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Health Care–Associated Infection in Solid Organ Transplant Recipients
Health CareeAssociated Infection in Solid Organ Transplant Recipients Anselmo A. Abdo-Cuzaa,*, Miguel A. Gómez-Bravob, Jose B. Pérez-Bernalc, Juliette Suárez-Lópezd, Francisco Gómez-Peirea, Jorge L. Leiva-Torresa, Nilda Bejerano-Gila, Geydy Leal-Alpizara, Namibia Espinosa-Nodarsea, and Roberto Castellanos-Gutiérreza a Servicio Medicina Intensiva, Centro de Investigaciones Médico Quirúrgicas, Havana, Cuba; bServicio de Trasplantes, Hospital Virgen del Rocío, Seville, Spain; cDirector General de Trasplantes del Real e Ilustre Colegio Oficial de Médicos de Sevilla, Seville, Spain; and d Servicio Cirugía Cardiovascular, Hospital Hermanos Ameijeiras, Havana, Cuba
ABSTRACT Background. Health careeassociated infection (HAI) represent a global health problem with an increase in hospital stays, deaths, and monetary costs. Recipients of solid organ transplants are a population at risk. The objectives of the study were to characterize the incidence of HAI in renal and hepatic transplant recipients as well as to compare them with the population without transplants in intensive care units (ICU). Methods. The data on the incidence of HAI, localization, microorganisms, and demographics were taken from the patients admitted between the years 2013 to 2018 (n ¼ 4307) from the registration of the Project for the Reduction of Nosocomial Infection in Intensive Care Units. The variables were compared with those of renal transplant (n ¼ 96) and liver transplants (n ¼ 68) recipients. Results. Renal transplant recipients showed 26% incidence of HAI. The most frequent were surgical site infection (SSI), urinary tract infection, and primary bacteremia; the most frequent microorganism was Staphylococcus spp, mortality 3.8%. Liver transplant recipients showed 41% incidence of HAI. The most frequent were tracheobronchitis associated with mechanical ventilation, SSI, and primary bacteremia; the most frequent microorganism was Staphylococcus spp, mortality 37%. The population without transplants in the ICU showed 17% incidence of HAI. The most frequent were respiratory infections associated with mechanical ventilation, primary bacteremia, and SSI; the most frequent microorganism was Acinetobacter spp, mortality 21%. Conclusions. HAI in recipients of solid organ transplants (renal and hepatic) have a higher incidence than in a population without transplants. The location and causal microorganisms have particularities that must be taken into account for the development of prevention protocols.
H
EALTH care-associated infection (HAI) represent a global health problem with an increase in hospital stays, deaths, and monetary costs [1]. Recipients of solid organ transplants are a population at risk [2]. Posttransplant infections represent one of the first causes of death [3]. The objectives of the present investigation were to characterize the incidence of HAI in renal and hepatic transplant recipients admitted to intensive care unit (ICU) as well as to compare them with the population without transplants in terms of incidence rates, mortality, location of infection, and more frequent microorganisms.
ª 2020 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, XX, 1e3 (2020)
MATERIALS AND METHODS Data on demographics, incidence of HAI, location, microorganisms, and final result were taken from kidney (n ¼ 96) and liver (n ¼ 68) transplant recipients admitted between 2013 and 2018 from the ICU data registry of the Centro de Investigaciones Medico
*Address correspondence to Anselmo A. Abdo-Cuza, Centro de Investigaciones Medico Quirurgicas, 216 e 11 y 13, 12100, La Habana, Cuba. Tel: þ(53) 7 8581511. E-mail: aaabdo@infomed. sld.cu 0041-1345/20 https://doi.org/10.1016/j.transproceed.2019.12.010
1
2
ABDO-CUZA, GÓMEZ-BRAVO, PÉREZ-BERNAL ET AL
Table 1. General Characteristics, Incidence Rate of HAI, and Mortality of Kidney and Liver Transplant Recipients Compared With the Population Without Transplants in Intensive Care Units Variables
Control Population
Kidney Transplant
N Age, mean (SD), y APACHE II, mean (SD) Death risk, mean (SD) HAI rate, % Mortality, %
4307 54.08 (20.07) 12.89 (8.00) 21.02 (19.82) 17.11 21.54
96 44.80 (14.58) 13.76 (8.01) 21.99 (20.89) 26.04 3.8
P Value
< .001 .194 .769
Liver Transplant
P Value
68 46.28 (14.53) 14.94 (7.07) 24.12 (18.46) 41.17 36.76
< .001 .272 .957 < .001 < .001
APACHE, Acute Physiology and Chronic Health Evaluation; HAI, health careeassociated infection.
