*Purpose: Spontaneous bacterial peritonitis prophylaxis (SBP-P) is increasingly prescribed to patients awaiting liver transplantation (LT), but its impact on multidrug resistant organisms (MDRO) or the presence of Clostridium difficile infections (CDI) post-LT is unclear.

*Methods: All adult LT recipients from 1/1/2010-12/31/2016 at our center were retrospectively reviewed. Per clinical protocol, surveillance of MDR gram negative rods (GNR) and vancomycin-resistant Enterococcus (VRE) via rectal swabs was performed in all patients at the time of LT. In addition, all cultures and CDI testing in the first year post-LT were evaluated. Patients missing an MDRO swab or SBP-P information were excluded. The primary outcome was the presence of a post-LT positive MDRO culture (either swab at time of LT or culture within 1 year post-LT) with a secondary outcome being the presence of post-LT CDI. SBP-P was defined as presence of an outpatient prescription for an antibiotic recommended for use as SBP-P at least 1 month prior to LT. Multivariable logistic regression was used to predict outcomes. Cox proportional hazard ratios were used to evaluate for association with post-LT mortality.

*Results: Of the 590 patients who underwent LT, 462 (78.3%) were included in the study. 86 (18.6%) were on SBP-P – 78 (90.7%) on a fluoroquinolone and 8 (9.3%) on trimethoprim-sulfamethoxazole. The median age was 59 years and 65% were male with no significant differences in baseline characteristics between those with and without SBP-P, including MELD at LT. Patients taking SBP-P had significantly more post-LT positive MDRO cultures (27.9% vs. 15.5%, p=0.007), but only trended towards significance in post-LT CDI prevalence (18.6% vs. 12.1%, p=0.11). On multivariable analysis, controlling for recipient age, days in ICU post-LT, and lab MELD at LT, SBP-P significantly predicted a positive post-LT MDRO culture (OR 2.11, 95% CI 1.20-3.72, p=0.01) but not CDI (p=0.15). The antibiotic used for SBP-P was not significantly associated with post-LT MDR cultures. While SBP-P (HR 1.47, 95% CI 0.88-2.57, p=0.14) did not impact mortality, the presence of a positive MDR culture significantly increased risk of mortality (HR 2.27, 95% CI 1.42-3.63, p=0.001).

*Conclusions: SBP-P is associated with an increased risk of post-LT MDRO culture positivity, but not CDI. Given these findings, caution for use of SBP-P in patients without strong indications should be considered.

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