Postoperative Infections and Antimicrobial Prophylaxis in the Pediatric Intensive Care Unit After Liver Transplantation in Children

Objective: To determine the incidence and risk factors for postoperative infections (POI) after pediatric liver transplantation (LT) while in the pediatric intensive care unit (PICU). Methods: This is a multicenter, retrospective cohort study of isolated pediatric LT recipients from 12 LT centers in the United States over 2 years. Pre- and postoperative variables were examined to determine POI risk factors during the PICU admission. Antimicrobial prophylaxis utilization was assessed. Comparative statistics were performed using chi-squared and Mann–Whitney U tests. Multivariable logistic regression modeling evaluated POI risk factors. Results: 76/327 (23%) patients developed POI (47% bacterial, 3% viral, 4% fungal, 22% polymicrobial, and 21% clinically adjudicated, culture negative). Abdominal/surgical site and bloodstream infections were most common at 29% and 26%, respectively. Independent predictors of POI included age under 1 (OR = 2.37 [95% CI 1.36–4.13], p = 0.002), open fascia (OR = 3.15 [95% CI 1.77–5.61], p < 0.001), and hospitalization pre-transplant (OR = 2.09 [95% CI 1.20–3.64], p = 0.009). Patients with POI had longer hospitalizations (23.0 days [17.0–34.0] vs. 13.0 days [9.0–20.0], p < 0.001), higher graft loss rates (9% vs. 0.4%, p < 0.001), and greater mortality (5% vs. 0.4%, p = 0.01). Significant variability in antimicrobial regimens existed amongst transplant centers. Conclusions: One in five patients developed POI while in the PICU. Predictors of POI included younger age, open fascia, and hospitalization pre-transplantation. POIs were associated with significant morbidity, including prolonged length of stay, graft loss, and mortality. Future prospective studies are needed to optimize antimicrobial regimens to prevent POI and improve outcomes.