Incidence and risk factors for surgical site infection after simultaneous pancreas ekidney transplantation
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Journal of Hospital Infection (2009) 72, 326e331
Available online at www.sciencedirect.com
www.elsevierhealth.com/journals/jhin
Incidence and risk factors for surgical site
infection after simultaneous pancreasekidney
transplantation
L.B. Perdiz a, G.H.C. Furtado a,*, M.M. Linhares b, A.M. Gonzalez b,
J.O.M. Pestana c, E.A.S. Medeiros a
a
Hospital Epidemiology Committee, Division of Infectious Diseases, Federal University of Sa~o Paulo,
Brazil
b
Department of Surgical Gastroenterology, Federal University of Sa~o Paulo, Brazil
c
Nephrology Division, Federal University of Sa~o Paulo, Brazil
Received 1 December 2008; accepted 27 April 2009
Available online 10 July 2009
KEYWORDS Summary A simultaneous pancreasekidney transplantation (SPKT) is the
Nosocomial infection; best treatment option for type I diabetic patients with advanced chronic
Risk factors; renal failure. Infectious complications affect 7e50% of the patients receiv-
Simultaneous
ing this procedure. We conducted a nested caseecontrol study to assess
pancreasekidney
transplantation;
the risk factors for surgical site infection (SSI) in patients receiving SPKT
Surgical site infection at our centre between 2000 and 2006. Of the 119 evaluated transplant
recipients, 55 (46.2%) developed SSIs and the 30 day mortality was
11.8%. Gram-negative organisms were the predominant organisms isolated
from SSIs. After multivariate logistic regression, the variables indepen-
dently associated with SSI were: acute tubular necrosis, post-transplant
fistula and graft rejection. This study demonstrated a high incidence of
SSI in this patient cohort and variables related to the surgical procedure
were closely associated with the development of SSI.
ª 2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.
Introduction
Simultaneous pancreasekidney transplantation
(SPKT) is the best treatment option for type I
* Corresponding author. Address: R. Dr. Diogo de Faria 1226,
~o Paulo-SP 04037-004, Brazil. Tel./fax: þ55 11 5571
apt 72, Sa
diabetic patients with advanced chronic renal
8935. failure.1 The increasing success in pancrease
E-mail address: ghfurtado@uol.com.br kidney transplantation is a result of advances in
0195-6701/$ - see front matter ª 2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2009.04.016SSI following pancreasekidney transplantation 327
surgical techniques, organ preservation, anti-rejection Variables related to donors and recipients were
therapy and the effective use of antibiotics to assessed. Data were extracted from patients’
prevent and treat infectious complications.2,3 medical records using a structured data instru-
Postoperative infectious complications affect ment. Data related to recipients included age,
w7e50% of the patients undergoing a pancreas gender, duration of renal failure, duration of pre-
transplant, with some studies documenting an transplant dialysis, post-transplant blood transfu-
infection incidence of >75%.4e7 Surgical site infec- sion, length of intensive care unit (ICU) and
tions (SSIs), abscesses and urinary tract infections hospital stay, presence and duration of invasive
(UTIs) are the most prevalent infections detected procedures, Acute Physiologic and Chronic Health
in these studies. Evaluation (APACHE) II score, pre-transplant in-
Postoperative infections remain a significant fection, duration of surgery, duration of cold renal
source of morbidity and mortality in spite of and pancreas ischaemia, length of venous anasto-
available prophylactic and empirical antibiotic mosis, American Society of Anesthesiologists (ASA)
treatment regimens.8 score, postoperative complications, use and dura-
In kidney transplantation, UTI and SSI are the tion of ureteric stent, immunosuppressive regimen
two most frequent nosocomial infections in the and graft rejection and graft loss. The potential
recipients. UTIs affect >50% of the patients during causative micro-organisms were also evaluated.
the first three months post transplantation and are For the donors we evaluated age, gender, cause of
the most frequent source of bacteraemia during death, prior history of substance use, length of ICU
this period.9,10 stay, presence of infection, antibiotic therapy and
Few reports have analysed the infectious com- blood transfusions.
plications in patients receiving pancreasekidney The great majority of patients transplanted
transplant. The aim of this study was to assess the received an immunosuppressive regimen consisting
incidence and risk factors for SSI in a cohort of of prednisone, tacrolimus and mycophenolate
patients. mofetil. Mycophenolate mofetil was replaced by
mycophenolic acid in several patients. Induction
treatment was used and consisted of antithymo-
Methods cyte globulin (ATG).
