Methods of preventing bacterial sepsis and wound complications for liver transplantation.

BACKGROUND: Bacterial sepsis and wound complications after liver transplantation increase mortality, morbidity, hospital stay, and overall transplant costs.
OBJECTIVES: To assess the benefits and harms of different methods aimed at preventing bacterial sepsis and wound complications in patients undergoing liver transplantation. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until June 2007. SELECTION CRITERIA: We included only randomised clinical trials irrespective of language or publication status. DATA COLLECTION AND ANALYSIS: We collected the data on infections, adverse effects of intervention, ITU (intensive therapy unit) stay, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis and risk ratio (RR) or weighted mean difference (WMD) with 95% confidence intervals (CI) based on intention-to-treat analysis. MAIN
RESULTS: We identified seven trials for inclusion including 614 patients. Four trials compared selective bowel decontamination versus placebo or no treatment. In one trial, patients were randomised to selective bowel decontamination, active lactobacillus with fibres (probiotic with prebiotic), or to inactivated lactobacillus with fibres (prebiotic). In another trial, different doses of granulocyte-colony stimulating factor and placebo were compared. The remaining two trials compared lactobacillus with fibres versus fibres alone and early enteral feeding versus no intervention. Only one trial was of low bias-risk. There was no statistically significant difference in any outcome between the selective bowel decontamination and the control groups. Selective bowel decontamination increased incidence of cholangitis (RR 4.84, 95% CI 1.15 to 20.35), incidence of bacterial infection (RR 3.63, 95% CI 1.36 to 9.74), and hospital stay (WMD 4.00, 95% CI 3.14 to 4.86) than the participants in the combined pre- and probiotic group. Hospital stay was prolonged in the selective bowel decontamination group compared to the prebiotic group. There was a statistically significant lower occurrence of urinary infection in the pre- and probiotic group than in the prebiotic group. The number of people experiencing gram-negative bacterial infection was not significantly lower in the probiotic group (RR 0.18, 95% CI 0.03 to 1.17). The ITU stay was lower in the probiotic group (WMD -1.41 days, 95% CI -2.09 to -0.73). There were no differences in any outcomes in the other comparisons. AUTHORS'
CONCLUSIONS: Currently, there is no clear evidence for any intervention offering significant benefits in the reduction of bacterial infections and wound complications in liver transplantation. Selective bowel decontamination increases the risk of infection and hospital stay compared to prebiotics and probiotics. The use of prebiotics and probiotics offers promise. Further randomised clinical trials are necessary.