E ec i eness and sa e y o s a egies o op imise
an imic obial use in solid o gan ansplan ecipien s.
Sys ema ic e iew and me a-analyses
Ma ía Paniagua-Ga cía,
a
,
b
,
c
,
e
Ana Belén Guisado-Gil,
a
,
b
,
c
,
d
,
e
José Molina Gil-Be mejo,
a
,
b
,
c
,
∗
Ge mán Peñal a,
a
,
b
,
c
Rocío Ál a ez-Ma ín,
a
,
b
,
c
Ma ía Eugenia Pachón-Ibáñez,
a
,
b
,
c
and José Miguel Cisne os
a
,
b
,
c
a
Clinical Uni o In ec ious Diseases, Mic obiology and Pa asi ology, Vi gen del Rocío Uni e si y Hospi al, Se ille, Spain
b
Ins i u e o Biomedicine o Se ille, Vi gen del Rocío Uni e si y Hospi al/CSIC/Uni e si y o Se ille, Se ille, Spain
c
CIBER de En e medades In ecciosas, Ins i u o de Salud Ca los III (CIBERINFEC, ISCIII), Mad id, Spain
d
Depa men o Pha macy, Vi gen del Rocío Uni e si y Hospi al, Se ille, Spain
Summa y
Backg ound Solid o gan ansplan ecipien s (SOT ) a e a high isk o in ec ious complica ions, and e ec i e
an imic obial s ewa dship (AMS) p og ammes need o be de eloped. We aimed o e iew he a ailable e idence on
he e ec i eness and sa e y o di e en s a egies o op imise an ibio ic use in SOT .
Me hods In ou sys ema ic e iew and me a-analyses, we sea ched MEDLINE ( ia PubMed), EMBASE, and SCOPUS
o o iginal esea ch a icles published up o 06 Ma ch 2025.
S udies wi h a con ol g oup e alua ing di e en s a egies o op imise an imic obial use in adul SOT we e included.
The ou comes assessed we e mo ali y, ansplan - ela ed complica ions, in ec ious ou comes, de elopmen o
an imic obial esis ance, an imic obial consump ion, hospi al ela ed a iables, and an imic obial oxici ies. A isk-
o -bias assessmen was pe o med using he Coch ane EPOC g oup’s c i e ia. Da a om included s udies we e
pooled in me a-analyses i h ee o mo e s udies had he same ype o in e en ion and compa ison g oup and
epo ed su icien da a on in ec ion ou comes o be combined. Me a-analyses we e pe o med using a andom-
e ec s model and he in e se a iance me hod wi h he I
2
s a is ic o es o inconsis ency be ween s udies.
Sensi i i y analyses we e also e alua ed. This s udy ollows he P e e ed Repo ing I ems o Sys ema ic Re iews
and Me a-Analyses (PRISMA) guidelines. PROSPERO ID: CRD42024554606.
Findings O he 4050 a icles iden i ied, 34 s udies me he inclusion c i e ia. Se en een s udies add essed pe iop-
e a i e an imic obial p ophylaxis (se en o which e alua ed speci ically du a ion o an imic obial p ophylaxis), wo
epo ed in o ma ion abou decolonisa ion s a egies, h ee add essed du a ion o an imic obial ea men as a ge
he apy, one e alua ed an ibio ic o al s ep-down s a egy, and six epo ed he impac o AMS implemen a ion
app oach on SOT . The o he i e s udies e alua ed speci ic a ge ed p ophylaxis. All he s udies had a mode a e
o high isk o bias. The me a-analysis o h ee s udies on he e ec o AMS p og ammes showed ha his
in e en ion may educe he a e o su gical si e in ec ions (OR 0⋅57, 95% CI 0⋅35–0⋅94). Fo pe iope a i e
an imic obial p ophylaxis, he me a-analysis o six ials showed esul s in a ou o p ophylaxis in e ms o
educing su gical si e in ec ions ( isk a io 1⋅93, 95% CI 1⋅14–3⋅27) in kidney SOT , bu p olonging p ophylaxis
beyond 24 h was no associa ed wi h imp o ed SSI a es (RR 0⋅87, 95% CI 0⋅51–1⋅48). Rega ding he du a ion o
an imic obial ea men o uncomplica ed g a - ela ed in ec ions (li e and kidney SOT ), he me a-analyses
ound no di e ence in e ms o ecu ence be ween sho and long an imic obial egimens (0⋅86, 95% CI
0⋅55–1⋅34). The ou me a-analyses had low he e ogenei y be ween s udies.
In e p e a ion S a egies o op imise an imic obial use a e sa e, wi h no nega i e impac on mo ali y o ansplan -
ela ed complica ions, and appea o imp o e some clinical ou comes in SOT , pa icula ly when using pe iope a i e
an imic obial p ophylaxis in kidney SOT and when implemen ing AMS p og ammes. No di e ence in he a e o
su gical si e in ec ion was ound be ween sho and ex ended du a ion o an imic obial p ophylaxis o kidney and
li e SOT . This sugges s ha a sho e du a ion o an imic obial su gical p ophylaxis may be sa e o ansplan
ecipien s. Sho cou ses o an ibio ics we e no associa ed wi h an inc eased a e o elapses o uncomplica ed
g a in ec ions, acco ding o obse a ional s udies pooled in ou me a-analysis. Howe e , u he high-quali y
*Co esponding au ho . Clinical Uni o In ec ious Diseases, Mic obiology and Pa asi ology, Vi gen del Rocío Uni e si y Hospi al, Se ille, Spain.
E-mail add ess: [email p o ec ed] (J. Molina Gil-Be mejo).
e
These au ho s con ibu ed equally o his wo k.
eClinicalMedicine
2025;85: 103310
Published Online xxx
h ps://doi.o g/10.
1016/j.eclinm.2025.
103310
www. helance .com Vol 85 July, 2025 1
A icles
clinical ials a e needed o be e unde s and he e ec s o hese s a egies in SOT and o design op imal AMS
in e en ions in his popula ion.
Funding This s udy was suppo ed by he Ins i u o de Salud Ca los III (ISCIII, e e ence ICI21/00075) and he Cen o
de In es igación Biomédica en de En e medades In ecciosas (CIBERINFEC, CB21/13/00006), ISCIII, Minis e io de
Ciencia e Inno ación.
Copy igh © 2025 The Au ho (s). Published by Else ie L d. This is an open access a icle unde he CC BY-NC-ND
license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
Keywo ds: Solid o gan ansplan a ion; An imic obial s ewa dship; An ibio ics; Immunosupp ession; An imic obial
esis ance
In oduc ion
Solid o gan ansplan a ion (SOT) has become an
impo an me hod o ea ing end-s age o gan disease.
Imp o emen s in su gical echnique and pos ope a i e
ca e, as well as ad ances in he p e en ion, diagnosis
and ea men o in ec ions, ha e led o a signi ican
imp o emen in quali y o li e and p olonged su i al.
Ne e heless, complex su ge ies, equen exposu e o
an ibio ics, and immunosupp essi e egimens pu solid
o gan ansplan ecipien s (SOT ) a a disp opo ion-
a ely high isk o in ec ion, especially by mul i- esis an
o ganisms (MDRO), which cloud he p ognosis.