Antimicrobial prophylaxis was standardised and
Setting consisted of ceftriaxone and ampicillin that was
given up to seven days after transplantation.
~o Paulo is a 650-bed tertiary care teach-
Hospital Sa Cotrimoxazole was given as prophylaxis for both
ing hospital belonging to the Federal University of UTIs and Pneumocystis jiroveci pneumonia. Anti-
~o Paulo, in Sa
Sa ~o Paulo, Brazil. From December 2000 fungal prophylaxis was not routinely used.
to December 2006, 122 pancreasekidney trans-
plants were performed at the hospital. Statistical analysis
Cohort study To assess the association between individual risk
factors in a univariate analysis, we used the c2-test
The study used a cohort of patients who under- for the analysis of ratios or Fisher’s exact test. Con-
went SPKT in the period from 1 December 2000 to tinuous variables were assessed using Student’s
31 December 2006. The patient records were t-test or the ManneWhitney test, as applicable.
assessed for the development of SSI in the one- P 0.05 was considered significant. To identify any
month period post transplantation using the Cen- correlation between the significant variables identi-
ters for Disease Control and Prevention criteria.11 fied in the univariate analysis, we conducted a corre-
These infections were divided into superficial and lation analysis using the Spearman coefficient.
deep infections. Briefly, a superficial wound infec- The multivariate analysis was performed using
tion was defined as involvement of skin or subcuta- multiple logistic regression of the variables iden-
neous tissue around the incision and deep wound tified in the univariate analysis with P 0.05 and
infection by involvement of intra-abdominal tissue. the stepwise forward method was used. Again,
A nested caseecontrol study was conducted to P 0.05 was considered significant.
assess the risk factors for SSI. The study used as
cases all patients who developed SSI in the one- Results
month period post transplantation, and the con-
trols were the remaining patients of the same From 1 December 2000, when pancreasekidney
cohort, who did not develop infection. transplantation was started at the institution, to328 L.B. Perdiz et al.
31 December 2006, 122 SPKTs were performed. Several variables related to the recipients
Three transplant cases were excluded due to (Table I), surgery (Table II) and donors (Table III)
incomplete medical records, leaving 119 trans- were assessed as risk factors for the development
plant cases for further study. The mean age of of SSIs using univariate analysis.
the patients receiving SPKT was 34 years, ranging Factors identified as significant (P 0.05) in uni-
from 16 to 51 years, and 52% were female patients. variate analysis were then analysed by multivariate
On average, patients remained hospitalised for analysis (Table IV). From the univariate analysis this
25 days post transplant (range: 3e322 days). included: length of stay in ICU (P ¼ 0.007), acute
The 30 day mortality was 11.8%. Infectious com- tubular necrosis (P < 0.001), use of ureteric
plications were detected in 73 of the 119 patients: stent (P ¼ 0.03), post-transplant oliguria/anuria
55 (46.2%) patients developed SSI, 29 (24.4%) (P ¼ 0.01), post-transplant fistula (P ¼ 0.01), reop-
developed UTI, 9 (7.5%) developed a bloodstream eration (P ¼ 0.01), graft rejection (P ¼ 0.01), length
infection, and 4 (3.4%) developed pneumonia. Some of use of a central venous catheter (P ¼ 0.02) and
patients presented with more than one infection. postoperative complications (P ¼ 0.003).
In 36 of 55 patients (65.4%) a specific pathogen Following the multivariate logistic regression,
was determined. The distribution of micro-organ- the variables independently associated with SSI
isms was as follows: Klebsiella pneumoniae (N ¼ 10; were: acute tubular necrosis (OR: 4.4; 95% CI:
28%), Staphylococcus aureus (N ¼ 8; 22%), Pseudo- 1.77e10.99; P ¼ 0.001), post-transplant fistula
monas aeruginosa (N ¼ 8; 22%), Acinetobacter (7.25; 1.35e38.99; P ¼ 0.02) and graft rejection
baumannii (N ¼ 4; 11%), Enterococcus spp. (N ¼ 2; (4.28; 1.59e11.48; P ¼ 0.004).