Quirurgicas. Surgical prophylaxis was performed with cefazolin 2 g intravenously prior to anesthetic induction and 2 doses of 2 g intravenously post transplant with a 4-hour interval. Similar data for comparison were obtained from the databases of the Project Reduction of Nosocomial Infection in Intensive Care Units (national multicenter surveillance study of HAI) [4] in equal periods of time (n ¼ 4472). The statistical evaluation was carried out with the SPSS 20 program for Windows (IBM, Armonk, NY, United States). For the descriptive analysis, the mean and standard deviation were used for the quantitative variables, and the percentage was used for the qualitative variables. The contingency tables method was used through the c2 statistic to establish the relationship between variables. The comparison of means was made using the Student t test. Statistical significance was declared when P < .05.
RESULTS
Table 1 shows the mean age, incidence rate of HAI, and mortality of the group of kidney and liver transplant recipients compared with the population without transplants in the ICU. The most frequent HAI in the population without transplants in the ICU were pneumonia associated with mechanical ventilation (6.8%), primary bacteremia (PB) (4.1%), and tracheobronchitis associated with mechanical ventilation (3.2%). The most frequently isolated microorganisms were Acinetobacter spp, Enterobacter spp, and Staphylococcus spp. The most frequent HAI in renal transplant recipients were surgical site infection (SSI) (24%), urinary tract infection (5%), and PB 3%. The most frequently isolated microorganisms were Staphylococcus spp, Escherichia coli, and Klebsiella spp. The most frequent HAI in liver transplant recipients were tracheobronchitis associated with mechanical ventilation (21%), SSI (19%), and PB (8%). The most frequently isolated microorganisms were Staphylococcus spp, Pseudomonas spp, and Acinetobacter spp.
compared with the renal one. On the other hand, the differences between the incidences of respiratory infections associated with ventilation may explain the lower mortality in renal transplant recipients as well as the possibility of maintaining organ function with extracorporeal support not available for liver failure. In renal and hepatic transplant recipients, the SSI occupies a prominent place among the HAI, above the reports of other series [2]. This finding advises about the need for review of prevention protocols and adequate adherence. Urinary tract infection appeared at a lower incidence than that reported in the literature [5,6]. Isolated microorganisms are similar to other series. Low respiratory infections associated with ventilation are an unsolved problem in patients in the ICU as well as in liver recipients. The literature reports incidence rates between 8.5% and 21.4% [7,8]. Enterobacteriaceae and Acinetobacter spp are predominant as in our series. The high frequency of multi- and extensively drug-resistant microorganisms favors the delay for the beginning of the appropriate antibiotic, which causes high mortality (risk of death odds ratio, 17.96) [8e10]. The results of this research may be useful for transplant groups in developing countries. The technological and economic gap between developed and developing countries explains the different incidence rates of HAI. The first step to chart improvement strategies is to characterize the problem.
CONCLUSIONS
Kidney and liver transplant recipients have higher rates of incidence of HAI compared with the population without transplants in the ICU. There are particularities in relation to the locations of the HAI and the causative microorganisms that must be taken into account for the adequacy of the protocols for prevention and empirical action.
DISCUSSION
Kidney and liver transplant recipients have a higher incidence of HAI than the population without transplants in the ICU because of their characteristics of chronic disease, surgical stress, and use of immunosuppressants [2]. Differences in ICU mortality between renal and hepatic transplant recipients could be explained by the high complexity of the second and the greater pretransplant deterioration
REFERENCES [1] Saleem Z, Godman B, Hassali MA, Hashmi FK, Azhar F, Rehman IU. Point prevalence surveys of health-care-associated infections: a systematic review. Pathog Glob Health 2019;113: 191e205. https://doi.org/10.1080/20477724.2019.1632070. [2] Winterbottom F, Jenkins M. Infections in the intensive care unit: posttransplant infections. Crit Care Nurs Clin North Am 2017;29:97e110. https://doi.org/10.1016/j.cnc.2016.09.002.