1–3
The cu en an imic obial and bac e ial esis ance
c isis
4
has a huge impac on hose mos ulne able o
in ec ion. In a 2018 s udy, da a on an imic obial use in
SOT show ha in sou he n Eu ope, up o 76⋅9% o
pa ien s admi ed o ansplan uni s (solid o gan o
bone ma ow) ecei e an ibio ics, compa ed wi h 66⋅5%
Resea ch in con ex
E idence be o e his s udy
Solid o gan ansplan a ion (SOT) exposes pa ien s o an
inc eased isk o impai ed clinical ou comes ela ed o
inapp op ia e an imic obial ea men and mul id ug
esis an mic oo ganisms. This is why de eloping sa e and
e ec i e an imic obial s ewa dship (AMS) ini ia i es is
especially ele an in his popula ion. SOT pa ien s ha e been
excluded om mos andomised ials ackling c i ical aspec s
o an imic obial op imisa ion (like ea men du a ion), and
only na a i e e iews and call- o-ac ion pape s ha e been
published on his ele an opic.
We conduc ed a li e a u e sea ch o o iginal esea ch a icles
published om incep ion o Ma ch 6, 2025, wi h no
language es ic ions, using MEDLINE, EMBASE and SCOPUS.
Randomised clinical ials, obse a ional analy ical s udies,
quasi-expe imen al, and in e up ed ime se ies analyses wi h
a con ol g oup we e included. Inclusion c i e ia we e based
on he Popula ion, In e en ion, Compa ison, Ou come
(PICO) app oach: (P) Adul SOT pa ien s; (I) Speci ic
in e en ions a ge ing in ec ion p e en ion, indi idual
pa ien ’s ea men op imisa ion, o ans e sal AMS
in e en ions implemen a ion in SOT uni s; (C) Pa ien s o
pe iods wi hou he assessed in e en ion; (O) A leas one
o he ollowing: mo ali y, ansplan - ela ed complica ions,
incidence o in ec ions, an imic obial consump ion,
an imic obial esis ance; hospi al s ay, eadmission a es,
and/o an imic obial oxici ies.
All iden i ied s udies had a mode a e o high isk o bias.
Added alue o his s udy
In his a icle we p esen a sys ema ic e iew wi h se e al
me a-analyses which aim, on one hand, o pool accumula ed
e idence on se e al AMS in e en ions de eloped speci ically
o SOT , and on he o he hand, o map cu en a eas o
unce ain y and p io i y esea ch needs.
S udies iden i ied in his e iew enabled ou me a-analyses
ega ding pe iope a i e p ophylaxis, ea men du a ion o
uncomplica ed g a - ela ed in ec ions and he e ec s o
ans e sal implemen a ion o AMS in SOT uni s.
Acco ding o ou esul s, sho e pe iope a i e an imic obial
p ophylaxis, sho e ea men du a ion o uncomplica ed
g a in ec ions, and he implemen a ion o an AMS
p og ammes in ansplan uni s, may educe an ibio ic
consump ion in hese uni s wi hou impai ing clinical
ou comes o in ec ions, and may help o p e en su gical si e
in ec ions.
Implica ions o all he a ailable e idence
The conclusions o ou sys ema ic e iew and me a-analyses
a e mainly d i en by obse a ional s udies wi h a signi ican
isk o bias, and hus mus be alida ed by u he
andomised ials, which could be suppo ed by he da a
p esen ed in his a icle.
In his e iew we also iden i ied c i ical a eas in u gen need
o e idence. The e is s ill a pauci y o da a o SOT o he
han kidney o li e ecipien s, and also on he
demons a ion o nea clinical bene i s o AMS in e en ions
beyond he educ ion o an ibio ic consump ion, including
imp o ed clinical ou comes and bac e ial esis ance in he
ansplan uni s.
A icles
2 www. helance .com Vol 85 July, 2025
in No h Ame ica.
5
Fu he mo e, in a e ospec i e
s udy o 176 audi s o an ibio ic ea men adequacy in
SOT , mo e han 40% o p esc ip ions we e ound o be
inapp op ia e.
6
These da a show he need o imp o e
he use o an imic obials in SOT , who a e pa icula ly
ulne able o in ec ion as well as d ug in e ac ions and
side e ec s.
In he igh agains an imic obial esis ance, p e-
en i e s a egies play an impo an ole in educing
isk o in ec ion and i s consequences o bo h pa ien
and g a su i al: ac i e su eillance o MDRO ca ie
s a us, a ge ed pe iope a i e an imic obial p ophylaxis,
decolonisa ion s a egies, pos - ansplan an imic obial
p ophylaxis, and ea ly ac i e empi ic ea men .
7
How-
e e , hese p e en i e s a egies should be in eg a ed
wi h an imic obial s ewa dship (AMS) p og ammes,
which aim o op imise clinical ou comes and minimise
he unin ended consequences o an imic obial use,
including oxici y, selec ion o pa hogenic o ganisms
(such as Clos idioides di icile) and he eme gence o
esis ance, as well as o educe cos s wi hou nega i ely
impac ing quali y o ca e.
8
In c oss-sec ional s udies o all hospi alised pa ien s,
AMS in e en ions ha e been shown o imp o e an i-
mic obial use, gene ally by educing consump ion and
mic obiological esis ance and by imp o ing he p e-
sc ibing p o ile, wi h clinical bene i s.
9
Howe e , he
gene alised applica ion o AMS measu es may no be
applicable in SOT , as i does no ake in o accoun all
he ansplan -speci ic a iables ( ime since ansplan ,
ype o immunosupp ession, o gan ansplan ed, in-
ec ions de i ed om dono , polypha macy and d ug
in e ac ions, among o he s).
8,10
In addi ion, he SOT
popula ion is o en unde - ep esen ed in clinical ials
o AMS in e en ions, and guidelines o en do no
p o ide speci ic ecommenda ions. The e a e also ba -
ie s ha hinde implemen a ion o AMS s a egies in
SOT popula ion, such as physician pe cep ions o pa-
ien complexi y, anxie y ega ding disease se e i y, and
a ia ion in hos isk ac o s, such as he le el o
immunosupp ession, ecen su ge y, and he po en ial
o d ug in e ac ions.
11
Gi en he lack o da a, ce ain
issues such as choice o empi ical ea men , du a ion
o ea men , among o he s, a e usually le o he
disc e ion o he ea ing physician.
8,10
Despi e ongoing e o s by solid o gan ansplan
socie ies
8,10
o inco po a e he p inciples o AMS in o
daily p ac ice, he e is s ill li le e idence in his popu-
la ion. Cu en AMS p ac ice guidelines do no add ess
speci ic in e en ions in SOT .
12,13
Howe e , AMS in-
e en ions ha e been shown o be e ec i e and sa e in
o he immunosupp essed popula ions, such as onco-
haema ological pa ien s.
14,15
In ecen yea s, se e al calls
o ac ion ha e been published highligh ing he need o
mul idisciplina y app oaches, including close collabo-
a ion wi h ansplan expe s, and he use o apid and
app op ia e mic obiological diagnos ics o guide
ea men and op imise du a ion.
16–18
Al hough his is a
p io i y opic, o da e only na a i e e iews o AMS in-
e en ions ha e been published, wi h no sys ema ic e-
iew o he a ailable e idence o ou knowledge.
To be e unde s and he exis ing e idence and o
suppo op imal AMS in e en ions in his popula ion,
ou s udy p esen s a sys ema ic e iew and me a-analyses
o s udies epo ing on he e ec i eness and sa e y o
di e en s a egies o op imise an imic obial use in SOT .
