Severe Sepsis in Pediatric Liver Transplant Patients: The Emergence of Multidrug-Resistant Organisms

Abstract

Objective: To describe characteristics of liver transplant patients with severe sepsis in the pediatric intensive care unit (PICU) Design: Retrospective descriptive analysis Setting: Tertiary children's hospital PICU Patients: Liver transplant recipients admitted Jan 2010 to Jul 2016 for pediatric severe sepsis Interventions: None Measurements and Main Results: Between Jan 2010-Jul 2016, 173 liver transplants were performed, and 36 of these patients (21%) were admitted with severe sepsis (54 episodes total). Median age at admission was 2 y [1-6.5 y], 47.2% were male. Bacterial infections were the most common (77.8%), followed by culture negative (12.9%) and viral infections (7.4%). Fungal infections accounted for only 1.9%. Median time from transplant for viral and culture negative infections was 18 d [8.25-39.75 d] and 25 d [9-41 d], while 54.5 d [17-131.25 d] for bacterial infections. Bloodstream and intra-abdominal were the most common bacterial sites (45% and 22.5%, respectively). Multidrug-resistant organisms (MDROs) accounted for 47.6% of bacterial sepsis. Vancomycin resistant enterococcus and extended spectrum beta-lactamase producers were the most frequently identified MDROs. Patients with MDRO sepsis demonstrated higher admission PELOD scores (P=0.043) and were noted to have an odds ratio of 3.8 and 3.6 for mechanical ventilation and MODS, respectively (P=0.047 and P=0.044). Overall mortality was 5.5% (n=2 patients), with both deaths occurring in MDRO episodes.

Bacteremia in Pediatric Liver Transplant Recipients

“…30 In a retrospective study of pLTRs admitted to the pediatric intensive care unit with severe sepsis, bacterial sources of infection (bloodstream and intra-abdominal) were the most common (78%). 19 We identified no patients with bacterial meningitis, consistent with prior studies in patients >16 years of age after solid organ transplants. Viral etiologies are the predominant cause of central nervous system infections, with a very low incidence of bacterial meningitis (<1%).…”

“…In prior work, the first 90 days post-transplant have been identified as the most likely period for severe infection in adults and children. [19][20][21] However, more than one-third of the encounters with bacteremia in our cohort occurred beyond 6 months from transplant and in the absence of CVCs, supporting the need to maintain vigilance and evaluate for bacteremia in this high-risk population. The association of bacteremia with the presence of a CVC is well-known, particularly in immunocompromised hosts, with reported rates of CVC infections of 0.09 per 1000 catheter-days in pLTRs to 0.1-11 per 1000 catheterdays in children with other underlying diseases.…”

A European International Multicentre Survey on the Current Practice of Perioperative Antibiotic Prophylaxis for Paediatric Liver Transplantations

“…An important barrier to narrowing the spectrum of perioperative prophylaxis after pLTX are MDR bacteria, as these pathogens constitute a clinically relevant cause of postoperative infections, sepsis, and septic shock [3,8,12,13,16,18]. The participants of our survey stated that they adapted antibiotic strategies according to the presence of MDR bacteria-centres with high prevalence of ESBL pathogens reported broader-spectrum regimens than low prevalence-centres.…”

“…The remaining causes of morbidity and mortality in children mainly comprise early postoperative complications such as non-and poor-function of the liver, thrombosis of the portal vein or hepatic artery, haemorrhage and infections [5][6][7]. Forty-seven to 82% of these infections derive from bacterial origin [8][9][10][11][12][13] with long surgery times, transfusion of blood products, medical immunosuppression and disturbance of the mucosal gut barrier as the main risk factors. In a large registry study that included 2291 patients, 38% experienced a bacterial or fungal infection within 30 days after transplantation, and 5.5% died as a consequence of infection [14].…”

Exploring the risk factors of early sepsis after liver transplantation: development of a novel predictive model

“…As LT is one of the most effective treatments for end-stage liver diseases, 34,694 LTs were performed globally in 2021, according to the International Registry on Organ Donation and Transplantation. However, the complications of LT, especially sepsis, are associated with a high risk of mortality ( 15 , 16 ). A single-center retrospective study showed that the incidence of early sepsis after LT was up to 67%, and the median time to infection was 9 days ( 6 , 17 ).…”