Risk factors and outcomes of carbapenem‐resistant K lebsiella pneumoniae infections in liver transplant recipients

Abstract

Carbapenem-resistant Klebsiella pneumoniae (CRKP) infection is increasing in incidence and is associated with increased mortality in liver transplantation (LT) recipients. We performed a retrospective cohort study of all patients transplanted between January 2010 and January 2013 to identify the incidence and risk factors for post-LT CRKP infection and evaluate the impact of this infection on outcomes in a CRKP-endemic area. We studied 304 recipients, of whom 20 (6.6%) developed CRKP and 36 (11.8%) carbapenem-susceptible Klebsiella pneumoniae (CSKP) infections in the year following LT. Among the 20 recipients with post-LT CRKP infection, 8 (40%) were infected in ≥ 2 sites; 13 (65%) had surgical site–intra-abdominal infections; 12 (60%) had pneumonia; and 3 (15%) had a urinary tract infection. There were 6 patients with a CRKP infection before LT, 5 of whom developed a CRKP infection after LT. Significant risk factors for post-LT CRKP infection in multivariate analysis included laboratory Model for End-Stage Liver Disease at LT (odds ratio [OR], 1.07; P = 0.001), hepatocellular carcinoma (OR, 3.19; P = 0.02), Roux-en-Y biliary choledochojejunostomy (OR, 3.15; P = 0.04), and bile leak (OR, 5.89; P = 0.001). One-year estimated patient survival was 55% (95% confidence interval, 31%–73%), 72% (55%–84%), and 93% (89%–96%), for patients with CRKP, CSKP, and no Klebsiella pneumoniae infection, respectively. In multivariate analysis, CRKP (hazard ratio [HR], 6.92; P < 0.001) and CSKP infections (CSKP, HR, 3.84; P < 0.001), as well as bile leak (HR, 2.10; P = 0.03) were the strongest predictors of post-LT mortality. In an endemic area, post-LT CRKP infection is common, occurring in 6.6% of recipients, and is strongly associated with post-LT mortality. Improved strategies for screening and prevention of CRKP infection are urgently needed.

Carbapenem-resistant Enterobacteriaceae in special populations: Solid organ transplant recipients, stem cell transplant recipients, and patients with hematologic malignancies

“…19 The incidence of post-SOT CRKP infection varies considerably by center and type of transplant (Table 1). [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] In general, CRKP infections occur early after transplant, with most studies reporting a median time of <50 days from transplant to infection. Reported mortality rates among SOT recipients with CRE infection generally range from 30-50%, and post-transplant CRKP infections have been associated with as much as a 10-fold risk of death.…”

“…Reported mortality rates among SOT recipients with CRE infection generally range from 30-50%, and post-transplant CRKP infections have been associated with as much as a 10-fold risk of death. [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] However, a more recent cohort of 164 SOT recipients across 15 international sites confirmed that while CRE infection typically occurs in the early post-transplant period, the one-year survival rate of patients who developed CRE infection within the first year of transplant was 72%. 34 While CRKP infections remain the most common type of CRE infection in SOT recipients, infections due to carbapenem-resistant Enterobacter spp., as well as NDM-and OXA-48-producing K. pneumoniae have also been reported.…”

“…Centers from New York City and Italy have reported that 6-9% of liver transplant recipients develop CRE infection. 20,23,24,39 In this group, surgical site and intraabdominal infections are common, and a high proportion of cases involve bacteremia. 23,24 Necrotizing soft The study evaluated episodes of CRE bacteremia only c The study evaluated episodes of CRE bacteriuria only tissue infections have also been described.…”

“…20,23,24,39 In this group, surgical site and intraabdominal infections are common, and a high proportion of cases involve bacteremia. 23,24 Necrotizing soft The study evaluated episodes of CRE bacteremia only c The study evaluated episodes of CRE bacteriuria only tissue infections have also been described. 40 CRKP infections, particularly bacteremia, have been associated with a 5 to 7-fold increased risk of death in this patient population.…”

Risk factors and outcomes of carbapenem‐resistant K lebsiella pneumoniae infections in liver transplant recipients

“…(5) Therefore, ERCP represents an important source for infection in this at-risk population. Although Pereira et al (1) found no association between ERCPs performed before or after LT and CRE infection, the number of studied patients (304) was small and this study should not provide reassurance in this particular matter. In light of recent outbreaks, LT teams should remain vigilant for this infection in patients undergoing this important therapeutic intervention.…”