Me hods
E hics
The sys ema ic e iew and me a-analyses we e con-
duc ed in acco dance wi h he P e e ed Repo ing
I ems o Sys ema ic Re iews and Me a-Analyses
(PRISMA) guidelines.
19
The e iew p o ocol was egis-
e ed in he In e na ional P ospec i e Regis e o Sys-
ema ic Re iews (PROSPERO) Da abase ( egis a ion
numbe : CRD42024554606).
Sea ch s a egy
We conduc ed an elec onic li e a u e sea ch o o ig-
inal esea ch a icles published om incep ion o 20
May 2024, wi h no language es ic ions, using h ee
heal h da abases: MEDLINE ( ia PubMed), EMBASE,
and SCOPUS. The sea ch ield was he i le and e ms
included bo h MeSH e ms and ee ex (keywo ds,
synonyms and wo d a ia ions) combined wi h Boolean
ope a o s (see Supplemen al Table S1 o he ull sea ch
s a egy). The sea ch s a egy was de eloped o
PubMed and hen adap ed app op ia ely o use in each
da abase. Ci a ions o included e e ences and ele an
sys ema ic e iews we e sea ched o iden i y addi ional
s udies. Email ale s we e c ea ed in he heal h da a-
bases o check o po en ial inclusion o a icles pub-
lished a e he sea ch da e and un il 06 Ma ch 2025.
Selec ion c i e ia
Inclusion c i e ia based on he Popula ion, In e en-
ion, Compa ison, Ou come and S udy (PICOS) design
o he sys ema ic e iew and me a-analyses we e adul
(≥18 yea s old) SOT , bo h inpa ien and ou pa ien ,
ega dless o he ime o ansplan a ion. The e alua ed
in e en ions included speci ic an imic obial s a egies
designed o op imise he p e en ion o in ec ions, such
as pe iope a i e an imic obial p ophylaxis (including
e icacy and du a ion), decolonisa ion s a egies and
o he speci ic s a egies o op imising p e en ion.
Speci ic s a egies o op imise an imic obial ea men
we e also e alua ed, including he iming o empi ical
ea men ini ia ion, he choice o empi ical o a ge ed
ea men agen s, de-escala ion, o al s ep-down he apy,
ea men du a ion, and an ibio ic alle gy de-labelling.
O he in e en ions e alua ed we e hose ela ed o
he implemen a ion o speci ic AMS in e en ions,
including educa ional, pe suasi e, es ic i e o
A icles
www. helance .com Vol 85 July, 2025 3
s uc u al app oaches. The compa a o was a con ol
g oup o SOT who did no ecei e he in e en ion
unde e alua ion, o co esponding ime pe iods in
p e-pos s udies. Ou comes included a leas one o
he ollowing, wi h no p ima y ou come equi ed:
ou comes ela ed o e ec i eness, such as global
mo ali y, ansplan - ela ed complica ions (e.g., g a
dys unc ion o ejec ion), in ec ions (including clinical
ailu e, mic obiological ailu e, elapse o ecu ence,
supe in ec ions, and C. di icile in ec ions), an imi-
c obial consump ion, and/o an imic obial esis ance;
and ou comes ela ed o sa e y, such as he need o
hospi alisa ion, p olonged hospi al s ay, need o
ehospi alisa ion, admission o in ensi e ca e uni s
(ICUs), and/o an imic obial oxici ies. Eligible s udy
designs included andomised clinical ials (RCTs),
obse a ional analy ical s udies (coho o case-con ol
s udies), p e-pos s udies, and in e up ed ime se ies
analyses.
We excluded duplica e eco ds using Mendeley,
20
cong ess abs ac s, and s udies assessing unapp o ed
subs ances o subs ances no used in ou ine clinical
p ac ice. T ials ela ed o i al in ec ions (cy omegalo-
i us and BK i us, among o he s) we e excluded, as
hese a e he subjec o mo e ex ensi e s udies
21
and a e
no he subjec o his e iew. We did no include
s udies abou managemen o asymp oma ic bac e iu ia
in kidney ansplan ecipien s, as hese ha e been
add essed in ecen sys ema ic e iews,
22,23
which sug-
ges ha sys ema ic sc eening and ea men o
asymp oma ic bac e iu ia beyond he second mon h
a e ansplan a ion p o ide no appa en bene i
among kidney ansplan ecipien s. An i ungal p o-
phylaxis was also excluded, as ecen sys ema ic e iews
ha e add essed his issue, bo h in he gene al SOT
popula ion and by ype o ansplan , mos commonly
lung
24,25
and li e ,
26,27
bu also hea ansplan a ion.
28
The i les and abs ac s o all iden i ied a icles we e
sc eened o eligibili y by wo independen e iewe s
(MPG and ABGG). I he eligibili y o a s udy was no
mu ually ag eed upon o was no clea om he i le
and abs ac alone, he a icle was included in he ull-
ex e iew s age. Finally, he ull pape s o he p e-
selec ed s udies we e assessed be o e a inal decision on
hei inclusion was made. Any disag eemen s we e
esol ed by consensus o wi h a hi d e iewe (JMC).
Da a ex ac ion
The da a was collec ed in duplica e by wo independen
e iewe s (MPG and ABGG) om a icles selec ed o
inclusion in he e iew. Fo each publica ion, he
ollowing a iables we e eco ded:
- Au ho and yea o publica ion.
- Coun y.
- S udy pe iod.
- S udy design.
- S udy unding: public o p i a e unding, o wi hou
inancial suppo .
- Numbe o hospi als included and mean numbe o
beds.
- Numbe o pa ien s.
- Pa ien ’s cha ac e is ics: age, sex, ype o ansplan ,
immunosupp ession/ ejec ion ea men .
- Time since ansplan (i a ailable).
- Type o in e en ion assessed.
- Type o in ec ion a ge ed by he in e en ion.
- Compa a o g oup: s anda d o ca e o a di e en
in e en ion.
- Du a ion o in e en ion and ou come measu emen
ime ame, in mon hs.
- Le el o compliance wi h he in e en ion:
comple eness and ideli y.
- Ou comes.
Quali y assessmen
The isk o bias o each s udy was assessed by wo in-
dependen au ho s (MPG and ABGG) using he
Coch ane EPOC g oup’s c i e ia. Disc epancies in he
quali y assessmen we e esol ed h ough discussion
wi h a hi d e iewe (JMC) o a i e a a inal desig-
na ion o each domain. Based on he Coch ane EPOC
g oup’s isk o bias ool,
29
s udies we e gi en a sco e o
low, high o unclea isk o bias o he ollowing
c i e ia: andom sequence gene a ion; alloca ion
concealmen ; baseline ou come measu emen s simila ;
baseline cha ac e is ics simila ; incomple e ou come
da a; knowledge o he alloca ed in e en ions
adequa ely p e en ed du ing he s udy; p o ec ion
agains con amina ion; selec i e ou come epo ing;
and o he isks o bias. A summa y o he isk-o -bias
assessmen sco es was assigned o each s udy as ol-
lows: ‘low isk o bias’ when all c i e ia we e sco ed as
‘low’; ‘mode a e isk o bias’ i one c i e ion o wo
c i e ia we e sco ed as ‘unclea ’ o ‘high’; and ‘high isk
o bias’ i mo e han wo c i e ia we e sco ed as ‘un-
clea ’ o ‘high’. REVMAN so wa e Ve sion 5⋅4⋅1 was
used o colla e and p esen he isk-o -bias esul s.
