Retrospective Cohort Study
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Apr 27, 2024; 16(4): 612-624
Published online Apr 27, 2024. doi: 10.4254/wjh.v16.i4.612
Klebsiella pneumoniae infections after liver transplantation: Drug resistance and distribution of pathogens, risk factors, and influence on outcomes
Long Guo, Peng Peng, Wei-Ting Peng, Jie Zhao, Qi-Quan Wan
Long Guo, Department of Respiratory and Critical Care Medicine, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
Peng Peng, Clinical Laboratory Medicine Center, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Zhuzhou 421007, Hunan Province, China
Wei-Ting Peng, The Second Affiliated Hospital Class, Xiangya School of Medicine, Central South University, Changsha 410013, Hunan Province, China
Jie Zhao, Department of Liver Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
Qi-Quan Wan, Department of Transplant Surgery, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
Qi-Quan Wan, Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
Author contributions: Guo L, Wan QQ, Peng WT, and Zhao J collected and analyzed the data; Wan QQ and Peng P wrote the original manuscript, revised the paper, and approved the final version.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of the Third Xiangya Hospital in accordance with the Declaration of Helsinki (No. 24029).
Informed consent statement: As the study used anonymous and pre-existing data, the requirement for the informed consent from patients was waived.
Conflict-of-interest statement: All the Authors have no conflict of interest related to the manuscript.
Data sharing statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Qi-Quan Wan, MD, Associate Professor, Department of Transplant Surgery, The Third Xiangya Hospital of Central South University, No. 138 Tongzipo Road, Changsha 410013, Hunan Province, China. 13548685542@163.com
Received: December 29, 2023
Peer-review started: December 29, 2023
First decision: January 23, 2024
Revised: February 1, 2024
Accepted: March 8, 2024
Article in press: March 8, 2024
Published online: April 27, 2024
ARTICLE HIGHLIGHTS
Research background

Liver transplantation (LT) is the only curative treatment available for end-stage liver disease. However, LT recipients are prone to many types of infections, which are the most common cause of early mortality after LT. Recent studies have demonstrated that LT recipients suffer from bloodstream infections caused by K. pneumoniae. In addition, there has been little discussion on the adverse impacts of K. pneumoniae infections (KPIs) or carbapenem-resistant K. pneumoniae (CRKP) infections among LT recipients.

Research motivation

The key to retrospective cohort studies is to explore the risk factors for the development of KPIs in patients after LT and analyze drug resistance. Careful follow-up is required to minimize the occurrence of KPIs in patients with LT, reduce the development of drug resistance, and improve patient survival and prognosis.

Research objectives

The primary objective of this study was to assess the incidence, timing, distribution, drug resistance, and risk factors of KPIs within 3 months of LT. The secondary objective was to evaluate the impact of KPIs, particularly CRKP, on outcomes.

Research methods

In total, 406 patients undergoing LT between January 2015 and January 2023 were included in the present retrospective study to investigate the risk factors for KPIs and assess the impact of KPIs and CRKP on the prognosis of LT recipients using logistic regression.

Research results

Of the 406 LT recipients recruited, 32 (7.9%) were infected with 44 strains of K. pneumoniae within 3 months post-LT. Of the 32 patients, 21 (65.6%) were infected with CRKP. The median time from LT to KPI onset was 7.5 d. KPIs (18.8%, 6/32) and CRKP infection (18.8%, 6/32) rates were significantly higher in patients who died than in those who survived (7.0%, 26/374 and 4.0%, 15/374, respectively). The multivariate analysis identified female sex [odds ratio (OR) = 2.827, 95% confidence interval (CI): 1.256-6.364, P = 0.012], pre-LT diabetes [OR = 2.794, 95%CI: 1.070-7.294, P = 0.036], day 1 post-LT alanine aminotransferase levels ≥ 1500 U/L (OR = 3.645, 95%CI: 1.671-7.950, P = 0.001), and post-LT urethral catheter durations > 4 d (OR = 2.266, 95%CI: 1.016-5.054, P = 0.046) were independently associated with the development of post-LT KPIs. On the prognosis of patients with LT, patients with KPIs were more likely to stay in the intensive care unit ≥ 7 d after LT than those without KPIs (56.3% vs 35.3%; P = 0.018). Patients with KPIs had a higher 6-month all-cause mortality rate than those without KPIs (17.6% vs 5.0%; P = 0.017). The multivariate analysis showed that KPIs were not risk factors for 6-month all-cause mortality after LT. However, infections caused by CRKP (OR = 1.534-18.524, 95%CI: 5.330, P = 0.008), female sex (OR = 2.829, 95%CI: 1.098-7.288, P = 0.031), intraoperative red blood cell transfusion ≥ 12 U (OR = 3.466, 95%CI: 1.259-9.543, P = 0.016), day 3 post-LT creatinine levels ≥ 2 mg/dL (OR = 9.724, 95%CI: 4.077-23.194, P < 0.001) and post-LT mechanical ventilation (OR = 4.118, 95%CI: 1.790-9.476, P = 0.001) were risk factors for 6-month all-cause mortality after LT.

Research conclusions

This novel retrospective assessment explored key factors in the prevention of KPIs or CRKP. Many risk factors play crucial roles in the development of KPIs after LT and in recipient prognosis. This study explored the role of KPIs in the prognosis of LT recipients and the risk factors for all KPIs after LT. By analyzing the distribution of KPIs and drug resistance, we demonstrated that risk factors are associated with surgical variables. Identifying these risk factors provides a basis for the prevention of KPIs, thereby improving the prognosis of LT recipients.

Research perspectives

In future studies, we should obtain more data to more accurately identify other potential correlates of KPIs in patients with LT to reduce the occurrence of KPIs. In addition, monitoring K. pneumoniae, especially CRKP, colonization before LT may provide new insights.