gms | German Medical Science

Background: Patients awaiting liver transplantation are frequently severely ill, with Meld scores above 30 at the time of transplantation. These patients are at high risk for bacterial infection due to their underlying immunosuppression. Physicians in charge face therefore sometimes the dilemma of accepting or not a high-risk transplant procedure in a recently infected recipient. In such situations transplant physicians are frequently reluctant to accept transplantation because of the risk of lethal uncontrolled post-transplant infections, whereas the organ could have benefited another patient with better chances of survival.

Here we report a patient with bacteremic peritonitis at the time of liver transplantation with a favorable outcome.

Method: Analyses of clinical charts, microbiology and pathology reports. Literature review of high risk transplant procedures for infectious complications.

Case report: A 52 years-old male was admitted for elective hepatectomy for a Klatskin tumor. Due to fulminant post-surgery liver failure secondary to vascular problems, he benefited from emergency liver transplantation five days later, while receiving piperacillin-tazobactam since 24 hours. Blood cultures drawn the day before transplantation became positive for Enterococcus faecalis at the time the transplant procedure had already been initiated. Perioperative peritoneal bacterial cultures confirmed polymicrobial peritonitis with multiresistant pathogens (Morganella morganii, Proteus vulgaris, Hafnia alveia and E. faecalis). Ciprofloxacin was added during transplantation. Eight days thereafter, this bi-therapy was replaced by meropenem plus amoxicillin because of severe sepsis. Caspofungine was added for antifungal prophylaxis. No new bacterial/fungal specimens grew on cultures and the patient improved without further surgical procedure. The antimicrobial therapy was stopped 30 days post-transplantation. One month later the patient presented an Escherichia coli blood stream infection concomitant with a peri-hepatic collection that was successfully treated with drainage and amoxicillin.

Conclusion: Ongoing systemic bacterial infection is usually considered a temporary contra-indication for liver transplantation. However, this case demonstrates that rapid recognition and appropriate targeted therapy, can lead to a favorable outcome. In specific cases, live saving liver transplantation might therefore still be considered despite ongoing bacterial infections.