Da a syn hesis and me a-analysis
Fo desc ip i e pu poses, we ex ac ed he da a a ailable
in he included s udies by in e en ion and con ol
g oups. Ra ios o o he s a is ics such as p- alues we e
also ex ac ed whe e a ailable.
We also sough o pool he da a om he a icles
included in he sys ema ic e iews. To do his, we
g ouped ials ha included di e en ypes o SOTs and
he same ype o in e en ion, assuming ha he
e ec i eness o he in e en ions was compa able.
Me a-analyses we e only pe o med i h ee o mo e
s udies wi h simila ypes o in e en ion, con ol
g oups and ou come measu es could be combined. Fo
his pu pose, da a on he p edic ed clinical ou comes
should be epo ed as he numbe o e en s and o al
A icles
4 www. helance .com Vol 85 July, 2025
pa ien s in each a m o , al e na i ely, he di e ence
be ween a ms as he mean and s anda d de ia ion.
Whene e possible, he same ime o ou come assess-
men was de ined o he me a-analyses. I his in o -
ma ion was no a ailable, we used he closes measu e.
In he case o duplica e coho s, p io i y was gi en o
esul s based on la ge sample sizes. I he e was
insu icien o incomple e in o ma ion in he published
ex , missing da a we e eques ed om he s udy au-
ho s. Subg oup analyses, using he same c i e ia as
desc ibed abo e, we e pe o med o analyse he e ec s
o in e en ions in di e en ansplan popula ions
when a su icien numbe o ials we e a ailable.
S a is ics
Me a-analyses we e pe o med using a andom-e ec s
model and he in e se a iance me hod. The odds a-
io (OR) o p e-pos s udies o he isk a io (RR) o
obse a ional s udies and RCTs wi h a 95% con idence
in e al (CI) we e calcula ed based on he epo ed da a.
S udies wi h 0 coun s in a leas one a m ecei ed a
con inui y co ec ion (adding 0⋅5). We used he I
2
es o
assess s a is ical he e ogenei y.
30
A alue o less han
40% ep esen ed low he e ogenei y, a alue be ween
40% and 60% ep esen ed mode a e he e ogenei y, and
a alue o mo e han 60% ep esen ed high he e oge-
nei y. Sensi i i y analyses we e pe o med by emo ing
ials wi h 0 coun s in a leas one a m o ensu e he
obus ness o he esul s. A ixed-e ec s model was also
used o sensi i i y analyses. REVMAN so wa e
Ve sion 5⋅4⋅1 was used o un he me a-analysis, and
he esul s we e p esen ed in o es plo s.
Role o he unding sou ce
This s udy was suppo ed by he Ins i u o de Salud Ca los
III, (ISCIII, e e ence ICI21/00075) and he CIBER de
En e medades In ecciosas (CIBERINFEC, CB21/13/
00006), ISCIII, Minis e io de Ciencia e Inno ación. The
Funde s had no ole in s udy design, da a collec ion, da a
analyses, in e p e a ion, o w i ing o he epo .
Resul s
The elec onic sea ch e u ned 4050 eco ds; 2063 we e
emo ed a e duplica e checking. A u he 1889 pub-
lica ions we e excluded a e i le and abs ac il e ing,
because hey did no mee he eligibili y c i e ia. This
le 98 po en ially ele an s udies ha we e e ie ed in
ull ex : 67 we e excluded be o e da a ex ac ion and 31
me he inclusion c i e ia. Th ee addi ional s udies we e
e ie ed om ci a ions, lea ing 34 included s udies
(Fig. 1).
31–64
Fi e au ho s we e con ac ed and h ee o
hem we e able o p o ide he eques ed da a.
Cha ac e is ics o s udies and in e en ions
Table 1 shows he cha ac e is ics o he s udies e alu-
a ed. S udy designs included 10 RCTs,
31–36,41,44,52,53
13 p e-
pos s udies,
37,39,42,43,45,48,49,59–64
and 11 obse a ional
s udies.
38,40,46,47,50,51,54–58
Mos o he s udies ook place in
he USA (n = 12),
31,36,42,44–49,51,58,62
ollowed by Spain
(n = 4),
35,37,61,63
and Ge many (n = 4).
32,43,50,56
Mos s udies
(33/34, 97⋅6%) epo ed he cha ac e is ics o pa ien s
included; howe e , ansplan speci ic de ails (i.e., g a
dis unc ion, ejec ion ea men , dono cha ac e is ics,
e c.) we e only epo ed in hal o he s udies (18/34,
52⋅9%). A o al o 7367 pa ien s we e included in he 34
e alua ed ials (mean numbe was 136⋅50 pa ien s pe
s udy, in e qua ile ange (IQR) 58⋅25–201⋅25). O
hese, 5967 we e SOT , as he s udy by Sha ekhani
e al.
64
also included in o ma ion on 1400 pa ien s on
he wai ing lis o ansplan a ion. In e ms o ype o
o gan ansplan ed, he dis ibu ion was as ollows:
3514 kidney (58⋅9%), 1920 li e (32⋅2%), 381 lung
(6⋅4%), 69 panc eas (1⋅2%), 55 li e -kidney (0⋅9%), 49
kidney-panc eas (0⋅8%), 40 in es inal/mul i isce al
(0⋅7%), 29 hea (0⋅5%), and 15 combined hea -lung
(0⋅3%). Some pa ien s may be included mo e han
once, as some s udies eco ded mo e han one episode
pe pa ien .
58
E alua ed in e en ions we e mul iple. A b ie
desc ip ion o each in e en ion is gi en in Table 2,
oge he wi h da a abou mo ali y, ansplan ela ed
a iables and in ec ions o each included s udy.
Se en een
33,34,36,39,43,44,46,47,51,54,55,57,58,60,61,63,64
epo ed da a
abou mo ali y, and e en i he e alua ed in e en ions
we e di e en , none o hem showed an inc ease in
mo ali y. Da a abou ansplan ela ed complica ions
(which include acu e ejec ion, g a dys unc ion,
dono -de i ed in ec ion, and e u n o dialysis) was e-
po ed in nine s udies
34,36,37,41,43,44,46,47,63
and no di e ence
among con ol and in e en ion g oup was ound. All
s udies excep one
64
epo ed in o ma ion abou inci-
dence o di e en in ec ions a e implemen a ion o a
gi en in e en ion. Mos common epo ed in ec ions
we e su gical si e in ec ions, ollowed by global pos -
ansplan in ec ion, bloods eam in ec ions, u ina y
ac in ec ions and C. di icile in ec ion.
Eigh s udies ga e in o ma ion abou an imic obial
consump ion,
47,57,58,60–64
12 abou an imic obial esis-
ance, and 12 on he ype and du a ion o he hospi al
ca e equi ed (hospi alisa ion, leng h o s ay, o
admission o ICU)
36,43–47,49,55,60,61,63,64
(Supplemen al
Table S2). None o he 34 ials epo ed da a on an i-
mic obial side e ec s.
Li le da a was p o ided on each pa icipa ing cen-
e’s le el o compliance wi h he e alua ed in e en-
ion, and only i e s udies o e ed da a abou
compliance.
41,43,44,47,63
Fou s udies assessed compliance
ela ed o an imic obial p ophylaxis,
41,43,44,47
epo ing
high adhe ence (>80%) in h ee o hem
41,43,44
and
mode a e in ano he s udy (<70%).
