Surgical site infection in liver transplant recipients: risk factors and microbial agents from a high volume liver transplant center in Iran
,
Abstract
Background and Objectives: Surgical site infection (SSI) is an important complication among liver transplant (LT) recipients. This study aimed to determine the prevalence, risk factors and microbial etiologies of SSI in LT recipients.
Materials and Methods: This retrospective observational study was conducted at a tertiary care hospital, Imam Khomeini Hospital complex, Tehran, Iran, between 2015 and 2020. Clinical data were collected from password-protected database.
Results: A total of 200 patients were included, of whom 121 (60.5%) were men. The mean age was 43.85 ± 14.59 years. Ninety-six patients (48%) developed SSI. broad-spectrum antibiotics use (p=.005), preoperative corticosteroids and immunosuppressive therapy (P = .000), Prolonged ICU stay (P=.000), and higher MELD score before transplantation (P = .002) were significantly associated with SSI. Graft rejection and one-year mortality rates were higher among patients with SSI; however, these differences were not statistically significant. SSI was also more common among patient with diabetes mellitus, other non-hepatic comorbidities, moderate-to-severe ascites, and those receiving piperacillin-tazobactam prophylaxis after surgery. The most frequently isolated microorganisms from SSI culture were Klebsiella pneumoniae (25%), Enterococcus spp. (22.9%) and Escherichia coli (16.6%).
Conclusion: SSI remains a common complication among LT in our canter and should be suspected in patients presenting with infection during the first postoperative month. Recipients with advanced liver disease, prolonged ICU stay, preoperative immunosuppressive therapy, and post-transplant hemodialysis may require monitoring.
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2. Shinde AS, Kapoor D. Infections after liver transplant: timeline, management and prevention. J Clin Exp Hepatol 2024; 14: 101316.
3. Chelala L, Kovacs CS, Taege AJ, Hanouneh IA. Common infectious complications of liver transplant. Cleve Clin J Med 2015; 82: 773-784.
4. Ferrarese A, Zanetto A, Becchetti C, Sciarrone SS, Shalaby S, Germani G, et al. Management of bacterial infection in the liver transplant candidate. World J Hepatol 2018; 10: 222-230.
5. Idossa DW, Simonetto DA. Infectious complications and malignancies arising after liver transplantation. Anesthesiol Clin 2017; 35: 381-393.
6. Patel G, Huprikar S. Infectious complications after orthotopic liver transplantation. Semin Respir Crit Care Med 2012; 33: 111-124.
7. Ferrarese A, Senzolo M, Sasset L, Bassi D, Cillo U, Burra P. Multidrug-resistant bacterial infections in the liver transplant setting. Updates Surg 2024; 76: 2521-2529.
8. Martin-Mateos R, Martínez-Arenas L, Carvalho-Gomes Á, Aceituno L, Cadahía V, Salcedo M, et al. Multidrug-resistant bacterial infections after liver transplantation: prevalence, impact, and risk factors. J Hepatol 2024; 80: 904-912.
9. Friedrich K, Krempl J, Schamoni S, Hippchen T, Pfeiffenberger J, Rupp C, et al. Multidrug-resistant bacteria and disease progression in patients with end-stage liver disease and after liver transplantation. J Gastrointestin Liver Dis 2019; 28: 303-310.
10. Rolak SC, Yetmar ZA, Lahr BD, Beam E, Razi S, Watt K et al. Risk factors for surgical site infections after liver transplant: does perioperative antibiotic regimen matter? Transplantation 2024; 108: 1179-1188.
11. Schreiber PW, Hoessly LD, Boggian K, Neofytos D, van Delden C, Egli A, et al. Surgical site infections, risk factors, and outcomes after liver transplant. JAMA Netw Open 2025; 8(3): e251333.
12. Chea N, Sapiano MRP, Zhou L, Epstein L, Guh A, Edwards JR, et al. Rates and causative pathogens of surgical site infections attributed to liver transplant procedures and other hepatic, biliary, or pancreatic procedures, 2015-2018. Transpl Infect Dis 2021; 23(4): e13589.
13. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN) patient safety component manual: Chapter 9. Surgical site infection (SSI) event. Atlanta, GA: CDC; 2025 [cited 2026 Aug 7]. Available from:
https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf
14. Baron EJ (2015). Specimen collection, transport, and processing: bacteriology. In: Manual of Clinical Microbiology. Eds, JH Jorgensen, KC Carroll, G Funke, MA Pfaller, ML Landry, SS Richter, et al. 11th ed. ASM Press. Washington, DC, pp. 270-315.
