Papanicolaou GA, Meyers BR, Meyers J, et al. Nosocomial infections with vancomycin-resistant Enterococcus faecium in liver transplant recipients: Risk factors for acquisition and mortality. Clin Infect Dis 1996; 23:760-766.
Because of the nature of their disease and extensive surgery, liver transplant patients are at increased risk for postoperative infections with pathogens of the gastrointestinal tract, including vancomycin-resistant enterococci (VRE), the authors report.
The presence of multiple VRE clones in the transplant patients studied suggests that the antibiotic selective pressure particularly the use of vancomycin may account for VRE colonization.
The authors studied the risk factors for acquisition of and mortality due to nosocomial infection with VRE orthotopic liver transplant (OLT) recipients at a tertiary care hospital. In all, 32 VRE-infected OLT patients (cases) were compared with 33 randomly selected OLT recipients (controls). Overall, more antibiotics were administered preoperatively to cases (mean, 4 antibiotics per patient for 474 antibiotic-days) than to controls (mean, 1.8 antibiotics per patient for 131 antibiotic-days). Cases were more likely than controls to have received vancomycin therapy preoperatively and to have been hospitalized in the intensive care unit (ICU) preoperatively.
"We would discourage the use of vancomycin as perioperative prophylaxis in institutions that still employ this regimen," they advised.
VRE infection may be an indicator of a generalized debilitated state associated with increased morbidity and mortality. In the study, hospitalization in the ICU before surgery, hemodialysis, and polymicrobial bacteremia further increased mortality.
The prognosis for transplant patients with established infections is poor, especially for those with polymicrobial bacteremia. Severe underlying disease, prolonged hospitalization, therapy with multiple antibiotics (including vancomycin), renal failure, and general immunosuppression have been previously associated with nosocomial infections due to VRE. In liver transplant recipients, additional risk factors coexist, including exogenous immunosuppression, liver failure, and surgery.
The impact of infection control measures on reducing the risk for colonization and infection with VRE has been controversial, the authors note. The use of gloves and gowns has been shown to control outbreaks due to dissemination of a specific strain, but infection control measures have not resulted in an overall decrease in the rate of colonization or a clear reduction in the number of infections caused in hospitals with endemic VRE, they note.
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