HEALTH CAREeASSOCIATED INFECTION [3] Idossa DW, Simonetto DA. Infectious complications and malignancies arising after liver transplantation. Anesthesiol Clin 2017;35:381e93. https://doi.org/10.1016/j.anclin.2017.04.002. [4] Group of Researchers of the Project for the Reduction of Nosocomial Infection in Intensive Care Units (DINUCIs Project). Incidence of infection related to health care in intensive care units in Cuba (2014). Results of the implementation of a package of prophylactic measures. Invest Medicoquir 2015;7: 182e202. [5] Camargo LF, Esteves AB, Ulisses LR, Rivelli GG, Mazzali M. Urinary tract infection in renal transplant recipients: incidence, risk factors, and impact on graft function. Transplant Proc 2014;46:1757e9. https://doi.org/10.1016/j.transproceed.2014. 05.006. _ Akdur A, [6] Yabanoglu H, Alıs¸kan HE, Çalıs¸kan K, Arer I, Yıldırım S, et al. Early infections in renal transplant recipients: incidence, risk factors, and causative microorganisms. Exp Clin Transplant 2015;13(Suppl. 3):11e4.
3 [7] El-Badrawy MK, Ali RE, Yassen A, AbouElela MA, Elmorsey RA. Early-onset pneumonia after liver transplant: microbial causes, risk factors, and outcomes, Mansoura University, Egypt, experience. Exp Clin Transplant 2017;15:547e53. https://doi. org/10.6002/ect.2016.0176. [8] Prieto Amorin J, Lopez M, Rando K, Castelli J, Medina Presentado J. Early bacterial pneumonia after hepatic transplantation: epidemiologic profile. Transplant Proc 2018;50:503e8. https://doi.org/10.1016/j.transproceed.2017.11.047. [9] Serifoglu I, Er Dedekarginoglu B, Savas Bozbas S, Akcay S, Haberal M. Clinical characteristics of Acinetobacter baumannii infection in solid-organ transplant recipients. Exp Clin Transplant https://doi.org/10.6002/ect.TOND2018;16(Suppl. 1):171e5. TDTD2017.P51. [10] Bartoletti M, Giannella M, Tedeschi S, Viale P. Multidrugresistant bacterial infections in solid organ transplant candidates and recipients. Infect Dis Clin North Am 2018;32:551e80. https:// doi.org/10.1016/j.idc.2018.04.004.
ABSTRACT Background. Health careeassociated infection (HAI) represent a global health problem with an increase in hospital stays, deaths, and monetary costs. Recipients of solid organ transplants are a population at risk. The objectives of the study were to characterize the incidence of HAI in renal and hepatic transplant recipients as well as to compare them with the population without transplants in intensive care units (ICU). Methods. The data on the incidence of HAI, localization, microorganisms, and demographics were taken from the patients admitted between the years 2013 to 2018 (n ¼ 4307) from the registration of the Project for the Reduction of Nosocomial Infection in Intensive Care Units. The variables were compared with those of renal transplant (n ¼ 96) and liver transplants (n ¼ 68) recipients. Results. Renal transplant recipients showed 26% incidence of HAI. The most frequent were surgical site infection (SSI), urinary tract infection, and primary bacteremia; the most frequent microorganism was Staphylococcus spp, mortality 3.8%. Liver transplant recipients showed 41% incidence of HAI. The most frequent were tracheobronchitis associated with mechanical ventilation, SSI, and primary bacteremia; the most frequent microorganism was Staphylococcus spp, mortality 37%. The population without transplants in the ICU showed 17% incidence of HAI. The most frequent were respiratory infections associated with mechanical ventilation, primary bacteremia, and SSI; the most frequent microorganism was Acinetobacter spp, mortality 21%. Conclusions. HAI in recipients of solid organ transplants (renal and hepatic) have a higher incidence than in a population without transplants. The location and causal microorganisms have particularities that must be taken into account for the development of prevention protocols.
