Published online Dec 7, 2020. doi: 10.3748/wjg.v26.i45.7191
Peer-review started: September 17, 2020
First decision: October 17, 2020
Revised: October 30, 2020
Accepted: November 9, 2020
Article in press: November 9, 2020
Published online: December 7, 2020
Bacterial infections continue to be the most common infectious complication after liver transplantation (LT), usually within 2 mo after LT. Immunosuppression (IS) is the single most important factor contributing to the incidence of infections in transplant recipients.
The management of IS therapy during infection after LT is highly controversial, although IS reduction (partially discontinue or reduce the dosage of at least one IS agent) or complete withdrawal may be a generally accepted option in life-threatening infections. Few studies are available on the management of IS treatment in the LT recipients complicated with infection.
To describe our experience in the management of IS treatment during bacterial bloodstream infection (BSI) in LT recipients and assess the effect of temporary IS withdrawal on 30 d mortality of recipients presenting with severe infection.
A retrospective study was conducted with the patients diagnosed with BSI after LT in the Department of Liver Surgery, Renji Hospital from January 1, 2016 through December 31, 2017. All recipients diagnosed with BSI infections after LT were included in this study. Univariate and multivariate Cox regression analysis of risk factors for 30 d mortality was conducted in LT patients with Gram-negative bacterial (GNB) infections.
Seventy-four episodes of BSI were identified in 70 LT recipients, including 45 episodes of Gram-positive bacterial (GPB) infections in 42 patients and 29 episodes of Gram-negative bacterial infections in 28 patients. Overall, IS reduction (at least 50% dose reduction or cessation of one or more immunosuppressive agent) was made in 28 (41.2%) cases, specifically, in 5 (11.9%) cases with GPB infections and 23 (82.1%) cases with GNB infection. The 180 d all-cause mortality rate was 18.5% (13/70). The mortality rate in GNB group (39.3%, 11/28) was significantly higher than that in GPB group (4.8%, 2/42) (P = 0.001). All the deaths in GNB group were attributed to worsening infection secondary to IS withdrawal but the deaths in GPB group were all due to graft-versus-host disease. GNB group was associated with significantly higher incidence of intra-abdominal infection, IS reduction, and complete IS withdrawal than GPB group (P < 0.05). Cox regression showed that rejection (adjusted hazard ratio 7.021, P = 0.001) and complete IS withdrawal (adjusted hazard ratio 12.65, P = 0.019) were independent risk factors for 30 d mortality in patients with GNB infections after LT.
IS reduction is more frequently associated with GNB infection than GPB infection in LT recipients. Complete IS withdrawal should be cautious due to increased risk of mortality in the LT recipients complicated with BSI.
IS reduction may be a generally accepted option in life-threatening infections after LT. However, this practice must be discussed thoroughly, as it seems to be associated with worse outcome in patients with BSI. A multidisciplinary approach, timely and appropriate successful antimicrobial therapy, and source control, when necessary, may be safer and more effective than IS reduction therapy in recipients with BSI after LT.