonization at liver transplantation: A management challenge

Giannella, Maddalena; Morelli, Cristina; Cristini, Francesco; Ercolani, Giorgio; Cescon, Matteo; Bartoletti, Michele; Tedeschi, Sara; Pasqualini, Eddi; Lewis, Russell E.; Pinna, Antonio Daniele; Viale, Pierluigi

doi:10.1002/lt.23857

Cited by 7 publications

(4 citation statements)

References 4 publications

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“…In a previous case-control study, we found that patients colonized before LT did not have a higher incidence of CR-KP infection after LT versus non-colonized patients. However, 6/20 patients of the control group acquired CR-KP colonization after LT (28). Here, we confirmed these data and show that acquisition of CR-KP colonization after LT was strongly associated with developing an infection.…”

Section: Discussionsupporting

confidence: 85%

Risk Factors for Infection With Carbapenem-Resistant Klebsiella pneumoniae

Giannella

Bartoletti

Morelli

et al. 2015

American Journal of Transplantation

108

101

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Improved understanding of risk factors associated with carbapenem-resistant-Klebsiella pneumoniae (CR-KP) infection after liver transplantation (LT) can aid development of effective preventive strategies. We performed a prospective cohort study of all adult patients undergoing LT at our hospital during 30-month period to define risk factors associated with CR-KP infection. All patients were screened for CR-KP carriage by rectal swabs before and after LT. No therapy was administered to decolonize or treat asymptomatic CR-KP carriers. All patients were monitored up to 180 days after LT. Of 237 transplant patients screened, 41 were identified as CR-KP carriers (11 at LT, 30 after LT), and 20 developed CR-KP infection (18 bloodstream-infection, 2 pneumonia) a median of 41.5 days after LT. CR-KP infection rates among patients non-colonized, colonized at LT, and colonized after LT were 2%, 18.2% and 46.7% (p < 0.001). Independent risk factors for CR-KP infection identified by multivariate analysis, included: renal-replacement-therapy; mechanical ventilation > 48 h; HCV recurrence, and colonization at any time with CR-KP. Based on these four variables, we developed a risk score that effectively discriminated patients at low versus higher risk for CR-KP infection (AUC 0.93, 95% CI 0.86-1.00, p < 0.001). Our results may help to design preventive strategies for LT recipients in CR-KP endemic areas.

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Section: Discussionsupporting

confidence: 85%

Risk Factors for Infection With Carbapenem-Resistant Klebsiella pneumoniae

Giannella

Bartoletti

Morelli

et al. 2015

American Journal of Transplantation

108

101

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“…However, there are several misgivings about the use of CRE decolonization. First, the need for decolonizing SOT candidates is under debate, mainly for liver transplantation; indeed, the risk for CRE infection has been shown to be similar between CRE colonized and noncolonized candidates [ 88 , 89 ]. Second, the efficacy of decolonization was short term [ 84 – 86 ].…”

Section: Decolonization Strategies For Mdr Gnbmentioning

confidence: 99%

Considerations About Antimicrobial Stewardship in Settings with Epidemic Extended-Spectrum β-Lactamase-Producing or Carbapenem-Resistant Enterobacteriaceae

et al. 2015

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Infections caused by gram-negative bacteria (GNB) resistant to multiple classes of antibiotics are increasing in many hospitals. Extended-spectrum β-lactamase (ESBL)-producing and carbapenem-resistant Enterobacteriaceae in particular are now endemic in many parts of the world and represent a serious public health threat. In this era, antimicrobial stewardship programs are essential as targeted and responsible use of antibiotics improves patient outcomes and hopefully limits the selective pressure that drives the further emergence of resistance. However, some stewardship strategies aimed at promoting carbapenem-sparing regimens remain controversial and are difficult to implement when resistance rates to non-carbapenem antibiotics are increasing. Coordinated efforts between stewardship programs and infection control are essential for reversing conditions that favor the emergence and dissemination of multidrug-resistant GNB within the hospital and identifying extra-institutional “feeder reservoirs” of resistant strains such as long-term care facilities, where colonization is common despite limited numbers of serious infections. In settings where ESBL resistance is endemic, the cost-effectiveness of expanded infection control efforts and antimicrobial stewardship is still unknown. Once a patient has been colonized, selective oral or digestive decontamination may be considered, but evidence supporting its effectiveness is limited in patients who are already colonized or in centers with high rates of resistance. Moreover, temporary success at decolonization may be associated with a higher risk of relapse with strains that are resistant to the decolonizing antibiotics.