H
EALTH care-associated infection (HAI) represent a global health problem with an increase in hospital stays, deaths, and monetary costs [1]. Recipients of solid organ transplants are a population at risk [2]. Posttransplant infections represent one of the first causes of death [3]. The objectives of the present investigation were to characterize the incidence of HAI in renal and hepatic transplant recipients admitted to intensive care unit (ICU) as well as to compare them with the population without transplants in terms of incidence rates, mortality, location of infection, and more frequent microorganisms.
ª 2020 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, XX, 1e3 (2020)
MATERIALS AND METHODS Data on demographics, incidence of HAI, location, microorganisms, and final result were taken from kidney (n ¼ 96) and liver (n ¼ 68) transplant recipients admitted between 2013 and 2018 from the ICU data registry of the Centro de Investigaciones Medico
*Address correspondence to Anselmo A. Abdo-Cuza, Centro de Investigaciones Medico Quirurgicas, 216 e 11 y 13, 12100, La Habana, Cuba. Tel: þ(53) 7 8581511. E-mail: aaabdo@infomed. sld.cu 0041-1345/20 https://doi.org/10.1016/j.transproceed.2019.12.010
1
2
ABDO-CUZA, GÓMEZ-BRAVO, PÉREZ-BERNAL ET AL
Table 1. General Characteristics, Incidence Rate of HAI, and Mortality of Kidney and Liver Transplant Recipients Compared With the Population Without Transplants in Intensive Care Units Variables
Control Population
Kidney Transplant
N Age, mean (SD), y APACHE II, mean (SD) Death risk, mean (SD) HAI rate, % Mortality, %
4307 54.08 (20.07) 12.89 (8.00) 21.02 (19.82) 17.11 21.54
96 44.80 (14.58) 13.76 (8.01) 21.99 (20.89) 26.04 3.8
P Value
< .001 .194 .769
Liver Transplant
P Value
68 46.28 (14.53) 14.94 (7.07) 24.12 (18.46) 41.17 36.76
< .001 .272 .957 < .001 < .001
APACHE, Acute Physiology and Chronic Health Evaluation; HAI, health careeassociated infection.
Quirurgicas. Surgical prophylaxis was performed with cefazolin 2 g intravenously prior to anesthetic induction and 2 doses of 2 g intravenously post transplant with a 4-hour interval. Similar data for comparison were obtained from the databases of the Project Reduction of Nosocomial Infection in Intensive Care Units (national multicenter surveillance study of HAI) [4] in equal periods of time (n ¼ 4472). The statistical evaluation was carried out with the SPSS 20 program for Windows (IBM, Armonk, NY, United States). For the descriptive analysis, the mean and standard deviation were used for the quantitative variables, and the percentage was used for the qualitative variables. The contingency tables method was used through the c2 statistic to establish the relationship between variables. The comparison of means was made using the Student t test. Statistical significance was declared when P < .05.
RESULTS
Table 1 shows the mean age, incidence rate of HAI, and mortality of the group of kidney and liver transplant recipients compared with the population without transplants in the ICU. The most frequent HAI in the population without transplants in the ICU were pneumonia associated with mechanical ventilation (6.8%), primary bacteremia (PB) (4.1%), and tracheobronchitis associated with mechanical ventilation (3.2%). The most frequently isolated microorganisms were Acinetobacter spp, Enterobacter spp, and Staphylococcus spp. The most frequent HAI in renal transplant recipients were surgical site infection (SSI) (24%), urinary tract infection (5%), and PB 3%. The most frequently isolated microorganisms were Staphylococcus spp, Escherichia coli, and Klebsiella spp. The most frequent HAI in liver transplant recipients were tracheobronchitis associated with mechanical ventilation (21%), SSI (19%), and PB (8%). The most frequently isolated microorganisms were Staphylococcus spp, Pseudomonas spp, and Acinetobacter spp.
