Eqbal B. QADDOUR, Duaa W. ALBUNNI, Aiman Y. ALWADI, Zoriah AZIZ
Experimental and Clinical Transplantation - 2026;24(6):470-480
Objectives: To our knowledge, a systematic review that has comprehensively evaluated the prevalence and clinical impact of multidrug-resistant bacteria in adult liver transplant recipients is not available. This review assessed the prevalence and clinical impact of multidrug-resistant bacteria among liver transplant recipients. Materials and Methods: In accordance with PRISMA guidelines, we searched Web of Science, PubMed, and Google Scholar through August 2025. The study protocol was registered in PROSPERO (CRD420251181202). We included cohort and case-control studies that reported on adult first liver transplant recipients harboring and not harboring multidrug-resistant bacteria. Two reviewers assessed eligibility and conducted a risk of bias evaluation using the Newcastle-Ottawa Scale. We synthesized data using the web-based Review Manager for a meta-analysis, with a random-effects model to compute the pooled odds ratio and 95% CI. Statistical heterogeneity was determined using the I2 statistic. Results: In the 13 included studies (12 cohort studies, 1 case-control study), multidrug-resistant bacteria were identified in 507 of 28 599 liver transplant recipients. Multidrug-resistant bacteria colonization significantly increased posttransplant infection (odds ratio 5.98; 95% CI, 2.24-15.94), and their presence significantly increased mortality (odds ratio 5.32; 95% CI, 2.36-11.97). Subgroup analyses suggested a regional variation in mortality risk with a higher association in China and Japan (odds ratio, 22.26; 95% CI, 6.83-72.6). Exposure to these bacteria was also associated with prolonged hospital and intensive care unit stay and showed a borderline association with acute kidney injury but not with graft rejection. Conclusions: Colonization with multidrug-resistant bacteria is associated with increased infection, and both colonization and infection raise the risk of mortality. Despite the variations across studies in geography, follow-up duration, and screening methods, actions to prevent colonization in transplant candidates are warranted.
