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Pathogenesis of early operative site infections after orthotopic liver transplantation
P M Arnow1, K C Zachary, J R Thistlethwaite
1Department of Medicine, University of Chicago Hospital, Illinois 60637, USA.
Background:
We hypothesized that operative site infections after orthotopic liver transplantation arise from bacteria in bile or jejunum.
Methods:
To ascertain the validity of this hypothesis and to assess the effect of systemic antibiotic prophylaxis, we obtained intraoperative cultures of peritoneum, fascia, explant and donor liver bile, and jejunal lumen in 77 liver transplantations, and we monitored outcome.
Results:
Pathogens were recovered from peritoneum, fascia, or bile in 11 cases. By univariate analysis, a positive culture was significantly associated with choledochojejunostomy (P=0.0002), previous liver transplantation (P=0.0002), and previous hepatobiliary surgery (P=0.002). Operative site infections during the first 2 weeks after transplantation occurred only in cases with positive intraoperative cultures, and three of the four infections were caused by the same bacteria detected intraoperatively. Antibiotic susceptibility of intraoperative isolates was tested in nine cases; infection occurred in two of three cases in which the isolates were resistant to the systemic antibiotic prophylaxis and in none of six cases with susceptible isolates.
Conclusions:
Our findings suggest that systemic antibiotic prophylaxis for more than 2 days may be beneficial in cases with bacterial contamination of the operative site but may not be necessary in other cases.
Insights
Operative site infections after liver transplantation may stem from bacterial contamination. Targeted antibiotic prophylaxis may reduce infections in contaminated cases, but routine extended use may not be necessary.
Area of Science:
- Hepatobiliary surgery
- Transplant infectious disease
- Surgical site infections
Background:
- Operative site infections (OSIs) following orthotopic liver transplantation (OLT) are a significant concern.
- The primary source of pathogens causing OSIs is hypothesized to be bacteria present in bile or the jejunum.
Purpose of the Study:
- To investigate the origin of bacteria causing OSIs after OLT.
- To evaluate the impact of systemic antibiotic prophylaxis on the incidence of OSIs.
Main Methods:
- Intraoperative cultures of peritoneum, fascia, explant, donor liver bile, and jejunal lumen were obtained from 77 liver transplantations.
- Patient outcomes, including operative site infections, were monitored post-transplantation.
- Antibiotic susceptibility testing was performed on intraoperative isolates.
Main Results:
- Pathogens were identified in intraoperative cultures from 11 cases.
- Positive intraoperative cultures were significantly associated with choledochojejunostomy, previous liver transplantation, and prior hepatobiliary surgery.
- Operative site infections occurred exclusively in patients with positive intraoperative cultures, and the causative bacteria often matched intraoperative isolates. Infection risk was higher when isolates were resistant to prophylactic antibiotics.
Conclusions:
- Findings suggest that bacterial contamination of the operative site contributes to OSIs in liver transplantation.
- Systemic antibiotic prophylaxis exceeding 2 days may be beneficial for patients with identified bacterial contamination.
- Extended antibiotic prophylaxis may not be required for patients without intraoperative bacterial contamination.