domingo, 20 de mayo de 2012

Pretransplant Fecal Carriage of Extended-Spectrum β-Lactamase–producing Enterobacteriaceae and Infection after Liver Transplant, France - Vol. 18 No. 6 - June 2012 - Emerging Infectious Disease journal - CDC

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Medscape CME articles
Volume 18, Number 6–June 2012

Volume 18, Number 6—June 2012

CME ACTIVITY

Pretransplant Fecal Carriage of Extended-Spectrum β-Lactamase–producing Enterobacteriaceae and Infection after Liver Transplant, France






Frédéric BertComments to Author , Béatrice Larroque, Catherine Paugam-Burtz, Federica Dondero, François Durand, Estelle Marcon, Jacques Belghiti, Richard Moreau, and Marie-Hélène Nicolas-Chanoine
Author affiliations: Hôpital Beaujon, Clichy, France (F. Bert, B. Larroque, C. Paugam-Burtz, F. Dondero, F. Durand, E. Marcon, J. Belghiti, R. Moreau, M.H. Nicolas-Chanoine); Université Paris VII Faculté de Médecine D. Diderot, Paris, France (C. Paugam-Burtz, F. Durand, J. Belghiti, M.H. Nicolas-Chanoine); INSERM U 773 Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris (F. Durand, R. Moreau, M.H. Nicolas-Chanoine)

Abstract

Extended-spectrum β-lactamase–producing Enterobacteriaceae isolates (ESBLE) are emerging pathogens that confer resistance to antimicrobial drugs. We conducted a 10-year study in France (January 2001–April 2010) to investigate the incidence of and risk factors for ESBLE infections after liver transplant. Of 710 transplant patients screened preoperatively for ESBLE fecal carriage, 5.5% had ESBLE infection develop within 4 months after surgery; patients with pretransplant ESBLE fecal carriage were more likely to have infection develop than were noncarriers. Typing showed extensive genetic diversity, with a large predominance of CTX-M enzymes. Independent predictors of ESBLE infection were pretransplant fecal carriage, Model for End Stage Liver Disease score >25, and return to surgery. Our results indicate that the influx of preoperatively acquired ESBLE isolates into the hospital outweighs cross-transmission in the epidemiology of ESBLE infections after liver transplant. Transplant candidates should be systematically screened for carriage, and posttransplant infection in carriers should be treated with carbapenems.

Extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae (ESBLE) isolates, notably ESBL-producing Escherichia coli isolates, have emerged worldwide as a frequent cause of infection in hospitals and in the community (1,2). ESBLs confer resistance to all β-lactam agents except carbapenems and cephamycins and are frequently associated with resistance to other classes of antimicrobial drugs, including aminoglycosides and fluoroquinolones (2,3). Therapeutic options for infections caused by these multidrug-resistant organisms are therefore limited, which may result in delayed effective therapy and increased risk for death (4,5). Identifying risk factors for ESBLE infections enables identification of patients who should receive empirical treatment targeted to these organisms.

ESBLE infections may pose a particularly serious threat in profoundly immunosuppressed patients, such as transplant recipients, who are often empirically treated for postoperative infections. Solid organ transplant has been shown to be a risk factor for nosocomial ESBLE bacteremia (6), but little research has been conducted to identify risk factors for ESBLE infections among these patients, and previous studies included only kidney transplant recipients (7,8). Liver transplant (LT) recipients are particularly at risk for bacterial infections because of the severity of illness associated with preoperative end-stage liver disease and the technical complexity of surgery (9). After LT, bacterial infections occur in 35%–70% of patients; these infections are predominantly caused by Enterobacteriaceae (1013). Although recent studies from Spain and China have reported alarmingly high rates of ESBL production in isolates from LT recipients (1416), to our knowledge, the epidemiology of ESBLE infections among these high-risk patients in a nonepidemic setting has not been investigated.

We assessed the incidence of, risk factors for, and molecular epidemiology of ESBLE infections in LT recipients. More specifically, we investigated whether ESBLE pretransplant fecal carriage was an independent predictor of ESBLE infection after LT.
Pretransplant Fecal Carriage of Extended-Spectrum β-Lactamase–producing Enterobacteriaceae and Infection after Liver Transplant, France - Vol. 18 No. 6 - June 2012 - Emerging Infectious Disease journal - CDC

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