47
The o he s udy
63
e alua ed he impac o an AMS p og amme, in
which ecommenda ions we e accep ed in 91⋅7% o
cases.
A icles
www. helance .com Vol 85 July, 2025 5
The compa a o g oup was a iable: in 18 ials he
con ol g oup ecei ed no ea men o in e en ion,
while in 16 ials he in e en ion g oup was compa ed
wi h ano he g oup ha ecei ed a speci ic ea men o
in e en ion acco ding o clinical p ac ice.
Quali y o s udies
Fig. 2 shows he sco es ob ained o each c i e ion o he
Coch ane EPOC g oup’s isk-o -bias ool. The o e all
isk o bias was high o 26 s udies
31–40,42,43,45,46,48,50–59,61,62
and mode a e o eigh ,
38,41,44,47,49,60,63,64
and none o he
s udies we e classi ied as ha ing ‘low isk o bias’.
Supplemen al Figu e S1 shows e iew au ho s’ judge-
men s abou each isk-o -bias i em p esen ed as pe -
cen ages ac oss all included s udies.
All s udies showed simila i ies in he sco es o each
domain. P e-pos s udies and non-RCTs (24/34, 70⋅6%)
we e sco ed as ‘high isk’ o andom sequence gene a-
ion and alloca ion concealmen . Fo RCTs (10/34,
29⋅4%), mos we e conside ed o be a low isk o selec ion
bias, wi h he excep ion o Salehipou e al.,
53
whe e in-
o ma ion on he andomisa ion and alloca ion me hod
was missing. Fo baseline ou comes and cha ac e is ics,
da a om he in e en ion and con ol g oups we e
compa able in 12 s udies (35⋅3%),
30,37–40,47–49,51,54,57,58
and in
he o he s udies s a is ically signi ican di e ences we e
obse ed in he baseline analysis o baseline measu es
we e no pe o med. Missing ou come measu es may
ha e biased he esul s in h ee s udies (8⋅8%).
32,39,51
The
p ima y ou come a iables we e assessed blindly o he
esul s we e objec i e in 12 s udies
(35⋅3%).
45,47,49,51,54,55,57,58,60,62–64
The s udy by Ga cía P ado ME
e al.
37
lacked mo ali y ou comes o he pa ien g oups.
Resul s o speci ic in e en ions
Pe iope a i e an imic obial p ophylaxis
Se en een s udies add essed pe iope a i e an imic o-
bial p ophylaxis, some o which included di e en ypes
o ansplan a ion: mainly enal (n = 12),
31–36,38–43
bu also
li e (n = 4),
37,44,45,47
hepa o enal (n = 2),
37,45
lung (n = 1),
46
and panc eas (n = 1).
36
No a icles abou p ophylaxis in
hea ansplan a ion we e ound. Se en s udies e alu-
a ed du a ion o an imic obial pe iope a i e p ophylaxis
in kidney (n = 3),
41–43
li e (n = 3),
44,45,47
and lung
ansplan a ion (n = 1).
46
The emaining se en s udies
assessed pe iope a i e an ibio ic p ophylaxis e icacy:
se en o hem compa ing an imic obial p ophylaxis
wi h no p ophylaxis in kidney ansplan a ion,
31–35,38,40
one o hem e alua ing he e icacy o addi ion o an-
comycin in kidney and panc eas ansplan ecipien s,
36
one e alua ing he addi ion o gen amicin in kidney
ansplan a ion,
39
and one las s udy in li e ans-
plan a ion compa ing amoxicillin/cla ulana e wi h
ce azolin p ophylaxis.
37
No di e ences ega ding global mo ali y we e e-
po ed in he eigh s udies whe e his a iable was
Fig. 1: PRISMA 2020 low diag am o new sys ema ic e iews which included sea ches o da abases and egis e s only.
A icles
6 www. helance .com Vol 85 July, 2025
S udy ID Coun y Pe iod
(yea s)
Design Numbe o
pa ien s
Type o
ansplan
In e en ion Du a ion
(mon hs) o
assessed
in e en ion
Main ou come assessed
Townsend e al.,
1980
31,
a
Uni ed
S a es
1976–1978 Randomised
clinical ial
37 Kidney Pe iope a i e an ibio ic p ophylaxis 17 Pos - ansplan global
in ec ions
Wilms e al.,
1986
32,
a
Ge many 1982 Randomised
clinical ial
34 Kidney Pe iope a i e an ibio ic p ophylaxis Un il hospi al
discha ge
Pos - ansplan global
in ec ions
E ans e al.,
1988
33,
a
Uni ed
Kingdom
1983 Randomised
clinical ial
46 (34
ansplan
su ge ies)
Kidney Pe iope a i e an ibio ic p ophylaxis 1 SSIs
Cohen e al.,
1988
34,
a
Uni ed
Kingdom
1984–1985 Randomised
clinical ial
53 Kidney Pe iope a i e an ibio ic p ophylaxis 14 days Pos - ansplan global
in ec ions
Robles e al.,
1990
35,
a
Spain 1986–1987 Randomised
clinical ial
60 Kidney Pe iope a i e p ophylaxis 1 SSIs, UTI
P unds ein e al.,
2001
36,
a
Uni ed
S a es
1994–1995 Randomised
clinical ial
112 Kidney, Panc eas Pe iope a i e an ibio ic p ophylaxis 12 Pos - ansplan global
in ec ion, SSIs
Ga cía P ado e al.,
2008
37
Spain 2003–2006 P e-pos
s udy
167 Li e , Li e -
kidney
Pe iope a i e an ibio ic p ophylaxis 12 SSIs
Choi S e al.,
2010
38
Sou h
Ko ea
2006–2008 Re ospec i e
obse a ional
106 Kidney Pe iope a i e an ibio ic p ophylaxis 36 Pos - ansplan global
in ec ions
Abboud e al.,
2013
39
B azil 2009–2011 P e-pos
s udy
45 Kidney Pe iope a i e an ibio ic p ophylaxis 10 Pos - ansplan heal hca e-
associa ed in ec ions
Choi e al.,
2013
40,
a
Sou h
Ko ea
2006–2010 Re ospec i e
obse a ional
174 Kidney Pe iope a i e an ibio ic p ophylaxis 55 Pos - ansplan in ec ion
O lando e al.,
2015
41,
a
I aly 2006–2012 Randomised
clinical ial
205 Kidney Pe iope a i e an ibio ic p ophylaxis
(du a ion)
65 SSIs
Bli en e al.,
2018
42,
a
Uni ed
S a es
2013–2015 P e-pos
s udy
100 Kidney Pe iope a i e an ibio ic p ophylaxis
(du a ion)
32 SSIs
Bachmann el al.
