Impact of selective digestive decontamination in brain-dead donors on postoperative infections in simultaneous pancreas-kidney transplant recipients: a retrospective cohort study

Brain death induces gut barrier disruption, bacterial translocation, and systemic inflammation in organ donors, potentially predisposing transplant recipients to postoperative infections. Selective digestive decontamination (SDD) reduces pathogenic microorganisms in the gastrointestinal tract and has demonstrated efficacy in preventing nosocomial infections in intensive care unit (ICU) settings. However, the impact of donor SDD on infection outcomes in simultaneous pancreas-kidney (SPK) transplant recipients remains unknown. We conducted a single-center retrospective cohort study of 276 consecutive SPK transplant recipients whose organs were procured from brain-dead donors (DBD) between January 2016 and June 30, 2025. Donors were classified as SDD ( n = 118; complete protocol: oropharyngeal paste and enteral suspension of polymyxin E, tobramycin, and amphotericin B, plus intravenous cefotaxime for 4 days) or non-SDD ( n = 158; standard care without SDD). Propensity score matching (PSM) was performed at 1:1 using donor and recipient covariates. The primary endpoint was a 90-day composite of surgical site infection (SSI), bacteremia, intra-abdominal infection, and pneumonia. Secondary endpoints included individual infection types, graft survival, and length of hospital stay. After PSM, 106 matched pairs were included. The composite infection endpoint at 90 days occurred in 27 patients (25.5%) in the SDD group versus 43 patients (40.6%) in the non-SDD group (adjusted hazard ratio [aHR] 0.57, 95% confidence interval [CI] 0.35–0.93, P = 0.024). Donor SDD was associated with lower rates of gram-negative bacteremia (aHR 0.39, 95% CI 0.16–0.92, P = 0.031) and intra-abdominal infections (aHR 0.44, 95% CI 0.21–0.93, P = 0.032). The incidence of SSI was also lower in the SDD group, though the difference did not reach statistical significance in the matched analysis (aHR 0.65, 95% CI 0.38–1.11, P = 0.117). Pancreas graft survival at 1 year was 94.3% in the SDD group versus 91.5% in the non-SDD group ( P = 0.428). Multidrug-resistant organism isolation rates did not differ between groups. Donor SDD was associated with a lower risk of postoperative infections, particularly gram-negative bacteremia and intra-abdominal infections, in SPK recipients. These findings provide a strong rationale for prospective trials to assess the efficacy and safety of donor SDD. Not applicable.