title: The clinical and molecular epidemiology of pre-transplant vancomycin-resistant enterococci colonization among liver transplant recipients.
abstract: Vancomycin-resistant enterococci (VRE) infections cause significant morbidity in liver transplant recipients. The epidemiology and impact of pre-transplant colonization with VRE among patients who undergo liver transplantation are poorly understood. We conducted an observational cohort study to identify risk factors and outcomes associated with pre-transplant VRE colonization and described the molecular diversity among VRE strains colonizing patients who undergo liver transplantation. Perirectal VRE surveillance cultures were performed prior to transplantation. Repetitive sequence-based polymerase chain reaction (rep-PCR) testing was used to identify clonality among VRE isolates. Of 61 patients who underwent pre-transplant VRE surveillance and subsequent liver transplantation, 27 (44%) were colonized with VRE. In multivariate analysis, pre-transplant VRE colonization was associated with central venous catheterization (OR 9.4, 95% confidence interval [CI]= 1.3-70.2, p = 0.03) and rifaximin use (OR 15.4, 95% CI 1.5-159.7, p = 0.02). Pre-transplant VRE colonization was associated with more hospital days post-transplant (26.6 vs. 16.1 d, p = 0.04). Of VRE-colonized patients analyzed with rep-PCR, 68% were colonized with the same strain as another patient in the cohort. Active surveillance identifies VRE-colonized patients who may benefit from targeted antimicrobial prophylaxis and enhanced infection prevention measures to prevent VRE spread. The relationship between rifaximin receipt and VRE colonization warrants further study. The identification of similar VRE isolates may suggest linked transmission during pre-transplant hospitalizations, which should be further investigated in prospective studies.
authors.affiliation: Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA.
authors.forename: David B
authors.initials: DB
authors.lastname: Banach
authors.affiliation: Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA.
authors.forename: David R
authors.initials: DR
authors.lastname: Peaper
authors.affiliation: Yale-New Haven Transplantation Center, New Haven, CT, USA.
authors.forename: Brett E
authors.initials: BE
authors.lastname: Fortune
authors.affiliation: Yale-New Haven Transplantation Center, New Haven, CT, USA.
authors.forename: Sukru
authors.initials: S
authors.lastname: Emre
authors.affiliation: Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA.
authors.forename: Louise M
authors.initials: LM
authors.lastname: Dembry
mesh_terms: D000900:Anti-Bacterial Agents / Q000009:adverse effects*; D003237:Connecticut / Q000453:epidemiology; D016983:Enterococcus / Q000187:drug effects* / Q000302:isolation & purification; D005260:Female; D005500:Follow-Up Studies; D016908:Gram-Positive Bacterial Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology / Q000473:pathology; D006801:Humans; D008107:Liver Diseases / Q000382:microbiology / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D014640:Vancomycin / Q000009:adverse effects*; D020713:Vancomycin Resistance
chemical_list: D000900:Anti-Bacterial Agents; D014640:Vancomycin
keywords: active surveillance; liver transplantation; multidrug resistant organisms; vancomycin-resistant enterococci