compared with the renal one. On the other hand, the differences between the incidences of respiratory infections associated with ventilation may explain the lower mortality in renal transplant recipients as well as the possibility of maintaining organ function with extracorporeal support not available for liver failure. In renal and hepatic transplant recipients, the SSI occupies a prominent place among the HAI, above the reports of other series [2]. This finding advises about the need for review of prevention protocols and adequate adherence. Urinary tract infection appeared at a lower incidence than that reported in the literature [5,6]. Isolated microorganisms are similar to other series. Low respiratory infections associated with ventilation are an unsolved problem in patients in the ICU as well as in liver recipients. The literature reports incidence rates between 8.5% and 21.4% [7,8]. Enterobacteriaceae and Acinetobacter spp are predominant as in our series. The high frequency of multi- and extensively drug-resistant microorganisms favors the delay for the beginning of the appropriate antibiotic, which causes high mortality (risk of death odds ratio, 17.96) [8e10]. The results of this research may be useful for transplant groups in developing countries. The technological and economic gap between developed and developing countries explains the different incidence rates of HAI. The first step to chart improvement strategies is to characterize the problem.
CONCLUSIONS
Kidney and liver transplant recipients have higher rates of incidence of HAI compared with the population without transplants in the ICU. There are particularities in relation to the locations of the HAI and the causative microorganisms that must be taken into account for the adequacy of the protocols for prevention and empirical action.
DISCUSSION
Kidney and liver transplant recipients have a higher incidence of HAI than the population without transplants in the ICU because of their characteristics of chronic disease, surgical stress, and use of immunosuppressants [2]. Differences in ICU mortality between renal and hepatic transplant recipients could be explained by the high complexity of the second and the greater pretransplant deterioration
REFERENCES [1] Saleem Z, Godman B, Hassali MA, Hashmi FK, Azhar F, Rehman IU. Point prevalence surveys of health-care-associated infections: a systematic review. Pathog Glob Health 2019;113: 191e205. https://doi.org/10.1080/20477724.2019.1632070. [2] Winterbottom F, Jenkins M. Infections in the intensive care unit: posttransplant infections. Crit Care Nurs Clin North Am 2017;29:97e110. https://doi.org/10.1016/j.cnc.2016.09.002.
HEALTH CAREeASSOCIATED INFECTION [3] Idossa DW, Simonetto DA. Infectious complications and malignancies arising after liver transplantation. Anesthesiol Clin 2017;35:381e93. https://doi.org/10.1016/j.anclin.2017.04.002. [4] Group of Researchers of the Project for the Reduction of Nosocomial Infection in Intensive Care Units (DINUCIs Project). Incidence of infection related to health care in intensive care units in Cuba (2014). Results of the implementation of a package of prophylactic measures. Invest Medicoquir 2015;7: 182e202. [5] Camargo LF, Esteves AB, Ulisses LR, Rivelli GG, Mazzali M. Urinary tract infection in renal transplant recipients: incidence, risk factors, and impact on graft function. Transplant Proc 2014;46:1757e9. https://doi.org/10.1016/j.transproceed.2014. 05.006. _ Akdur A, [6] Yabanoglu H, Alıs¸kan HE, Çalıs¸kan K, Arer I, Yıldırım S, et al. Early infections in renal transplant recipients: incidence, risk factors, and causative microorganisms. Exp Clin Transplant 2015;13(Suppl. 3):11e4.
3 [7] El-Badrawy MK, Ali RE, Yassen A, AbouElela MA, Elmorsey RA. Early-onset pneumonia after liver transplant: microbial causes, risk factors, and outcomes, Mansoura University, Egypt, experience. Exp Clin Transplant 2017;15:547e53. https://doi. org/10.6002/ect.2016.0176. [8] Prieto Amorin J, Lopez M, Rando K, Castelli J, Medina Presentado J. Early bacterial pneumonia after hepatic transplantation: epidemiologic profile. Transplant Proc 2018;50:503e8. https://doi.org/10.1016/j.transproceed.2017.11.047. [9] Serifoglu I, Er Dedekarginoglu B, Savas Bozbas S, Akcay S, Haberal M. Clinical characteristics of Acinetobacter baumannii infection in solid-organ transplant recipients. Exp Clin Transplant https://doi.org/10.6002/ect.TOND2018;16(Suppl. 1):171e5. TDTD2017.P51. [10] Bartoletti M, Giannella M, Tedeschi S, Viale P. Multidrugresistant bacterial infections in solid organ transplant candidates and recipients. Infect Dis Clin North Am 2018;32:551e80. https:// doi.org/10.1016/j.idc.2018.04.004.