5.5%), Providencia spp. (N ¼ 1; 3%), Serratia spp.
(N ¼ 1; 3%), Enterobacter spp. (N ¼ 1; 3%) and
Candida tropicalis (N ¼ 1; 3%). Forty-two percent Discussion
of the Klebsiella pneumoniae strains harboured an
extended-spectrum b-lactamase (ESBL). No out- In our study population, 73 of 119 (61%) patients
break occurred during the study period. receiving SPKT developed a healthcare-related
The average length of the hospital stay for patients infection. SSI occurred in 55 (46.2%) patients,
who developed SSI was 35 days, whereas for the followed by UTI in 29 (24.4%) patients, bloodstream
patients in the control group it was 16 days (P ¼ 0.003). infection in 9 (7.5%) and pneumonia in 4 (3.4%).
Table I Univariate analysis of risk factors for surgical site infection (SSI) after simultaneous pancreasekidney
transplantation: variables related to recipients
Patients with SSI Patients without SSI P
N ¼ 55 N ¼ 64
Female 29 (53%) 33 (52%) NS
Age (years)a 34 (19e51) 34 (16e50) NS
Duration of chronic renal failure (years)a 4 (1e7) 3 (0.5e11) NS
Duration of pre-transplant dialysis (years)a 3 (0.5e8) 2 (0.08e9) NS
Post-transplant blood transfusion 36 (67%) 35 (55%) NS
Length of stay in ICU (days)a 4 (1e22) 2 (1e6) NS
Length of hospital stay (days)a 17 (4e30) 16 (3e30) NS
APACHE II score >15 2 (2.5%) 4 (6%) NS
Invasive procedures
IUC 55 (100%) 64 (100%) ***
CVC 53 (96%) 63 (98%) NS
MV 6 (11%) 5 (8%) NS
Length of use (days)a of:
IUC 7 (1e13) 7 (4e27) NS
CVC 7 (1e15) 5 (1e13) NS
MV 4 (1e12) 2 (1e5) NS
Drain 7 (1e18) 6 (2e14) NS
Pre-transplant infection 5 (10%) 3 (5%) NS
ICU, intensive care unit; APACHE II, Acute Physiologic and Chronic Health Evaluation II; IUC, indwelling urinary catheter; CVC,
central venous catheter; MV, mechanical ventilation; NS, not significant.
***P-value.
a
Mean (range).SSI following pancreasekidney transplantation 329
Table II Univariate analysis of risk factors for surgical site infection (SSI) after simultaneous pancreasekidney
transplantation: surgery-related factors
Patients with SSI Patients without SSI P
N ¼ 55 N ¼ 64
Surgery duration >6 h 44 (81%) 50 (79%) NS
Duration of cold renal ischaemia (h)a 14 (6e26) 14 (1e29) NS
Duration of cold pancreas ischaemia (h)a 13 (6e27) 14 (2e27) NS
Length of venous anastomosis (min)a 37 (23e50) 39 (20e80) NS
ASA NS
2 4 (21%) 2 (12%)
3 13 (68%) 9 (53%)
4 2 (11%) 6 (35%)
Postoperative complications 42 (76%) 32 (50%) 0.003
Acute tubular necrosis 26 (47%) 11 (17.5%)330 L.B. Perdiz et al.
Table III Univariate analysis of risk factors for surgical site infection (SSI) after simultaneous pancreasekidney
transplantation: variables related to donors
Patients with SSI Patients without SSI P
N ¼ 55 N ¼ 64
Male 33 (60%) 37 (58%) NS
Age (years)a 27 (13e45) 24 (10e45) NS
Cause of death
Head trauma 27 (50%) 23 (36%) NS
Stroke 11 (20%) 19 (30%) NS
Gunfire wound 10 (18.5%) 13 (21%) NS
Subarachnoid haemorrhage 3 (5.5%) 4 (6%) NS
Brain tumour 2 (4%) 4 (6%) NS
Prior history
Alcohol 3 (6%) 3 (5%) NS
Smoking 7 (13.5%) 7 (12%) NS
Drug abuse 5 (10%) 2 (3%) NS
Hypertension 3 (6%) 4 (7%) NS
Length of stay in ICU (days)a 5 (1e11) 4 (1e14) NS
Presence of infection 21 (38%) 26 (41%) NS
Pneumonia 12 (26%) 16 (28%) NS
Bloodstream infection 2 (4%) 3 (5%) NS
Urinary tract infection 1 (2%) 5 (9%) NS
Antibiotic therapy 50 (92%) 57 (89.5%) NS
Blood transfusion 22 (40%) 26 (41%) NS
NS, not significant.
a
Mean (range).
postoperative complications in SPKTs and fungal a significant risk factor (P ¼ 0.002), as well as the
infections in solid-organ transplants.19,20 length of stay in ICU (P ¼ 0.03).
