Pfundstein J, Roghmann M C, Schwalbe R S, Qaiyumi S Q, McCarter R J, Keay S, Schweitzer E, Bartlett S T, Morris J G, Oldach D W
Department of Medicine, University of Maryland School of Medicine, Baltimore, USA.
Clin Transplant. 1999 Jun;13(3):245-52. doi: 10.1034/j.1399-0012.1999.130305.x.
Gram-positive organisms, including vancomycin-resistant enterococci (VRE), have emerged as major pathogens on the organ transplant service at our institution. We hypothesized that our use of vancomycin as part of routine surgical prophylaxis increased the risk of VRE colonization and infection; conversely, there was concern that failure to use vancomycin prophylaxis would increase peri-operative morbidity due to gram-positive organisms.
Renal transplant recipients (n = 88) were randomized to receive either a) vancomycin/ceftriaxone or b) cefazolin; and pancreas transplants (n = 24) to receive either a) vancomycin/gentamicin or b) cefazolin/gentamicin. Stool samples or rectal swabs were obtained for culture for enterococci within 24 h of transplantation and weekly while hospitalized.
Enterococci were isolated on stool culture from 38 (34%) of 102 patients at the time of transplantation; 4 (11%) of the isolates were VRE. The percentage of patients who subsequently acquired VRE was low (1-7% per wk) but remained constant during hospitalization. There was no association between new VRE detection and vancomycin use for either prophylactic or therapeutic purposes. Forty-four patients (39%) had a post-operative infection with 46% of these infections due to gram-positive organisms; rates were unaffected by prophylactic vancomycin use. Pancreas transplant patients who did not receive vancomycin prophylaxis had a significantly longer initial hospitalization (p = 0.03); however, differences were not statistically significant when total length of stay (LOS) within the first 90 d of transplantation was compared.
Vancomycin surgical prophylaxis does not appear to have an effect on VRE colonization or infection, or on rates of infection with gram-positive bacteria. Elimination of vancomycin prophylaxis in renal transplant patients may be a reasonable part of an overall program to limit vancomycin usage, although as a single measure, its impact may be minimal. Vancomycin surgical prophylaxis may be of greater importance in pancreas transplants.
革兰氏阳性菌，包括耐万古霉素肠球菌（VRE），已成为我们机构器官移植服务中的主要病原体。我们推测，将万古霉素用作常规手术预防措施的一部分会增加VRE定植和感染的风险；相反，有人担心不使用万古霉素预防会因革兰氏阳性菌增加围手术期发病率。
肾移植受者（n = 88）被随机分为两组，分别接受a）万古霉素/头孢曲松或b）头孢唑林；胰腺移植受者（n = 24）被随机分为两组，分别接受a）万古霉素/庆大霉素或b）头孢唑林/庆大霉素。在移植后24小时内及住院期间每周采集粪便样本或直肠拭子进行肠球菌培养。
102例患者中有38例（34%）在移植时粪便培养中分离出肠球菌；其中4株（11%）为VRE。随后获得VRE的患者百分比很低（每周1 - 7%），但在住院期间保持稳定。新检测到的VRE与用于预防或治疗目的的万古霉素使用之间没有关联。有44例患者（39%）发生术后感染，其中46% 的感染是由革兰氏阳性菌引起的；感染率不受预防性使用万古霉素的影响。未接受万古霉素预防的胰腺移植患者初始住院时间明显更长（p = 0.03）；然而，比较移植后前90天的总住院时间（LOS）时，差异无统计学意义。
万古霉素手术预防似乎对VRE定植或感染以及革兰氏阳性菌感染率没有影响。在肾移植患者中取消万古霉素预防可能是限制万古霉素使用的总体计划的合理组成部分，尽管作为单一措施，其影响可能很小。万古霉素手术预防在胰腺移植中可能更为重要。
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