title: Coagulase-negative staphylococcus and enterococcus as predominant pathogens in liver transplant recipients with Gram-positive coccal bacteremia.
abstract: BACKGROUND
  Gram-positive bacteria such as Staphylococcus aureus have been a common cause of infection among liver transplant (LT) recipients in recent decades. The understanding of local epidemiology and its evolving trends with regard to pathogenic spectra and antibiotic susceptibility is beneficial to prophylactic and empiric treatment for LT recipients. This study aimed to investigate etiology, timing, antibiotic susceptibility and risk factors for multidrug resistant (MDR) Gram-positive coccal bacteremia after LT.
  
  
  METHODS
  A cohort analysis of prospectively recorded data was performed to investigate etiologies, timing, antibiotic susceptibility and risk factors for MDR Gram-positive coccal bacteremia in 475 LT recipients.
  
  
  RESULTS
  In 475 LT recipients in the first six months after LT, there were a total of 98 episodes of bacteremia caused by Gram-positive cocci in 82 (17%) patients. Seventy-five (77%) bacteremic episodes occurred in the first post-LT month. The most frequent Gram-positive cocci were methicillin-resistant coagulase-negative staphylococcus (CoNS, 46 isolates), methicillin-resistant Staphylococcus aureus (MRSA, 13) and enterococcus (34, E. faecium 30, E. faecalis 4). In all Gram-positive bacteremic isolates, 59 of 98 (60%) were MDR. Gram-positive coccal bacteremia and MDR Gram-positive coccal bacteremia predominantly occurred in patients with acute severe exacerbation of chronic hepatitis B and with fulminant/subfulminant hepatitis. Four independent risk factors for development of bacteremia caused by MDR Gram-positive coccus were: LT candidates with encephalopathy grades II - IV (P = 0.013, OR: 16.253, 95%CI: 1.822 - 144.995), pre-LT use of empirical antibiotics (P = 0.018, OR: 1.029, 95%CI: 1.002 - 1.057), post-LT urinary tract infections (P < 0.001, OR: 20.340, 95%CI: 4.135 - 100.048) and abdominal infection (P = 0.004, OR: 2.820, 95%CI: 1.122 - 10.114). The main infectious manifestations were coinfections due to gram-positive cocci and gram-negative bacilli.
  
  
  CONCLUSIONS
  Methicillin-resistant CoNS and enterococci are predominant pathogens among LT recipients with Gram-positive coccal bacteremia. Occurrences of Gram-positive coccal bacteremia may be associated with the severity of illness in the perioperative stage.
authors.affiliation: Department of Hepatobiliary Surgery and Center of Liver Transplantation, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, China.
authors.forename: Shao-hua
authors.initials: SH
authors.lastname: Shi
authors.forename: Hai-shen
authors.initials: HS
authors.lastname: Kong
authors.forename: Chang-ku
authors.initials: CK
authors.lastname: Jia
authors.forename: Jian
authors.initials: J
authors.lastname: Xu
authors.forename: Wen-jin
authors.initials: WJ
authors.lastname: Zhang
authors.forename: Wei-lin
authors.initials: WL
authors.lastname: Wang
authors.forename: Yan
authors.initials: Y
authors.lastname: Shen
authors.forename: Min
authors.initials: M
authors.lastname: Zhang
authors.forename: Shu-sen
authors.initials: SS
authors.lastname: Zheng
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology; D016470:Bacteremia / Q000209:etiology / Q000382:microbiology*; D003030:Coagulase / Q000378:metabolism*; D024901:Drug Resistance, Multiple, Bacterial; D016983:Enterococcus / Q000187:drug effects / Q000201:enzymology / Q000502:physiology*; D016908:Gram-Positive Bacterial Infections / Q000201:enzymology / Q000382:microbiology / Q000635:transmission*; D006801:Humans; D008107:Liver Diseases / Q000382:microbiology; D016031:Liver Transplantation / Q000009:adverse effects*; D012307:Risk Factors; D013203:Staphylococcal Infections / Q000201:enzymology / Q000382:microbiology / Q000635:transmission*; D013210:Staphylococcus / Q000187:drug effects / Q000201:enzymology / Q000502:physiology*
chemical_list: D000900:Anti-Bacterial Agents; D003030:Coagulase