title: A single-center experience with infections due to daptomycin-nonsusceptible Enterococcus faecium in liver transplant recipients.
abstract: BACKGROUND
  Infections caused by vancomycin-resistant Enterococcus faecium (VRE) are a major cause of morbidity and mortality in the liver transplant population. Daptomycin (DAP) is often used to treat infections caused by VRE, but DAP nonsusceptibility in Enterococcus is increasing.
  
  
  METHODS
  Patients with DAP-nonsusceptible Enterococcus (DNSE) infections who had undergone liver transplantation between January 1, 2010 and July 31, 2014 were retrospectively reviewed. A convenience sample of DNSE isolates was analyzed by pulsed-field gel electrophoresis (PFGE).
  
  
  RESULTS
  We identified 14 liver transplant recipients (LTRs) who developed DNSE infections post transplantation. Postoperative complications were common, and most patients required repeat abdominal surgery within 90 days of transplantation. The initial DNSE culture was taken a median of 74.5 days post transplant and was secondary to an intra-abdominal infection in all but 1 patient. Half of patients were VRE colonized before or at the time of organ transplantation, and all those who were not VRE colonized at the time of transplantation later became colonized, a median of 27 days post transplant. Overall mortality in this cohort was 71%. PFGE did not demonstrate genetic relatedness among DNSE isolates.
  
  
  CONCLUSIONS
  This study, the largest published series to our knowledge of DNSE infections in LTRs, demonstrates that these infections occur in patients with serious surgical complications and are associated with high morbidity and mortality. Established risk factors for VRE infection were common, as was DAP exposure. Although many risk factors for DNSE infection cannot be changed, this case series identifies several potentially modifiable variables. Further work is needed to identify interventions to decrease the risk of developing DNSE infections in this complex patient population.
authors.affiliation: Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: J D
authors.initials: JD
authors.lastname: Lewis
authors.affiliation: Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.|Office of Hospital Epidemiology/Infection Prevention & Control, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: K B
authors.initials: KB
authors.lastname: Enfield
authors.affiliation: Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: H L
authors.initials: HL
authors.lastname: Cox
authors.affiliation: Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: A J
authors.initials: AJ
authors.lastname: Mathers
authors.affiliation: Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.|Office of Hospital Epidemiology/Infection Prevention & Control, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: C D
authors.initials: CD
authors.lastname: Sifri
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D017576:Daptomycin / Q000494:pharmacology*; D024881:Drug Resistance, Bacterial; D018432:Drug Resistance, Multiple; D016521:Electrophoresis, Gel, Pulsed-Field; D016984:Enterococcus faecium / Q000187:drug effects* / Q000235:genetics; D005260:Female; D016908:Gram-Positive Bacterial Infections / Q000453:epidemiology / Q000382:microbiology*; D006801:Humans; D015994:Incidence; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D020713:Vancomycin Resistance
chemical_list: D000900:Anti-Bacterial Agents; D017576:Daptomycin
keywords: Enterococcus; daptomycin nonsusceptibility; daptomycin resistance; liver transplant; vancomycin-resistant Enterococcus