15. CLSI (2020). Performance Standards for Antimicrobial Susceptibility Testing. 30th ed. CLSI supplement M100. Wayne, PA. Clinical and Laboratory Standards Institute.
16. Merli M, Lucidi C, Giannelli V, Giusto M, Riggio O, Falcone M, et al. Cirrhotic patients are at risk for health care-associated bacterial infections. Clin Gastroenterol Hepatol 2010; 8: 979-985.
17. Jafarpour Z, Pouladfar G, Malek Hosseini SA, Firoozifar M, Jafari P. Bacterial infections in the early period after liver transplantation in adults: A prospective single-center cohort study. Microbiol Immunol 2020; 64: 407-415.
18. Freire MP, Oshiro ICVS, Bonazzi PR, Guimarães T, Figueira ER, Bacchella T, et al. Surgical site infections in liver transplant recipients in the model for end-stage liver disease era: an analysis of the epidemiology, risk factors, and outcomes. Liver Transpl 2013; 19: 1011-1019.
19. Bruns T, Zimmermann HW, Stallmach A. Risk factors and outcome of bacterial infections in cirrhosis. World J Gastroenterol 2014; 20: 2542-2554.
20. Galbois A, Aegerter P, Martel-Samb P, Housset C, Thabut D, Offenstadt G, et al. Improved prognosis of septic shock in patients with cirrhosis: a multicenter study. Crit Care Med 2014; 42: 1666-1675.
21. Pita A, Nguyen B, Rios D, Maalouf N, Lo M, Genyk Y, et al. Variability in intensive care unit length of stay after liver transplant: determinants and potential opportunities for improvement. J Crit Care 2019; 50: 296-302.
22. Panackel CF, Mathew JF, Fawas NM, Jacob M. Immunosuppressive drugs in liver transplant: an insight. J Clin Exp Hepatol 2022; 12: 1557-1571.
23. Hisanaga T, Hidaka I, Sakaida I, Nakayama N, Ido A, Kato N, et al. Analysis of the safety of pretransplant corticosteroid therapy in patients with acute liver failure and late-onset hepatic failure in Japan. JGH Open 2021; 5: 428-433.
24. Hsu SC, Thorat A, Jeng LB, Li PC, Chen TH, Yang HR, et al. ABO-incompatible living donor liver transplantation with reduced rituximab dose: a retrospective analysis of 65 patients—can we fast-track liver transplant surgery and improve long-term survival? Ann Transplant 2020; 25: e923502.
25. Reddy KR, O'Leary JG, Kamath PS, Fallon MB, Biggins SW, Wong F, et al. High risk of delisting or death in liver transplant candidates following infections: results from the North American Consortium for the Study of End-Stage Liver Disease. Liver Transpl 2015; 21: 881-888.
26. Incicco S, Tonon M, Zeni N, Gambino C, Gagliardi R, Calvino V, et al. Impact of bacterial infections prior to liver transplantation on post-transplant outcomes in patients with cirrhosis. JHEP Rep 2023; 5: 100808.
27. Phichaphop C, Apiwattanakul N, Techasaensiri C, Lertudomphonwanit C, Treepongkaruna S, Thirapattaraphan C, et al. High prevalence of multidrug-resistant gram-negative bacterial infection following pediatric liver transplantation. Medicine (Baltimore) 2020; 99(45): e23169.
28. Taddei R, Riccardi N, Tiseo G, Galfo V, Biancofiore G. Early intra-abdominal bacterial infections after orthotopic liver transplantation: a narrative review for clinicians. Antibiotics (Basel) 2023; 12: 1316.
29. Oliveira RA, Turrini RNT, Poveda VB. Risk factors for development of surgical site infections among liver transplantation recipients: an integrative literature review. Am J Infect Control 2018; 46: 88-93.
30. Carugati M, Arif S, Yarrington ME, King LY, Harris M, Evans K, et al. Risk factors for invasive surgical site infections among adult single liver transplant recipients at Duke University Hospital in the period 2015-2020. Transplant Direct 2024; 10(12): e1719.
31. Oliveira RA, Mancero JMP, Faria DF, Poveda VB. A retrospective cohort study of risk factors for surgical site infection following liver transplantation. Prog Transplant 2019; 29: 144-149.
32. Hellinger WC, Heckman MG, Crook JE, Taner CB, Willingham DL, Diehl NN, et al. Association of surgeon with surgical site infection after liver transplantation. Am J Transplant 2011; 11: 1877-1884.
33. Aktas A, Kayaalp C, Gunes O, Gokler C, Uylas U, Cicek E, et al. Surgical site infection and risk factors following right lobe living donor liver transplantation in adults: a single-center prospective cohort study. Transpl Infect Dis 2019; 21(6): e13176.
