Perioperative Antibiotic Strategies in Liver Transplantation: A Propensity Score Analysis of Prophylaxis Versus...

Surgical site infections (SSIs) are common after liver transplantation (LT), with perioperative antibiotic strategies varying across centers. This study compared the incidence of SSIs in patients receiving perioperative antibiotic prophylaxis (PAP) versus preemptive antibiotic therapy (PAT).

This retrospective multicenter study included adult LT patients from 5 French hospitals (2019-2022). Exclusion criteria were prior antibiotic use at LT, prophylaxis extended beyond 24 h postoperatively, antibiotic allergies, fulminant hepatitis, and multiorgan transplants. The PAP group received narrow-spectrum antibiotics without extension beyond 24 h, whereas the PAT group received broad-spectrum antibiotics extended postoperatively. Propensity score-based overlap weighting was used for comparisons.

Among 595 patients, 271 received PAP and 324 received PAT for a median of 5 (2-7) d ( P  < 0.001). Cefoxitin (24%) and amoxicillin-clavulanic acid (21%) were most used in the PAP group, whereas piperacillin (19%) and piperacillin-tazobactam (33%) dominated in the PAT group. SSIs occurred in 19% of PAP and 15% of PAT patients (odds ratio [OR] 0.81; 95% confidence interval [CI], 0.29-2.30; P  = 0.7). PAT was associated with reduced postoperative infections (OR 0.27; 95% CI, 0.12-0.63; P  = 0.002), shorter intensive care unit (-5.2 d; P  < 0.0001) and hospital stays (-5.5 d; P  = 0.002), and lower early allograft dysfunction (OR 0.12; 95% CI, 0.02-0.87; P  = 0.04) but with increased extended-spectrum beta-lactamase SSIs (47% versus 6%; P  = 0.006).

PAP effectively prevents SSIs and antimicrobial resistance. Broad-spectrum antibiotics should be reserved for early treatment of suspected infections or prophylaxis for carefully selected high-risk patients.