Purpose

Daptomycin (DAP) has become an important therapeutic agent to treat infections due to vancomycin-resistant Enterococcus faecium (VRE), including in liver transplant recipients (LTRs); however, DAP-nonsusceptible enterococci (DNSE) are being reported with increasing frequency. The purpose of this study was to compare clinical characteristics and outcomes of LTRs with infections due to DNSE and DAP-susceptible VRE (DS-VRE) in a single institution.

Methods

Patients who underwent liver transplantation between 1/1/2010 and 7/31/ 2014 and developed DS-VRE and DNSE infection post-transplant were identified via review of existing databases. Clinical data were abstracted from the electronic medical record. Comparison of categorical and continuous variables between groups was performed using the Fisher's exact test and the Mann-Whitney U test, respectively.

Results

Fourteen LTRs developed DNSE and 26 LTRs developed DS-VRE infection post-transplantation. No significant differences were observed in demographics, model for end-stage liver disease (MELD) scores, causes of end-stage liver disease (ESLD), need for repeat surgery, incidence of acute rejection, and rate of pre-transplant perirectal VRE-colonization between groups. The duration of transplant hospitalization was significantly longer (median 31 days, interquartile range [IQR] 12-53) in the DNSE group than in the DS-VRE group (median 11 days, IQR 7-26) (P=0.021). Patients developed DS-VRE infection more rapidly (median 16 days, IQR 9-37) than DNSE infection (median 74.5 days, IQR 30-151) (P=0.010) following transplantation and were less likely to have been exposed to DAP prior to the onset of infection (4% versus 93%, P<0.001). The mortality rate associated with DNSE infection was significantly higher than that associated with DS-VRE infection (57% versus 15%, P=0.011).

Conclusions

While LTRs are known to be at increased risk for VRE acquisition and have an increased mortality associated with VRE infection, little is known regarding the epidemiology of DNSE in this population. Our data suggest worse outcomes for LTRs who develop DNSE infection compared to those who develop DS-VRE infection post-transplantation. Further study is needed to determine whether poor outcomes were due to failure in treatment or other factors and to identify opportunities to prevent and treat DNSE infections in LTRs.

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