Surgical Site Infections in the Early Posttransplant Period After Simultaneous Pancreas–Kidney Transplantation

Ultrasound of pancreatic transplant complications: a primer for radiologists

Pancreatic transplantation is an established treatment for patients with type 1 diabetes patients and select type 2 diabetes patients, with excellent survival rates as graft health is evaluated through regular imaging and early detection of complications. Amongst the various imaging methods that may aid in diagnosis of pancreatic transplant complications, ultrasound is a widely available, quick, portable, and cost-effective technique, often used as the sole method to assess for pancreatic transplant complications. When assessing a patient with a pancreatic transplant, the radiologist should be methodical in assessing the vasculature, the pancreatic parenchyma, and the peripancreatic regions. Complications can be categorised based on time from transplant and type of complications, and include vascular, parenchymal, and enteric/anastomotic complications. Doppler has a major role in the diagnosis of vascular complications including arterial and venous thrombosis, arterial stenosis, pseudoaneurysms, and haematomas. Pancreatic complications include rejections and pancreatitis, and are often diagnosed through a combination of clinical, laboratory, and imaging findings, such as pancreatic heterogeneity or the presence of pancreatic pseudocysts. Enteric/anastomotic complications include leaks and bowel obstructions, and may require cross-sectional imaging in addition to ultrasound. This review covers the most common and high-impact vascular, parenchymal, and enteric/anastomotic complications that should be considered in every radiologist's search pattern when assessing a pancreatic graft, as well as their respective postoperative timeframes.

Impact of Perioperative Prophylaxis With Enterococcus Activity on Risk of Surgical-Site Infection After Pancreas Transplantation

Surgical-site infection (SSI) is the most common early infectious complication after pancreas transplantation (PT). Although SSI has been shown to worsen outcomes, little data exist to guide optimal choices in perioperative prophylaxis.

Methods

We performed a retrospective cohort study of PT recipients from 2010-2020 to examine the effect of perioperative antibiotic prophylaxis with Enterococcus coverage. Enterococcus coverage included antibiotics that would be active for penicillin-susceptible Enterococcus isolates. The primary outcome was SSI within 30 d of transplantation, and secondary outcomes were Clostridioides difficile infection (CDI) and a composite of pancreas allograft failure or death. Outcomes were analyzed by multivariable Cox regression.

Results

Of 477 PT recipients, 217 (45.5%) received perioperative prophylaxis with Enterococcus coverage. Eighty-seven recipients (18.2%) developed an SSI after a median of 15 d from transplantation. In multivariable Cox regression analysis, perioperative Enterococcus prophylaxis was associated with reduced risk of SSI (hazard ratio [HR] 0.58; 95% confidence interval [CI], 0.35-0.96; P = 0.034). Anastomotic leak was also significantly associated with elevated risk of SSI (HR 13.95; 95% CI, 8.72-22.32; P < 0.001). Overall, 90-d CDI was 7.4%, with no difference between prophylaxis groups (P = 0.680). SSI was associated with pancreas allograft failure or death, even after adjusting for clinical factors (HR 1.94; 95% CI, 1.16-3.23; P = 0.011).

Conclusions

Perioperative prophylaxis with Enterococcus coverage was associated with reduced risk of 30-d SSI but did not seem to influence risk of 90-d CDI after PT. This difference may be because of the use of beta-lactam/beta-lactamase inhibitor combinations, which provide better activity against enteric organisms such as Enterococcus and anaerobes compared with cephalosporin. Risk of SSI was also related to anastomotic leak from surgery, and SSI itself was associated with subsequent risk of a poor outcome. Measures to mitigate or prevent early complications are warranted.

Surgical site infections after simultaneous pancreas kidney and pancreas transplantation in the Swiss Transplant Cohort Study

BACKGROUND

Among hospital-acquired infections, surgical site infections (SSI) are common. The occurrence of SSIs in the early post-transplant course poses a relevant threat for simultaneous pancreas kidney transplant (SPK-Tx) or pancreas transplant (P-Tx) recipients.

METHODS

Adult SPK-Tx and P-Tx recipients with a follow-up of at least 90 days were identified in the Swiss Transplant Cohort Study (STCS) dataset. Except the categorization of SSIs according to CDC criteria, all other data were prospectively collected. Risk factors for SSIs were investigated with logistic regression. A Weibull accelerated failure-time model was applied to address the impact of SSIs on length of stay, correcting for transplant-related complications and delayed graft function.

RESULTS

Of 130 transplant recipients, 108 SPK-Tx and 22 P-Tx, 18 (14%) individuals developed SSIs within the first 90 days after transplantation. Deep incisional (7, 38.9%) and organ/space infections (8, 44.4%) predominated. In the majority of SSIs (11, 61.1%; 2 SSIs with simultaneous identification of fungal pathogens) bacteria were detected with Enterococcus spp. being most frequent. The median duration of hospitalization after transplantation was significantly longer in recipients with SSI (median 26d; IQR [19, 44]) than in patients without SSI (median 17d; IQR [12, 25], P = 0.002). In multivariable analysis, SSIs were significantly associated with an increased length of stay and prolonged the duration of hospitalization by 36% [95% CI: 4, 79].

CONCLUSIONS

SSIs after SPK-Tx and P-Tx were found at a quite low frequency of 14%. Among pathogens, Enterococcus spp. predominated. SSIs were independently associated with a longer hospitalization after transplantation.

Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.