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“…Second, screening for MDR-GNB carriage relied exclusively on rectal swab in the half of centers, multiple screening often includes urine sample, while concomitant respiratory or other samples are seldom obtained. As multisite colonization is a main predictor of MDR-GNB infection 4,20 attempt to screen multiple sites could be improved. Third, almost all centers limited screening at transplantation with less than one-third of respondents stating to follow screening after transplant.…”

Section: Discussionmentioning

confidence: 99%

Survey on the approach to antibiotic prophylaxis in liver and kidney transplant recipients colonized with “difficult to treat” Gram‐negative bacteria

Bonazzetti,

Rinaldi,

Cosentino

et al. 2024

Transplant Infectious Dis

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BackgroundPerformance of active screening for multidrug‐resistant Gram‐negative bacteria (MDR‐GNB) and administration of targeted antibiotic prophylaxis (TAP) in colonized patients undergoing liver (LT) and/or kidney transplantation (KT) are controversial issues.MethodsSelf‐administered electronic cross‐sectional survey disseminated from January to February 2022. Questionnaire consisted of four parts: hospital/transplant program characteristics, standard screening and antibiotic prophylaxis, clinical vignettes asking for TAP in patients undergoing LT and KT with prior infection/colonization with four different MDR‐GNB (extended‐spectrum cephalosporin‐resistant Enterobacterales [ESCR‐E], carbapenem‐resistant Enterobacterales [CRE], multidrug‐resistant Pseudomonas aeruginosa [MDR‐Pa], and carbapenem‐resistant Acinetobacter baumannii [CRAb]).ResultsFifty‐five respondents participated from 14 countries, mostly infectious disease specialists (69%) with active transplant programs (>100 procedures/year for 34.5% KT and 23.6% LT), and heterogeneous local MDR‐GNB prevalence from <15% (30.9%), 15%–30% (43.6%) to >30% (16.4%). The frequency of screening for ESCR‐E, CRE, MDR‐Pa, and CRAb was 22%, 54%, 17%, and 24% for LT, respectively, and 18%, 36%, 16%, and 11% for KT. Screening time‐points were mainly at transplantation 100%, only one‐third following transplantation. Screening was always based on rectal swab cultures (100%); multi‐site sampling was reported in 40% of KT and 35% of LT. In LT clinical cases, 84%, 58%, 84%, and 40% of respondents reported TAP for prior infection/colonization with ESCR‐E, CRE, MDR‐Pa, and CRAb, respectively. In KT clinical cases, 55%, 39%, 87%, and 42% of respondents reported TAP use for prior infection/colonization with ESCR‐E, CRE, MDR‐Pa, and CRAb, respectively.ConclusionThere is a large heterogeneity in screening and management of MDR‐GNB carriage in LT and KT. image

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Carbapenem-resistantKlebsiella pneumoniaecolonization at liver transplantation: A management challenge

Cited by 7 publications

References 4 publications

Risk Factors for Infection With Carbapenem-Resistant Klebsiella pneumoniae

Risk Factors for Infection With Carbapenem-Resistant Klebsiella pneumoniae

Considerations About Antimicrobial Stewardship in Settings with Epidemic Extended-Spectrum β-Lactamase-Producing or Carbapenem-Resistant Enterobacteriaceae

Survey on the approach to antibiotic prophylaxis in liver and kidney transplant recipients colonized with “difficult to treat” Gram‐negative bacteria

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