DRE bacteremia associated with high mortality following liver transplant
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Liver transplant recipients with daptomycin-resistant Enterococcus bacteremia were more than twice as likely to die within a year compared with those who had vancomycin-resistant Enterococcus bacteremia, a study found.
“In our institution, we noted a significant increase in Enterococcus isolates resistant to daptomycin, leaving few options for treatment,” Rachael A. Lee, MD, MSPH, associate professor of infectious diseases at the University of Alabama at Birmingham, told Healio. “Prior studies have shown a high prevalence of Enterococcus — especially vancomycin-resistant Enterococcus, or VRE — colonization and the potential for subsequent infection in liver transplant recipients, which is associated with an increased 90-day mortality.”
Lee said they wanted to know “if becoming infected with a multidrug-resistant Enterococcus isolate such as daptomycin-resistant Enterococcus (DRE) would have a higher mortality in this patient population compared with VRE.”
Lee and colleagues conducted a retrospective cohort study of adult liver transplant recipients with a history of resistant enterococcal bacteremia at nine acute care academic hospitals in the U.S. According to the study, the primary outcome was death within 1 year of transplantation.
They identified 139 cases of Enterococcus bacteremia — 78% VRE and 22% DRE. After they adjusted for total ICU days in the first transplant year, liver-kidney transplantation and calcineurin inhibitor use, they calculated that patients with DRE bacteremia were 2.65 times more likely to die within a year of transplantation (adjusted OR = 2.648; 95% CI, 1.025-6.84) compared with patients with VRE bacteremia.
Additionally, they identified prior daptomycin exposure as an independent predictor of DRE bacteremia (aOR = 30.62; 95% CI, 10.087-92.955).
“Drug-resistant Enterococcus poses a clinical therapeutic challenge, and in patients at high risk for colonization and subsequent infection, can be deleterious,” Lee said. “As expected, prior exposure to daptomycin is associated with DRE infection and our data provide strong support for focusing infection prevention and antimicrobial stewardship efforts, particularly for transplant recipients.”
Perspective
Back to TopNicole M. Theodoropoulos, MD, MS, FAST, FIDSA
This important work by the members of the multidrug-resistant organism working group of the American Society of Transplantation Infectious Diseases Community of Practice shines a light on the ever-increasing antibacterial resistance in Enterococcus faecium. Although once a seemingly benign bacteria, Enterococcus has become prevalent in many immunocompromised patients, especially liver transplant recipients, and as this study shows, it is associated with substantial mortality. The most concerning thing about daptomycin-resistant Enterococcus is the lack of durable treatment options, and this likely contributes to the increase in mortality rates in these patients. This study highlights the need for guidance on treatment of enterococcal bacteremia with increasing minimum inhibitory concentrations to daptomycin, improved antimicrobial stewardship efforts in transplant patients, and the need for antibiotic development.
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