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.