2019
43,
a
Ge many 2014–2017 P e-pos
s udy
212 Kidney Pe iope a i e an ibio ic p ophylaxis
(du a ion)
21 SSIs
Be y e al.,
2019
44,
a
Uni ed
S a es
2010–2015 Randomised
clinical ial
102 Li e Pe iope a i e an ibio ic p ophylaxis
(du a ion)
63 SSIs
Bandali e al.,
2020
45,
a
Uni ed
S a es
2013–2015 P e-pos
s udy
44 Li e , Li e -
kidney
Pe iope a i e an ibio ic p ophylaxis
(du a ion)
16 Pos - ansplan global
in ec ions
G o e al., 2021
46
Uni ed
S a es
2013–2019 Re ospec i e
obse a ional
147 Lung Pe iope a i e an ibio ic p ophylaxis
(du a ion)
74 Recipien eedom om
dono -de i ed espi a o y
bac e ial in ec ion
Yau e al., 2022
47,
a
Uni ed
S a es
2016–2019 Re ospec i e
obse a ional
216 Li e Pe iope a i e an ibio ic p ophylaxis
(du a ion)
45 DOT a e ansplan su ge y
Singh e al.,
2006
48
Uni ed
S a es
1996–2004 P e-pos
s udy
144 Li e S. au eus sc eening and decolonisa ion 48 S. au eus in ec ion o
colonisa ion
Lee e al., 2020
49
Uni ed
S a es
2014–2016 P e-pos
s udy
121 Kidney Uni e sal pos ope a i e decolonisa ion 23 Pos - ansplan global
in ec ions
Wol e s e al.,
2014
50
Ge many NS P ospec i e
obse a ional
40 Kidney An imic obial p ophylaxis p io o u ina y
ca he e emo al
NS UTIs
Kohli e al., 2018
51
Uni ed
S a es
2008–2015 Re ospec i e
obse a ional
69 Li e An imic obial p ophylaxis p io o ERCP 24 h wi hin ERCP ERCP ela ed BSIs
Salmela e al.,
1990
52
Finland 1987–1989 Randomised
clinical ial
182 Kidney Pe iope a i e in a esically an ibio ic
i iga ion
24 UTIs, SSIs
Salehipou e al.,
2009
53
I an 2006–2007 Randomised
clinical ial
200 Kidney Pe iope a i e in a esically an ibio ic
i iga ion
5 UTIs
Haja Mydin e al.,
2012
54
Uni ed
Kingdom
2000–2010 Re ospec i e
obse a ional
129 Lung Speci ic p e en ion op imisa ion s a egies
(Choice o p e-su gical p ophylaxis acco ding
o mic obiological es )
120 Pos -lung ansplan global
in ec ions
A ni-Nachman
e al., 2021
55,
a
Is ael 2011–2019 Re ospec i e
obse a ional
214 Kidney Du a ion o ea men (UTI) No applicable UTIs
Fe s l e al.,
2022
56,
a
Ge many 2008–2019 Re ospec i e
obse a ional
30 Li e Du a ion o ea men (cholangi is) No applicable Acu e cholangi is
Miwa e al.,
2025
57,
a
Japan 2010–2022 Re ospec i e
obse a ional
91 Li e Du a ion o ea men (uncomplica ed G am
nega i e-BSI)
No applicable Composi e end-pon : 30-day
mo ali y and ecu ence o
in ec ion o BSI
Nussbaum e al.,
2024
58
Uni ed
S a es
2016–2021 Re ospec i e
obse a ional
147 All ypes (>65%
Kidney)
O al an ibio ic s ep-down he apy No applicable Uncomplica ed g am-
nega i e BSIs
(Table 1 con inues on nex page)
A icles
www. helance .com Vol 85 July, 2025 7
included.
33,34,36,39,43,44,46,47
No di e ences in ansplan -
ela ed complica ions we e epo ed in he eigh a i-
cles ha add essed his issue.
34,36,37,41,43,44,46,47
All he ials
looked a in ec ious complica ions. None o hem
showed an inc ease in in ec ion a es a e he in e -
en ion, and some e en showed signi ican pos -
in e en ion bene i s.
When compa ed wi h no p ophylaxis, pe iope a i e
an imic obial p ophylaxis was shown o signi ican ly
dec ease he numbe o o al in ec ions in one s udy,
34
bu no di e ences be ween he wo g oups we e
obse ed in he o he six s udies.
31–33,35,38,40
Da a om
six o hese se en s udies we e pooled in a me a-
analysis compa ing pe iope a i e an imic obial p o-
phylaxis s no p ophylaxis and hei espec i e impac
on he a e o su gical si e in ec ions (SSIs) in kidney
ecipien s.
31–35,40
The s udy o Choi e al. (2010)
38
was
no included, as da a was duplica ed om Choi e al.
(2013).
40
The pooled da a om hese six s udies
(Fig. 3A) showed a signi ican educ ion in SSIs, wi h
an RR o 1⋅93 in a ou o an imic obial p ophylaxis
(95% CI 1⋅14–3⋅27) and low he e ogenei y be ween
ials (I
2
0%). These esul s we e consis en wi h he
sensi i i y analysis using a ixed-e ec model (RR 1⋅93,
95% CI 1⋅14–3⋅27). The E ans e al.
33
s udy had
0 coun s in he p ophylaxis g oup, so he con inui y
co ec ion was applied by de aul and a e y wide CI
(0⋅82–243) was obse ed. This indica es a e y imp e-
cise and po en ially biased e ec es ima e, e en
hough he con ibu ion o his s udy o he me a-
analysis was he lowes (3⋅4%). As a consequence,
he esul s o he sensi i i y analysis excluding his
s udy emained una ec ed (RR 1⋅80, 95% CI
1⋅05–3⋅07).
The addi ion o gen amicin in kidney ans-
plan a ion
39
p oduced no di e ence in su gical si e
in ec ions, bu a signi ican dec ease was obse ed in
u ina y ac in ec ions (UTIs). On he o he hand,
addi ion o ancomycin o he s anda d pe iope a i e
p ophylaxis in kidney and panc ea ic ansplan a ion
p oduced no di e ence in g am-posi i e in ec ion
a es in bo h ypes o ansplan s. No di e ences in
SSIs o bloods eam in ec ions (BSIs) we e ound
when compa ing amoxicillin-cla ulana e wi h ce a-
zolin as p ophylaxis in li e ansplan a ion.
37
Rega ding du a ion o p esu gical an imic obial
p ophylaxis, he se en s udies ha e alua ed his
aspec in enal,
41–43
li e
44,45,47
o lung
46
ansplan pa-
ien s concluded ha p olonged p ophylaxis did no
dec ease he o al numbe o in ec ions. A me a-
analysis o pooled da a om six s udies
41–45,47
e alu-
a ing sho (a single p esu gical dose
41–44,47
o 24 h
45
) s
ex ended p ophylaxis (>24 h) on he a e o SSIs was
pe o med (Fig. 3B), bo h in kidney
41–43
and li e
ansplan ecipien s.
44,45,47
The s udy by G o was
excluded om he me a-analysis as i assessed a
di e en clinical con ex ; p ophylaxis du a ion in lung
ansplan ecipien s om cul u e-posi i e dono s,
wi h dono -de i ed in ec ions as he p ima y endpoin ,
a he han su gical si e in ec ions. Gi en his unda-
men al di e ence, i was no conside ed compa able o
he s udies included. The e we e no signi ican di -
e ences in he a e o SSIs when compa ing sho and
ex ended p ophylaxis (RR 0⋅87, 95% CI 0⋅51–1⋅48).
