Aim:

Intestinal transplant (ITx) recipients harbor risk factors implicated in surgical site infections (SSI): multiple prior abdominal surgeries, complex operative course, grafts with significant microbial load, ostomy, and immunosuppression. The patterns of SSI in ITx have not yet been characterized. As a preliminary step of a strategy to reduce its incidence, we analyzed SSI rates and distribution in our series of ITx recipients.

Methods:

The records of 187 consecutive ITx patients (107 males, 80 females, 22 infants, 59 children ages 1-5 y, and 66 others, ages 6-66 y) transplanted for intestinal failure at our center between 2004 and 2014 were reviewed. Grafts were 105 small intestine (including colon in 47), 49 liver-intestine, and 33 multivisceral/ modified multivisceral. 144 patients (77%) had primary closure of the abdomen at the time of transplant (no mesh). Immunosuppression consisted of induction (depleting or non-depleting antibodies) and maintenance therapy with tacrolimus, sirolimus, and steroids. Infection prophylaxis consisted of peri-operative broad-spectrum antibacterials, antifungals and antivirals. SSI within the first 30 post-operative days was classified into superficial, deep, and organ-space (CDC guidelines).

Results:

Overall, 74/187 recipients (40%) developed 4 (5%) superficial, 11 (15%) deep, and 59 (80%) organ space SSI with no significant gender (male 35%, female 45% p=0.27) or age differences (infants 27%, children age 1-5y 33%, others 44%; p=0.1). The majority of SSI (47%) grew mixed cultures, followed by Enterococcus spp.(17%) and Staph-Strept spp. (9%). 64% of multivisceral recipients had SSI compared to 34% of other grafts (p=0.0008). The inclusion of the colon did not increase the incidence of SSI (34% vs. 34%). SSI occurred in 57% of patients with mesh closure or delayed abdominal closure compared to 34% of primary closure (p=0.003).

Conclusion:

Polymicrobial SSI occurred in 40% of ITx in our series, mostly as organ space infection. Recipients of multivisceral grafts and patients with mesh or delayed abdominal closure were significantly more prone to SSI compared to others. In line with our previous study, the inclusion of the colon in the graft did not increase the frequency of SSI. Future studies and treatment strategies are needed for an effective prevention of SSI after ITx.

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