Steurer et al. conducted a study to assess the The length of stay in ICU was also reported as
incidence of intra-abdominal infection in 40 a significant risk factor for the development of
patients who received immunosuppressive therapy fungal infections after solid-organ transplantation
with tacrolimus and micophenolate mofetil follow- (P < 0.0001) by Pugliese et al.20 In our study, the
ing a pancreas transplant.19 They identified the recipient’s length of stay in ICU after the trans-
time of cold renal ischaemia (P ¼ 0.02), time of plantation was significant in the univariate analysis
cold pancreatic ischaemia (P ¼ 0.02), donor age (P ¼ 0.007). However, in the multivariate analysis,
(P ¼ 0.01) and length of hospital stay (P 0.0001) this variable was not shown to be significant.
as significant risk factors. These factors were not In our study, acute graft rejection was also
shown to be significant in our study. shown to be a significant risk factor for SSI in the
In a cohort of 42 patients who underwent SPKT, multivariate analysis (P ¼ 0.004). Reoperation
Martins et al. compared 18 patients with postoper- after the transplantation procedure, although
ative complications with 24 patients who did not significant in the univariate analysis (P ¼ 0.01),
develop postoperative complications in order to was not significant in the multivariate analysis.
identify the associated risk factors.21 The authors Another recent study assessing risk factors for
also found that the length of hospital stay was SSI in kidney transplant recipients undertaken at
Table IV Multivariate analysis of risk factors for surgical site infection after simultaneous pancreasekidney
transplantation
Variable OR 95% CI P
Acute tubular necrosis 4.40 1.77e10.99 0.001
Post-transplant fistula 7.25 1.35e38.99 NS
Graft rejection 4.28 1.59e11.48 0.004
OR, odds ratio; CI confidence interval; NS, not significant.SSI following pancreasekidney transplantation 331
our hospital also identified these two variables as 5. Everett JE, Wahoff DC, Statz C, et al. Characterization and
statistically significant factors for SSI.22 Acute impact of wound infection after pancreas transplantation.
Arch Surg 1994;129:1310e1316. discussion 1316e1317.
graft rejection may predispose the patient to 6. Baktavatsalam R, Little DM, Connolly EM, Farrell JG,
a higher risk of infection, because in these cases Hickey DP. Complications relating to the urinary tract asso-
the patient must receive more aggressive immuno- ciated with bladder-drained pancreatic transplantation.
suppressive therapy, usually with high dose corti- Br J Urol 1998;81:219e223.
costeroids and antithymocyte globulin.21 7. Gettman MT, Levy JB, Engen DE, Nehra A. Urological com-
plications after kidneyepancreas transplantation. J Urol
In addition, some authors have addressed the 1998;159:38e42; discussion 42e43.
infectious complications associated with the type of 8. Patel R, Paya CV. Infections in solid-organ transplant recip-
pancreatic drainage, using the type of drainage as ients. Clin Microbiol Rev 1997;10:86e124.
the dependent variable.13,16,19,23 Our study did not 9. Pirsch JD, Odorico JS, D’Alessandro AM, Knechtle SJ,
assess this variable as a risk factor for infection, Becker BN, Sollinger HW. Posttransplant infection in enteric
versus bladder-drained simultaneous pancreasekidney
since bladder-drained transplants were only used transplant recipients. Transplantation 1998;66:1746e1750.
in the first seven procedures at our hospital; the 10. Smets YF, van der Pijl JW, van Dissel JT, Ringers J,
remaining transplants were all enteric-drained. Lemkes HH, van der Woude FJ. Major bacterial and fungal
In a recent study, Verschuren et al. demon- infections after 50 simultaneous pancreasekidney trans-
strated that the use of prophylactic cotrimoxazole plantations. Transplant Proc 1995;27:3089e3090.
11. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC
in these patients is not a risk factor for urinary sep- definitions for nosocomial infections, 1988. Am J Infect
sis.17 This was one of the few studies that assessed Control 1988;16:128e140.
antimicrobial prophylaxis as a risk factor for infec- 12. Kim RD, Oreopoulos DG, Qiu K, et al. Impact of mode of
tion. However, the authors did not evaluate anti- dialysis on intra-abdominal infection after simultaneous
microbial prophylaxis during surgical procedure. pancreasekidney transplantation. Transplantation 2005;
80:339e343.
Our study also did not assess the use of antimicro- 13. Berger N, Guggenbichler S, Steurer W, et al. Bloodstream
bial prophylaxis, since all patients received the infection following 217 consecutive systemiceenteric
standard regimen. drained pancreas transplants. BMC Infect Dis 2006;6:127.
In summary, our study demonstrated a close 14. Bassetti M, Salvalaggio PR, Topal J, et al. Incidence, timing
relationship between the development of SSI and and site of infections among pancreas transplant recipients.
J Hosp Infect 2004;56:184e190.
variables related to surgical procedure, such as 15. Linhares MM, Gonzalez AM, Triviño T, et al. Simultaneous
acute tubular necrosis, post-transplant fistula and pancreasekidney transplantation: infectious complications
graft rejection. and microbiological aspects. Transplant Proc 2004;36:
980e981.
16. Orsenigo E, Florina P, Cristallo M, et al. Outcome of simul-
taneous kidney pancreas transplantation: a single center
analysis. Transplant Proc 2004;36:1519e1523.
Conflict of interest statement
17. Verschuren JJ, Roos A, Schaapherder AF, et al. Infectious
None declared. complications after simultaneous pancreasekidney trans-
plantation: a role for the lectin pathway of complement
Funding sources activation. Transplantation 2008;85:75e80.
None. 18. Michalak G, Kwiatkowski A, Czerwiński J, et al. Simulta-
neous pancreasekidney transplantation: analysis of donor
factors. Transplant Proc 2003;35:2337e2338.
19. Steurer W, Bonatti H, Obrist P, et al. Incidence of intraabdo-
References minal infection in a consecutive series of 40 enteric-drained
pancreas transplants with FK506 and MMF immunosuppres-
1. Robertson P, Davis C, Larsen J, Stratta R, Sutherland DE, sion. Transpl Int 2000;13(Suppl. 1):S195e198.
American Diabetes Association. Pancreas transplantation 20. Pugliese F, Ruberto F, Cappannoli A, et al. Incidence of fun-
in type 1 diabetes. Diabetes Care 2004;27(Suppl. 1):S105. gal infections in a solid organ recipients dedicated intensive
2. Kaufman DB, Leventhal JR, Koffron AJ, et al. A prospective care unit. Transplant Proc 2007;39:2005e2007.
study of rapid corticosteroid elimination in simultaneous 21. Martins L, Pedroso S, Henriques AC, et al. Simulta-
pancreasekidney transplantation: comparison of two main- neous pancreasekidney transplantation: five-year re-
tenance immunosuppression protocols: tacrolimus/mycophe- sults from a single center. Transplant Proc 2006;38:
nolate mofetil versus tacrolimus/sirolimus. Transplantation 1929e1932.
2002;73:169e177. 22. Menezes FG, Wey SB, Peres CA, Medina-Pestana JO,
3. Gruessner AC, Sutherland DE. Report for the international Camargo LF. Risk factors for surgical site infection in kidney
pancreas transplant registry e 2000. Transplant Proc transplant recipients. Infect Control Hosp Epidemiol 2008;
2001;33:1643e1646. 29:771e773.
4. Sollinger HW, Ploeg RJ, Eckhoff DE, et al. Two hundred con- 23. Stratta RJ, Alloway RR, Lo A, Hodge EE, PIVOT Study Group.
secutive simultaneous pancreasekidney transplants with Does surgical technique influence outcomes after simulta-
bladder drainage. Surgery 1993;114:736e743. discussion neous kidneyepancreas transplantation? Transplant Proc
743e744. 2004;36:1076e1077.You can also read
