title: Bundled strategies against infection after liver transplantation: Lessons from multidrug-resistant Pseudomonas aeruginosa.
abstract: Infection is a life-threatening complication after liver transplantation (LT). A recent outbreak of multidrug-resistant Pseudomonas aeruginosa triggered changes in our infection control measures. This study investigated the usefulness of our bundled interventions against postoperative infection after LT. This before-and-after analysis enrolled 130 patients who underwent living donor or deceased donor LT between January 2011 and October 2014. We initiated 3 measures after January 2013: (1) we required LT candidates to be able to walk independently; (2) we increased the hand hygiene compliance rate and contact precautions; and (3) we introduced procalcitonin (PCT) measurement for a more precise determination of empirical antimicrobial treatment. We compared factors affecting the emergence of drug-resistant microorganisms, such as the duration of antimicrobial and carbapenem therapy and hospital stay, and outcomes such as bacteremia and death from infection between before (n = 77) and after (n = 53) the LT suspension period. The utility of PCT measurement was also evaluated. Patients' backgrounds were not significantly different before and after the protocol revision. Incidence of bacteremia (44% versus 25%; P = 0.02), detection rate of multiple bacteria (18% versus 4%; P = 0.01), and deaths from infections (12% versus 2%; P =  0.04) significantly decreased after the protocol revision. Duration of antibiotic (42.3 versus 25.1 days; P =  0.002) and carbapenem administration (15.1 versus 5.2 days; P < 0.001) and the length of postoperative hospital stay (85.4 versus 63.5 days; P =  0.048) also decreased after the protocol revision. PCT mean values were significantly higher in the bacteremia group (10.10 ng/mL), compared with the uneventful group (0.65 ng/mL; P =  0.002) and rejection group (2.30 ng/mL; P =  0.02). One-year overall survival after LT significantly increased in the latter period (71% versus 94%; P =  0.001). In conclusion, the bundled interventions were useful in preventing infections and lengthening overall survival after LT.
authors.affiliation: Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto, Japan.
authors.forename: Asahi
authors.initials: A
authors.lastname: Sato
authors.affiliation: Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto, Japan.
authors.forename: Toshimi
authors.initials: T
authors.lastname: Kaido
authors.affiliation: Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto, Japan.
authors.forename: Taku
authors.initials: T
authors.lastname: Iida
authors.affiliation: Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto, Japan.
authors.forename: Shintaro
authors.initials: S
authors.lastname: Yagi
authors.affiliation: Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto, Japan.
authors.forename: Koichiro
authors.initials: K
authors.lastname: Hata
authors.affiliation: Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto, Japan.
authors.forename: Hideaki
authors.initials: H
authors.lastname: Okajima
authors.affiliation: Department of Infection Control and Prevention, Kyoto University, Kyoto, Japan.
authors.forename: Shunji
authors.initials: S
authors.lastname: Takakura
authors.affiliation: Department of Infection Control and Prevention, Kyoto University, Kyoto, Japan.
authors.forename: Satoshi
authors.initials: S
authors.lastname: Ichiyama
authors.affiliation: Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto, Japan.
authors.forename: Shinji
authors.initials: S
authors.lastname: Uemoto
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016470:Bacteremia / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*; D002116:Calcitonin / Q000097:blood; D015780:Carbapenems / Q000627:therapeutic use*; D002985:Clinical Protocols; D024901:Drug Resistance, Multiple, Bacterial / Q000187:drug effects*; D005260:Female; D063373:Hand Hygiene; D006801:Humans; D015994:Incidence; D017053:Infection Control / Q000379:methods; D007564:Japan / Q000453:epidemiology; D007902:Length of Stay; D008107:Liver Diseases / Q000601:surgery; D016031:Liver Transplantation / Q000009:adverse effects*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D011550:Pseudomonas aeruginosa / Q000502:physiology; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D015780:Carbapenems; D002116:Calcitonin