34. Freire MP, Song ATW, Oshiro ICV, Andraus W, D'Albuquerque LAC, Abdala E. Surgical site infection after liver transplantation in the era of multidrug-resistant bacteria: what new risks should be considered? Diagn Microbiol Infect Dis 2021; 99: 115220.
35. Ljungman P, Boeckh M, Hirsch HH, Josephson F, Lundgren J, Nichols G, et al. Definitions of cytomegalovirus infection and disease in transplant patients for use in clinical trials. Clin Infect Dis 2017; 64: 87-91.
2. Shinde AS, Kapoor D. Infections after liver transplant: timeline, management and prevention. J Clin Exp Hepatol 2024; 14: 101316.
3. Chelala L, Kovacs CS, Taege AJ, Hanouneh IA. Common infectious complications of liver transplant. Cleve Clin J Med 2015; 82: 773-784.
4. Ferrarese A, Zanetto A, Becchetti C, Sciarrone SS, Shalaby S, Germani G, et al. Management of bacterial infection in the liver transplant candidate. World J Hepatol 2018; 10: 222-230.
5. Idossa DW, Simonetto DA. Infectious complications and malignancies arising after liver transplantation. Anesthesiol Clin 2017; 35: 381-393.
6. Patel G, Huprikar S. Infectious complications after orthotopic liver transplantation. Semin Respir Crit Care Med 2012; 33: 111-124.
7. Ferrarese A, Senzolo M, Sasset L, Bassi D, Cillo U, Burra P. Multidrug-resistant bacterial infections in the liver transplant setting. Updates Surg 2024; 76: 2521-2529.
8. Martin-Mateos R, Martínez-Arenas L, Carvalho-Gomes Á, Aceituno L, Cadahía V, Salcedo M, et al. Multidrug-resistant bacterial infections after liver transplantation: prevalence, impact, and risk factors. J Hepatol 2024; 80: 904-912.
9. Friedrich K, Krempl J, Schamoni S, Hippchen T, Pfeiffenberger J, Rupp C, et al. Multidrug-resistant bacteria and disease progression in patients with end-stage liver disease and after liver transplantation. J Gastrointestin Liver Dis 2019; 28: 303-310.
10. Rolak SC, Yetmar ZA, Lahr BD, Beam E, Razi S, Watt K et al. Risk factors for surgical site infections after liver transplant: does perioperative antibiotic regimen matter? Transplantation 2024; 108: 1179-1188.
11. Schreiber PW, Hoessly LD, Boggian K, Neofytos D, van Delden C, Egli A, et al. Surgical site infections, risk factors, and outcomes after liver transplant. JAMA Netw Open 2025; 8(3): e251333.
12. Chea N, Sapiano MRP, Zhou L, Epstein L, Guh A, Edwards JR, et al. Rates and causative pathogens of surgical site infections attributed to liver transplant procedures and other hepatic, biliary, or pancreatic procedures, 2015-2018. Transpl Infect Dis 2021; 23(4): e13589.
13. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN) patient safety component manual: Chapter 9. Surgical site infection (SSI) event. Atlanta, GA: CDC; 2025 [cited 2026 Aug 7]. Available from:
https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf
14. Baron EJ (2015). Specimen collection, transport, and processing: bacteriology. In: Manual of Clinical Microbiology. Eds, JH Jorgensen, KC Carroll, G Funke, MA Pfaller, ML Landry, SS Richter, et al. 11th ed. ASM Press. Washington, DC, pp. 270-315.
15. CLSI (2020). Performance Standards for Antimicrobial Susceptibility Testing. 30th ed. CLSI supplement M100. Wayne, PA. Clinical and Laboratory Standards Institute.
16. Merli M, Lucidi C, Giannelli V, Giusto M, Riggio O, Falcone M, et al. Cirrhotic patients are at risk for health care-associated bacterial infections. Clin Gastroenterol Hepatol 2010; 8: 979-985.
17. Jafarpour Z, Pouladfar G, Malek Hosseini SA, Firoozifar M, Jafari P. Bacterial infections in the early period after liver transplantation in adults: A prospective single-center cohort study. Microbiol Immunol 2020; 64: 407-415.
18. Freire MP, Oshiro ICVS, Bonazzi PR, Guimarães T, Figueira ER, Bacchella T, et al. Surgical site infections in liver transplant recipients in the model for end-stage liver disease era: an analysis of the epidemiology, risk factors, and outcomes. Liver Transpl 2013; 19: 1011-1019.
19. Bruns T, Zimmermann HW, Stallmach A. Risk factors and outcome of bacterial infections in cirrhosis. World J Gastroenterol 2014; 20: 2542-2554.
