Impact of surveillance stool culture guided selection of antibiotics in the management of pediatric small bowel transplant recipients Serious infectious complications following SBT are common in children, accounting for almost 50% of deaths in one series (1–4). Bacterial infections occur early after transplantation. In one study, the mean time at which the first bacterial infection occurred was 9 days after surgery, with 68% of patients having had an infection by the end of the first month after transplantation (1, 5). Based on a limited number of published reports, which vary in their definition of infection and the period of follow-up, the incidence of infectious complica- tions following SBT ranges from 16% to as high as 90% (1, 3). Because SBT recipients undergo major intesti- nal surgery that is potentially associated with ischemia and reperfusion injury and with rejec- tion, translocation of organisms from the gut may be a key event leading to the high incidence of infections in this population (6–8). In addition, the level of immunosuppression required follow- ing SBT is typically higher than that required for most other types of solid organ transplants. In this context, SSCs have been used to guide antibiotic selection in the perioperative period. However, to our knowledge, the impact of this strategy on patient outcome has not been eval- uated in SBT recipients. We conducted a retro- spective study to determine if the incidence of infections and the clinical outcome were impac- ted by the use of SSC as a part of patient management. In addition, we also investigated whether organisms associated with infections John M, Gondolesi G, Herold BC, Kaufman S, Fishbein T, Posada R. Impact of surveillance stool culture guided selection of antibiotics in the management of pediatric small bowel transplant recipients. Pediatr Transplantation 2006: 10: 198–204. Ó 2005 Blackwell Munksgaard Abstract: Surveillance stool cultures (SSC) have been used in immun- ocompromised populations to predict the organisms associated with invasive infections and aid in the selection of empiric antibiotic regi- mens. To evaluate the utility of this approach in pediatric small bowel transplant (SBT) recipients, we conducted a retrospective review of 33 patients who underwent SBT, 16 of whom had SSC done. In no case was the same organism isolated from SSC and subsequent blood, peritoneal fluid or wound cultures. In the first month post-transplan- tation, blood cultures were positive in 44% and 35% of patients that had and did not have SSC done, respectively (p ¼ 0.73); peritoneal fluid cultures in 44% and 65% (p ¼ 0.30); and wound cultures in 44% and 24% (p ¼ 0.28). There were no significant differences among both groups in time to first infection, duration of ICU stay following SBT, graft survival or long-term patient survival. We conclude that SSC- guided antibiotic selection does not have a significant impact on the incidence of invasive infections in the first month following SBT or on specific indicators of patient outcome. This suggests that empiric anti- biotic regimens should be selected based on clinical presentation and hospital flora and susceptibility patterns. Minnie John 1,2 , Gabriel Gondolesi 3 , Betsy C. Herold 1 , Stuart Kaufman 1,4 , Thomas Fishbein 3,4 and Roberto Posada 1 1 Department of Pediatrics, The Mount Sinai School of Medicine, New York, NY, USA, 2 Department of Pediatrics, Long Island College Hospital and State University of New York, Brooklyn, NY, USA, 3 Recanati/Miller Transplantation Institute, The Mount Sinai School of Medicine, New York, NY, USA, 4 Children's National Medical Center and Georgetown University Transplant Institute, Washington, DC, USA Key words: transplant – small intestine – pediatrics – infection Roberto Posada, MD, Mount Sinai School of Medicine, One Gustave L. Levy Place, Annenberg 14-08, Box 1657, New York, NY 10029, USA E-mail: roberto.posada@mssm.edu Accepted for publication 1 August 2005 Abbreviations: CNS, coagulase-negative Staphylococci; ICU, intensive care unit; SBT, small bowel transplantation; SSC, surveillance stool culture. Pediatr Transplantation 2006: 10: 198–204 Copyright Ó 2005 Blackwell Munksgaard Pediatric Transplantation DOI: 10.1111/j.1399-3046.2005.00424.x 198