Authors: Anesi, Judith A. MD et al
Transplantation: January 2018 – Volume 102 – Issue 1 – p 21–34
Antibiotic prophylaxis in the perioperative period is the standard of care for nearly all surgical procedures and routinely prescribed during solid organ transplantation (SOT). The primary goal of perioperative antibiotic prophylaxis is to minimize postoperative surgical site infections (SSIs). SSIs are a significant issue in SOT. Depending on the organ transplanted, SSIs occur in 3% to 53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. SOT recipients are also at increased risk of developing SSIs with antimicrobial-resistant organisms. In this article, we describe the epidemiology and risk factors for SSIs in SOT and examine the available literature to guide the use of different regimens for perioperative antibiotic prophylaxis for each organ. We have further addressed specific situations that are unique to each organ transplant type, such as the use of extracorporeal membrane oxygenation in thoracic organ transplantation, as well as an approach to perioperative antibiotic prophylaxis in the setting of recipient and/or donor infection before transplantation. We provide potential approaches to the selection, dosing, and duration of perioperative antibiotic prophylaxis for each of these clinical situations.
According to the Centers for Disease Control and Prevention, approximately 16 million operative procedures were performed in acute care hospitals in the United States in 2010. In 2015, the Organ Procurement and Transplantation Network reported that 30 973 solid organ transplantation (SOT) procedures were performed in the US. Although there has been progress in infection control practices, surgical site infections (SSIs) remain one of the most common healthcare-associated infections and a substantial cause of morbidity, prolonged hospitalization, and death.
Antibiotic prophylaxis (ppx) in the perioperative period is the standard of care for nearly all surgical procedures, including SOT. Although there have been intermittent reports that question its efficacy, evidence points to a benefit of perioperative antibiotic ppx in reducing postoperative SSIs in SOT recipients. However, specific antibiotic regimens and durations vary widely across transplant centers and SOT procedures, and the quality of the evidence supporting specific practices is varied.
Currently, there are no formal recommendations on perioperative antibiotic ppx in SOT outside of the “Clinical practice guidelines for antimicrobial ppx in surgery” by the Infectious Diseases Society of America, American Society of Health-System Pharmacists, Surgical Infection Society, and Society for Healthcare Epidemiology of America (IDSA/ASHP/SIS/SHEA guidelines). These provide general prophylactic antibiotic recommendations for SOT but do not address the unique circumstances of the transplant population. Thus, the IDSA/ASHP/SIS/SHEA guidelines are not used in many transplant centers in the United States. Given the complexities of SOT and the unique risks for SSIs, guidance that is more customized to each SOT scenario is needed. To date, no formal guidelines for antimicrobial perioperative ppx have been published by any of the SOT societies as well. In the absence of formal guidelines, we believe there is value in sharing possible best practices based on the available data. Consequently, in this article, we describe the epidemiology and risk factors for SSIs and the available evidence for different perioperative antibiotic ppx regimens individualized by organ transplant type. We also address specific situations unique to each organ and provide a possible approach to perioperative antibiotic ppx. The potential approaches to perioperative ppx outlined at the conclusion of each section in this article represent the opinion of the authors and reflect the approaches used at their institutions; these possible approaches will not be graded because they are not formal guidelines, and in many cases, there is very limited data on which to base these recommendations.