Abstract
BACKGROUND: Pretransplant colonization with carbapenem-resistant Enterobacterales (CRE) is associated with poorer post-liver transplantation (LT) outcomes. We aimed to analyze the incidence and risk factors for CRE colonization in adult living-donor LT recipients from January 2019 to September 2022 and its impact on post-LT outcomes. METHODS: Relevant perioperative parameters including bacteremia within one month post LT were recorded. Rectal swabs were used for screening living-donor liver transplantation (LDLT) recipients for CRE colonization and divided into CRE-positive (CRE-POS) and CRE-negative (CRE-NEG) groups. RESULTS: A total of 499 patients were included in study, and 163 (32.6%) were CRE colonized and received pre-emptive probiotics. Median Model for End-Stage Liver Disease score (odds ratio [OR]: 1.05 [95% confidence interval {CI}: 1.02-1.08]) and preoperative acute kidney injury (AKI) (OR: 1.95 [95% CI: 1.28-2.98]) were independently associated with preoperative CRE colonization. CRE-POS patients had higher intraoperative packed red blood cell transfusion (5 [3, 7] vs 3 [1, 6]) along with a higher incidence of post-LT bacteremia (19.6% vs 9.8%, P = 0.004), chest infections (25.7% vs 13.6%, P = 0.04), and longer intensive care unit stay (7 days [interquartile range {IQR}: 5-10] vs 6 days [IQR: 5-8] P = 0.006). All other perioperative parameters including survival were comparable between the two groups. Bacteremia developed in 65 of 499 patients of which 61 (93.8%) were Enterobacterales. Preoperative CRE colonization (OR: 1.9 (95% CI: 1.08-3.7]), metabolic dysfunction-associated steatotic liver disease as an etiology of liver disease (OR: 2.0 [95% CI: 1.03-3.89]), preoperative AKI (OR: 2.4 [95% CI: 1.3-4.5]), and massive transfusion (OR: 2.0 (95% CI: 1.03-3.89]) were independently associated with postoperative Enterobacterales septicemia. Patients with bacteremia due to CRE had a higher 90-day mortality (38.4% vs 14.2% P = 0.03). Postoperative CRE bacteremia was not associated with preoperative CRE colonization (42.8% CRE-POS vs 57.1% CRE-NEG). CONCLUSION: One-third of patients presenting for LDLT are already colonized with CRE. Preoperative CRE colonization is a risk factor for postoperative Enterobacterales septicemia but not with CRE bacteremia. Post-liver transplant CRE bacteremia has a significantly higher mortality. Active pre-LT surveillance for CRE, along with the use of targeted pre-emptive therapy as probiotics and a low threshold for discretionary use of appropriate guideline-based antibiotic therapy based on CRE colonization status, in the event of sepsis, can help improve outcomes in this cohort of LDLT recipients.