The same esul was ound in he sensi i i y analyses
using a ixed-e ec model. Fo kidney SOT , he RR
was 1⋅52 (95% CI 0⋅43–5⋅37) wi h low he e ogenei y
be ween s udies (I
2
17%), and o li e SOT , he RR
S udy ID Coun y Pe iod
(yea s)
Design Numbe o
pa ien s
Type o
ansplan
In e en ion Du a ion
(mon hs) o
assessed
in e en ion
Main ou come assessed
(Con inued om p e ious page)
F ene e e al.,
2016
59,
a
Canada 2010–2014 P e-pos
s udy
1386 Li e , Kidney,
Panc eas,
Panc eas–kidney
AMS in e en ion + in ec ion con ol 24 SSIs
So e al., 2019
60
Canada 2013–2016 P e-pos
s udy
318 Lung, Kidney,
Li e , Kidney-
panc eas, Hea
AMS in e en ion 12 Pos - ansplan global
in ec ions
Fe nández e al.,
2022
61,
a
Spain 2016–2019 P e-pos
s udy
76 Li e AMS in e en ion 12 Colonisa ion and in ec ion by
MDR and XDR bac e ia
Kueh e al.,
2022
62
Uni ed
S a es
2016–2019 P e-pos
s udy
172 All ypes (mainly
kidney and li e )
AMS in e en ion 24 C. di icile es ing
Sil a e al.,
2023
63,
a
Spain 2014–2016 P e-pos
s udy
196 Kidney, Kidney-
panc eas, Li e -
kidney
AMS in e en ion + in ec ion con ol 10 Pos - ansplan global
in ec ions
Sha iekhani e al.,
2023
64
I an 2020–2021 P e-pos
s udy
2791 All ypes (mainly
kidney and li e )
AMS in e en ion 12 Pos - ansplan global
in ec ions
AMS: an imic obial s ewa dship; BSIs: bloods eam in ec ions; CDI: Clos idioides di icile in ec ion; DOT: days o an ibio ic he apy; ERCP: endoscopic e og ade cholangiog aphy; MDR: mul id ug-
esis an ; SSIs: su gical si e in ec ions; UTIs: u ina y ac in ec ions; XDR: ex ensi ely d ug- esis an ; NS: No speci ied.
a
S udies included in he me a-analyses.
Table 1: Cha ac e is ics o included s udies and in e en ions assessed.
A icles
8 www. helance .com Vol 85 July, 2025
S udy ID Desc ip ion o he in e en ion and con ol
g oups
Numbe o pa ien s
n (%)
Mo ali y
n (%)
T ansplan ela ed
complica ions
n (%)
In ec ions n (%)
Pe iope a i e an imic obial p ophylaxis
Townsend
e al., 1980
31,
a
Pe iope a i e an ibio ic p ophylaxis
(ce amandole + ob amycin)
Con ol g oup: no pe iope a i e an ibio ic
p ophylaxis
37
C: 17
INT: 20
– – In ec ion in he i s 7 d a e ansplan a ion
C: 10 (59); INT: 4 (20)
p = 0⋅04
Pos ope a i e wound in ec ion
C: 5 (29⋅4); INT: 3 (15) NS (p = 0⋅51)
UTIs
C: 14 (82⋅35); INT: 12 (60) NS (p = 0⋅26)
BSIs
C: 3 (17⋅65); INT: 2 (10) NS (p = 0⋅84)
Wilms e al.,
1986
32,
a
Pe iope a i e p ophylaxis (cephalospo in p ophylaxis
2 g p e- ansplan and 500 mg a 12, 24, and 38 h
hou s).
Con ol g oup: no pe iope a i e an ibio ic
p ophylaxis
34
C: 18
INT: 16
– – Su gical si e in ec ions
C: 7/18 (38⋅9); INT: 5/16 (31⋅2) NS
E ans e al.,
1988
33,
a
Pe iope a i e p ophylaxis (amoxicillin-cla ulana e
1 gg/200 mg wo doses du ing su ge y)
Con ol g oup: no pe iope a i e an ibio ic
p ophylaxis
46 (34 ansplan
su ge ies)
C: 22
INT: 24
2/46 (4⋅3)
C: 2 (9⋅1)
INT: 0 (0)
–Su gical si e in ec ions in ansplan su ge ies
C: 4/13 (30⋅8); INT: 0/21 (0)
Cohen e al.,
1988
34,
a
Pe iope a i e an ibio ic p ophylaxis (ce u oxime
750 mg and pipe acillin 4 g)
Con ol g oup: no pe iope a i e an ibio ic
p ophylaxis
53
C: 26
INT: 27
30-day
mo ali y due
o in ec ion
C: 0; INT: 1
(3⋅7) NS
Requi ed dialysis
(30 days)
C: 11 (42⋅3); INT: 8
(29⋅63)
To al numbe o in ec ions
0–14 days:
C: 30 (115⋅38); INT: 24 (88⋅9)
0–5 days:
C: 11 (42⋅31); INT: 3 (11⋅1) p = 0⋅04
Su gical wound in ec ion
0–14 days:
C: 11 (3⋅85); INT: 4 (14⋅8)
0–5 days:
C 5 (19⋅2); INT: 1 (3⋅7) p = 0⋅027
UTIs
0–14 days:
C: 18 (69⋅2); INT: 19 (70⋅4)
0–5 days:
C: 5 (19⋅2); INT: 2 (7⋅41)
Robles e al.,
1990
35,
a
Pe iope a i e p ophylaxis wi h 1 dose o ce o axime
1 g (a m A), ce iaxone 1 g (a m B)
Con ol g oup: no pe iope a i e p ophylaxis
60
C: 20
INT: 40 (20 + 20)
– – SSI
C: 2/20 (10); INT: 3/40 (7⋅5) NS
UTI
C: 7/20 (35); INT: 12/40 (30) NS
P unds ein
e al., 2001
36
Addi ion o ancomycin o pe iope a i e an ibio ic
p ophylaxis
Con ol g oup: no addi ion o ancomycin o
pe iope a i e an ibio ic p ophylaxis ancomycin
Kidney: 88
C: 45
INT: 43
Panc eas: 24
C: 12
INT: 12
Pa ien 1-y
su i al
Kidney:
C: 89; INT: 95
NS
Panc eas:
C: 92; INT: 100
NS
Rejec ion du ing
ansplan
admission
Kidney:
C: 24%; INT: 23%
NS (p = 0⋅90)
Panc eas:
C: 42%; INT: 8% NS
(p = 0⋅06)
Allog a 1-y
su i al
Kidney:
C: 78%; INT: 93%
NS (p = 0⋅07)
Panc eas:
C: 92%; INT: 92 %
NS (p = 1⋅00)
G am-posi i e in ec ion
Kidney:
C: 22%; INT: 20% NS (p = 0⋅76)
Panc eas:
C: 50%; INT: 33% NS (p = 0⋅41)
Ga cía P ado
e al., 2008
37
Pe iope a i e an ibio ic p ophylaxis wi h
amoxicillin/cla ulana e
Con ol g oup: pe iope a i e an ibio ic p ophylaxis
wi h ce azolin
167
P e-INT: 94
Pos -INT: 73
–G a su i al 30
days
C: 89 (92⋅6); INT:
66 (90⋅4) NS
(p = 0⋅41)
SSIs
C: 34 (36⋅2); INT: 22 (30⋅1) NS
BSIs
C: 4 (4⋅3); INT: 5 (6⋅8) NS (p = 0⋅35)
(Table 2 con inues on nex page)
A icles
www. helance .com Vol 85 July, 2025 9
pa ien s who swi ched o o al he apy. No di e ences in
o al an ibio ic du a ion we e epo ed.
Speci ic AMS implemen a ion app oach
Six s udies epo ed he impac o speci ic AMS
implemen a ion app oach on SOT .
