title: Vancomycin-resistant enterococcal colonization and infection in liver transplant candidates and recipients: a prospective surveillance study.
abstract: BACKGROUND
  Vancomycin-resistant enterococcal (VRE) infections cause significant morbidity and mortality among patients undergoing liver transplantation. We performed a prospective study among patients awaiting transplantation to assess rates, risk factors, and outcomes associated with VRE colonization before and after transplantation.
  
  
  METHODS
  All adults on the transplantation waiting list from 2000-2003 were eligible. Demographic, historical, and laboratory data, as well as stool samples to be analyzed for VRE, were collected at enrollment and every 4-6 months thereafter until transplantation. After transplantation, samples were obtained every 3 days during hospitalization and were analyzed for VRE; outcomes were assessed at 90 days.
  
  
  RESULTS
  Overall, 375 patients were enrolled in our study, and 142 received transplants. VRE colonization occurred in 50 (13%) of 375 patients before transplantation and was independently associated with treatment with antianaerobic antimicrobials, third-generation cephalosporins, proton pump inhibitors, or neomycin; having a recent endoscopic retrograde cholangiopancreatogram or paracentesis procedure; and admission to the liver unit. Of these 50 patients, 22 (44%) received a transplant, and 7 (32%) of 22 developed a VRE infection after transplantation. An additional 22 patients (18%) who were not colonized before transplantation acquired VRE after transplantation; VRE infection developed in 5 (23%) of these patients. Patients colonized with VRE either before or after transplantation had longer stays in the intensive care unit and the hospital. Mortality at 90 days was significantly greater among those who acquired VRE after transplantation (5 [23%] of 22), compared with those who had VRE colonization before transplantation (2 [9%] of 22).
  
  
  CONCLUSIONS
  Liver transplantation candidates with VRE colonization before transplantation experience greater morbidity but not greater mortality, compared with noncolonized candidates. Transplant recipients who acquire VRE after transplantation have a higher mortality rate than noncolonized recipients. Strategies should be implemented to reduce nosocomial VRE acquisition after transplantation among this vulnerable group.
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA.
authors.forename: Shelly A
authors.initials: SA
authors.lastname: McNeil
authors.forename: Preeti N
authors.initials: PN
authors.lastname: Malani
authors.forename: Carol E
authors.initials: CE
authors.lastname: Chenoweth
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Fontana
authors.forename: John C
authors.initials: JC
authors.lastname: Magee
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Punch
authors.forename: Monica L
authors.initials: ML
authors.lastname: Mackin
authors.forename: Carol A
authors.initials: CA
authors.lastname: Kauffman
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D002353:Carrier State / Q000382:microbiology*; D016022:Case-Control Studies; D016983:Enterococcus / Q000187:drug effects* / Q000302:isolation & purification; D005260:Female; D016908:Gram-Positive Bacterial Infections / Q000382:microbiology*; D006801:Humans; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011446:Prospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014640:Vancomycin / Q000494:pharmacology*; D020713:Vancomycin Resistance
chemical_list: D000900:Anti-Bacterial Agents; D014640:Vancomycin