Vancomycin Resistant Enterococcus (VRE) infection is recognized as a cause of morbidity in liver transplant patients. In the wake of Share 35, sick patients receiving liver transplants may be exposed to more risk factors for development of VRE infection. The purpose of this study was to identify the incidence and risk factors associated with VRE infection in liver transplant patients, as well as review the impact of VRE infection on morbidity and mortality.

Methods

This study was a retrospective, single center review of liver or combined liver-kidney transplants completed from 2010 through 2013. All culture data for enterococcus species through November 2014 was recorded. Patients were defined as having VRE infection if they had positive blood cultures, greater than 100,000 cfu/ml urine culture, sputum cultures or peritoneal, intra-operative, or wound cultures. Demographic data included patient age, MELD score, cause of liver disease, date of transplant and the use of broad-spectrum antibiotics. Outcomes data included all positive cultures for enterococcus, graft loss, and death.

Results

A total of 148 isolates for enterococcus were cultured from 69 out of 311 transplant patients. A total of 31 (10%) patients had 78 different positive VRE cultures that caused infection (18 blood, 11 urine, 5 sputum, and 44 peritoneal, intra-operative or wound culture). Patients developed VRE infections a median of 118 days after transplant. All patients received broad-spectrum antibiotics prior to VRE infection, with 83.9% receiving vancomycin, 77.4% receiving piperacillin/tazobactam, and 51.6% receiving carbapenems.

Of patients who had a pre-transplant MELD score of 35 or greater, 20.6% of patients developed infection with VRE, compared to 8.7% of patients with a MELD of less than 35 (p=0.028). Patients who became infected with VRE had worse graft survival and overall survival than those who did not develop VRE infection, with only 38.7% of VRE infected patients alive at the end of the study period. Patients who did not survive died a median of 49 days after their first VRE infection.

Conclusions: VRE infection is more likely in patients with higher MELD scores pre-transplant and may be due to frequent use of broad-spectrum antibiotics. Antimicrobial stewardship and careful monitoring proves important in this population as VRE infection may be associated with increased graft loss and death.

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