20. Galbois A, Aegerter P, Martel-Samb P, Housset C, Thabut D, Offenstadt G, et al. Improved prognosis of septic shock in patients with cirrhosis: a multicenter study. Crit Care Med 2014; 42: 1666-1675.
21. Pita A, Nguyen B, Rios D, Maalouf N, Lo M, Genyk Y, et al. Variability in intensive care unit length of stay after liver transplant: determinants and potential opportunities for improvement. J Crit Care 2019; 50: 296-302.
22. Panackel CF, Mathew JF, Fawas NM, Jacob M. Immunosuppressive drugs in liver transplant: an insight. J Clin Exp Hepatol 2022; 12: 1557-1571.
23. Hisanaga T, Hidaka I, Sakaida I, Nakayama N, Ido A, Kato N, et al. Analysis of the safety of pretransplant corticosteroid therapy in patients with acute liver failure and late-onset hepatic failure in Japan. JGH Open 2021; 5: 428-433.
24. Hsu SC, Thorat A, Jeng LB, Li PC, Chen TH, Yang HR, et al. ABO-incompatible living donor liver transplantation with reduced rituximab dose: a retrospective analysis of 65 patients—can we fast-track liver transplant surgery and improve long-term survival? Ann Transplant 2020; 25: e923502.
25. Reddy KR, O'Leary JG, Kamath PS, Fallon MB, Biggins SW, Wong F, et al. High risk of delisting or death in liver transplant candidates following infections: results from the North American Consortium for the Study of End-Stage Liver Disease. Liver Transpl 2015; 21: 881-888.
26. Incicco S, Tonon M, Zeni N, Gambino C, Gagliardi R, Calvino V, et al. Impact of bacterial infections prior to liver transplantation on post-transplant outcomes in patients with cirrhosis. JHEP Rep 2023; 5: 100808.
27. Phichaphop C, Apiwattanakul N, Techasaensiri C, Lertudomphonwanit C, Treepongkaruna S, Thirapattaraphan C, et al. High prevalence of multidrug-resistant gram-negative bacterial infection following pediatric liver transplantation. Medicine (Baltimore) 2020; 99(45): e23169.
28. Taddei R, Riccardi N, Tiseo G, Galfo V, Biancofiore G. Early intra-abdominal bacterial infections after orthotopic liver transplantation: a narrative review for clinicians. Antibiotics (Basel) 2023; 12: 1316.
29. Oliveira RA, Turrini RNT, Poveda VB. Risk factors for development of surgical site infections among liver transplantation recipients: an integrative literature review. Am J Infect Control 2018; 46: 88-93.
30. Carugati M, Arif S, Yarrington ME, King LY, Harris M, Evans K, et al. Risk factors for invasive surgical site infections among adult single liver transplant recipients at Duke University Hospital in the period 2015-2020. Transplant Direct 2024; 10(12): e1719.
31. Oliveira RA, Mancero JMP, Faria DF, Poveda VB. A retrospective cohort study of risk factors for surgical site infection following liver transplantation. Prog Transplant 2019; 29: 144-149.
32. Hellinger WC, Heckman MG, Crook JE, Taner CB, Willingham DL, Diehl NN, et al. Association of surgeon with surgical site infection after liver transplantation. Am J Transplant 2011; 11: 1877-1884.
33. Aktas A, Kayaalp C, Gunes O, Gokler C, Uylas U, Cicek E, et al. Surgical site infection and risk factors following right lobe living donor liver transplantation in adults: a single-center prospective cohort study. Transpl Infect Dis 2019; 21(6): e13176.
34. Freire MP, Song ATW, Oshiro ICV, Andraus W, D'Albuquerque LAC, Abdala E. Surgical site infection after liver transplantation in the era of multidrug-resistant bacteria: what new risks should be considered? Diagn Microbiol Infect Dis 2021; 99: 115220.
35. Ljungman P, Boeckh M, Hirsch HH, Josephson F, Lundgren J, Nichols G, et al. Definitions of cytomegalovirus infection and disease in transplant patients for use in clinical trials. Clin Infect Dis 2017; 64: 87-91.
| Files | ||
| Issue | Vol 18 No 5 (2026) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/ijm.v18i5.22857 | |
| Keywords | ||
| Liver transplantation Surgical wound infection Risk factors Drug resistance Multiple Klebsiella pneumoniae Enterococcus Escherichia coli | ||
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Ghiasvand F, Jahani Z, Jafarian A, Madreseh E, Ahmadinejad Z. Surgical site infection in liver transplant recipients: risk factors and microbial agents from a high volume liver transplant center in Iran. Iran J Microbiol. 2026;18(5):685-693.
