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Surgical Site Infections After Liver Transplantation: Prospective Surveillance and Evaluation of 250 Transplant Recipients in Canada

  • Yoichiro Natori (a1) (a2), Rawan Kassar (a1) (a2), Aled Iaboni (a1), Seyed M. Hosseini-Moghaddam (a1) (a3), James Vu (a1) (a2), Shahid Husain (a1) (a2), Eberhard L. Renner (a1) (a4), David Grant (a1) (a5) and Coleman Rotstein (a1) (a2)...

To evaluate the incidence of surgical-site infections (SSIs) in a cohort of liver transplant recipients and to assess risk factors predisposing patients to these infections.


Prospective observational cohort study.


Single transplant center in Canada.


Patients who underwent liver transplantation between February 2011 and August 2014.


Multivariate logistic regression was used to identify independent risk factors for SSIs in liver transplant patients.


We enrolled 250 liver transplant recipients. The recipients’ median age at the time of transplantation was 56 years (range, 19–70 years), and 166 patients (66.4%) were male. Moreover, 47 SSIs were documented in 43 patients (17.2%). Organ-space, superficial, and deep SSIs were noted in 29, 7, and 3 patients, respectively. In addition, 2 patients developed superficial and organ-space SSIs, and another 2 patients were found to have deep as well as organ-space infections. In total, we identified 33 organ-space SSIs (70.2%), 9 superficial SSIs (19.1%), and 5 deep SSIs (10.6%). Factors predictive of SSIs by multivariate analysis were duct-to-duct anastomosis (odds ratio [OR], 3.88; 95% CI, 1.85–8.13; P<.001) and dialysis (OR, 3.57; 95% CI, 1.02–12.50; P=.046). Of the 66 organisms isolated in both deep and organ-space SSIs, 55 (83%) were resistant to cefazolin.


Organ-space SSIs are a common complication after liver transplantation. Duct-to-duct anastomosis and dialysis were independent risk factors associated with SSIs. Appropriate perioperative prophylaxis targeting patients with duct-to-duct anastomosis and dialysis while simultaneously providing optimum coverage for the potential pathogens causing SSIs is warranted.

Infect Control Hosp Epidemiol 2017;38:1084–1090

Corresponding author
Address correspondence to Coleman Rotstein, MD, University Health Network, Toronto General Hospital, 200 Elizabeth Street, PMB 11-139, Toronto, Ontario M5G 2C4 (
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1. Asensio A, Ramos A, Cuervas-Mons V, et al. Effect of antibiotic prophylaxis on the risk of surgical site infection in orthotopic liver transplant. Liver Transpl 2008;14:799805.
2. García Prado ME, Matia EC, Ciuro FP, et al. Surgical site infection in liver transplant recipients: impact of the type of perioperative prophylaxis. Transplantation 2008;85:18491854.
3. Kawecki D, Chmura A, Pacholczyk M, et al. Surgical site infections in liver recipients in the early posttransplantation period: etiological agents and susceptibility profiles. Transplant Proc 2007;39:28002806.
4. Mehrabi A, Fonouni H, Wente M, et al. Wound complications following kidney and liver transplantation. Clin Transplant 2006;20(Suppl 17):97110.
5. Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Rep 2007;122:160166.
6. Cruse P. Wound infection surveillance. Rev Infect Dis 1981;3:734737.
7. Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013;173:20392046.
8. Anderson DJ, Kaye KS, Chen LF, et al. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS One 2009;4:e8305.
9. Prevention CfDCa. Surgical Site Infection (SSI) Event. Centers for Disease Control and Prevention website. Published 2016. Accessed November 24, 2016.
10. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250278.
11. Iinuma Y, Senda K, Fujihara N, et al. Surgical site infection in living-donor liver transplant recipients: a prospective study. Transplantation 2004;78:704709.
12. Kusne S. Regarding the risk for development of surgical site infections and bacterial prophylaxis in liver transplantation. Liver Transpl 2008;14:747749.
13. Hollenbeak CS, Alfrey EJ, Souba WW. The effect of surgical site infections on outcomes and resource utilization after liver transplantation. Surgery 2001;130:388395.
14. Narayanan Menon KV, Nyberg SL, Harmsen WS, et al. MELD and other factors associated with survival after liver transplantation. Am J Transplant 2004;4:819825.
15. Matsuo K, Sekido H, Morioka D, et al. Surveillance of perioperative infections after adult living donor liver transplantation. Transplant Proc 2004;36:22992301.
16. Hellinger WC, Crook JE, Heckman MG, et al. Surgical site infection after liver transplantation: risk factors and association with graft loss or death. Transplantation 2009;87:13871393.
17. Beltangady M, Knupp CA, Gustafson N, et al. Relation between plasma concentrations of didanosine and markers of antiviral efficacy in adults with AIDS or AIDS-related complex. Clin Infect Dis 1993;16(Suppl 1):S26S31.
18. Viehman JA, Clancy CJ, Clarke L, et al. Surgical site infections after liver transplantation: emergence of multidrug-resistant bacteria and implications for prophylaxis and treatment strategies. Transplantation 2016;100:21072114.
19. Moreno A, Cervera C, Gavaldá J, et al. Bloodstream infections among transplant recipients: results of a nationwide surveillance in Spain. Am J Transplant 2007;7:25792586.
20. Yamamoto M, Takakura S, Iinuma Y, et al. Changes in surgical site infections after living donor liver transplantation. PLoS One 2015;10:e0136559.
21. McElroy LM, Daud A, Davis AE, et al. A meta-analysis of complications following deceased donor liver transplant. Am J Surg 2014;208:605618.
22. Ozaki CF, Katz SM, Monsour HP, Dyer CH, Wood RP. Surgical complications of liver transplantation. Surg Clin North Am 1994;74:11551167.
23. Kusne S, Dummer JS, Singh N, et al. Infections after liver transplantation. An analysis of 101 consecutive cases. Medicine (Baltimore) 1988;67:132143.
24. Keating MR, Wilhelm MP. Management of infectious complications following liver transplantation. Curr Clin Top Infect Dis 1993;13:226249.
25. Kato S, Chmielewski M, Honda H, et al. Aspects of immune dysfunction in end-stage renal disease. Clin J Am Soc Nephrol 2008;3:15261533.
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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