59–64
Fi e o hem
epo ed esul s abou implemen a ion o a gene al
AMS p og amme in di e en ansplan uni s: one
61
in
li e ansplan ; one
59
in li e , kidney, panc eas, and
kidney-panc eas; one
60
in lung, kidney, li e , kidney-
panc eas, and hea ansplan pa ien s; one
63
in kid-
ney, kidney-panc eas, and kidney-li e ; and one
64
in all
ypes o ansplan a ion (p incipally kidney and li e ).
Finally, one s udy
62
e alua ed an AMS app oach p io o
o de ing C. di icile es s ( equi ing p esc ibe s o
answe a se ies o sho ques ions wi hin he elec onic
medical eco d be o e o de ing C. di icile es s), whe e
all ypes o ansplan we e included (mainly kidney and
li e ).
Wi h espec o e alua ion o implemen a ion o a
gene al AMS p og amme in di e en ansplan uni s,
none o he s udies showed any di e ence ega ding
mo ali y, one o hem epo ed a dec ease in o e all
SSI a e,
59
ano he a dec ease in UTI and cys i is.
63
One
s udy epo ed da a ela ed o ansplan a ion,
63
wi h no
di e ence among g oups. No o he di e ences in o he
in ec ion- ela ed a iables we e desc ibed.
An imic obial consump ion was assessed in i e
s udies,
60–64
all o hem showing a dec ease in o e all
consump ion o an ibio ics. Rega ding an imic obial
esis ance, Sil a e al.
63
epo ed a educ ion in he
incidence o in ec ions due o AmpC-p oducing En e -
obac e ales du ing he in e en ion pe iod, a e
implemen a ion o a join p og amme o AMS and
hospi al-acqui ed in ec ion con ol in a kidney,
panc eas and li e ansplan uni . No di e ences in
episodes due o ex ended-spec um be a-lac amase
(ESBL)-p oducing En e obac e ales o mul id ug-
esis an (MDR) P. ae uginosa we e epo ed.
Sha iekhani e al.
64
epo ed a signi ican educ ion in
equency o pa ien s wi h me hicillin- esis an
S. au eus, ca bapenem- esis an En e obac e ales, Kleb-
siella pneumoniae ca bapenemase (KPC) isola es and
ancomycin- esis an En e ococcus colonisa ion a e he
implemen a ion o an AMS p og amme in a ansplan
uni . No di e ences ega ding an imic obial esis ance
among bo h in e en ion and con ol g oups we e e-
po ed by Fe nández e al.
61
The s udy
62
ha e alua ed an AMS app oach p io o
o de ing C. di icile es s showed a signi ican dec ease
in numbe o o de s o C. di icile oxin, wi h no di -
e ences acco ding o a es o nega i e C. di icile oxin
es s be ween bo h g oups.
O all he s udies, only h ee epo ed ou comes
homogeneously and p o ided su icien in o ma ion o
be included in he me a-analysis. Thus, we we e able o
pool he da a om hese h ee s udies o assess he
e ec o AMS implemen a ion in SOT on SSI
a es.
57,59,61
They we e p e-pos s udies wi h a mode a e
o high isk o bias. Fe nández e al.
61
and Sil a e al.
57
did no ind a signi ican educ ion in he numbe o
SSIs as a esul o he in e en ion, in con as o he
s udy by F ene e e al.,
59
whe e he au ho s obse ed a
educ ion om 15⋅5% o 7⋅5% o SSI a es in SOT .
The pooled da a om hese s udies (Fig. 3D) showed a
signi ican educ ion in his ou come, wi h an OR o
0⋅57 in a ou o AMS p og ammes (95% CI 0⋅35–0⋅94)
and low he e ogenei y be ween s udies (I
2
21%). These
esul s we e consis en wi h he sensi i i y analyses
using a ixed-e ec model (OR 0⋅54, 95% CI 0⋅36–0⋅81).
Discussion
SOT a e a agile popula ion a high isk o in ec ious
complica ions due o MDRO. The e o e, de eloping
adequa e AMS p og ammes in his se ing is an u gen
need.
10,18
A e sea ching a ious da abases, a o al o 34
publica ions wi h a mode a e o high isk o bias we e
included. All we e o iginal a icles epo ing da a om
con olled clinical ials, p e-pos s udies o obse a-
ional s udies wi h a con ol g oup ha analysed he
e ec o di e en ypes o s a egies o op imising
an imic obial use in SOT on mo ali y, in ec ious
complica ions, g a ela ed complica ions, an imic o-
bial esis ance, an imic obial consump ion, and/o
hospi alisa ion. We would like o highligh some o he
mos ele an pape s published in ecen yea s, g ouped
oge he by assessed in e en ion.
Rega ding p esu gical an imic obial p ophylaxis, we
ound wo ecen sys ema ic e iews add essing he
issue. A sys ema ic e iew and me a-analysis
65
pe -
o med in 2020, including RCTs and quasi-RCTs
assessing he sa e y and/o e icacy o pe iope a i e
an ibio ics in SSIs in SOT , included eigh s udies (718
andomised pa icipan s) wi h high isk o bias. They
concluded ha , based on he da a a ailable, he e is e y
low ce ain y e idence o suppo ou ine ea men o
SOT wi h an ibio ics o p e en SSIs, so hey could no
make speci ic ecommenda ions. In addi ion, a ecen
sys ema ic e iew conduc ed by Campos-Vale a e al.,
66
which included eigh s udies ocussing on li e ans-
plan ecipien s, concluded ha he ecommenda ion
s eng h o pe iope a i e li e ansplan a ion an imi-
c obial p ophylaxis was s ong o p e en ing bac e ial
in ec ions, leng h o s ay (LOS), and mo ali y, bu weak
o de e mining he op imal an ibio ic egimen. This
e iew included wo non-compa a i e s udies
67,68
and
ano he s udy
69
add essing a ge ed p ophylaxis agains
ESBL-p oducing En e obac e iaceae- ela ed in ec ion
among ca ie s ollowing li e ansplan a ion. Ou
sea ch included 17 a icles ha deal wi h pe iope a i e
an imic obial p ophylaxis, mainly in kidney and li e
ansplan a ion. The sea ch did no iden i y he op imal
an imic obial egimen o p ophylaxis, bu i did
A icles
16 www. helance .com Vol 85 July, 2025
include se en s udies ha looked a he du a ion o
p ophylaxis, and none o hese showed di e ences in
in ec ious complica ions, g a ela ed complica ions o
inc eased mo ali y a e a sho p ophylaxis egimen,
e en in lung ansplan a ion (<10 days in his case).
Based on he esul s o ou me a-analysis, he e was no
di e ence in he a e o SSIs be ween sho and
ex ended du a ion o an imic obial p ophylaxis o
kidney and li e SOT .
As ega ds du a ion o ea men , ou pooled da a
esul s om h ee obse a ional s udies sugges ha
in cases o non-complica ed g a in ec ions (p ima ily
u ina y, cholangi is, and o he in a-abdominal in-
ec ions) whe e adequa e sou ce con ol has been
achie ed, longe egimens o an imic obial ea men s
may no ha e a po en ial impac in e ms o ecu ence
o he in ec ion. In addi ion, no s udies epo ed an
inc ease in mo ali y. The ac ha sho e an imic o-
bial egimens may be su icien in SOT , as long as
g a in ec ion is no complica ed, is consis en wi h
cu en e idence.
70
Un o una ely, SOT ha e been
excluded om mos ials o ea men du a ion. Da a
om his me a-analysis may allow hem o be included
in u u e andomised ials o inally answe his
ques ion.
O he i e ials ha looked a he implemen a ion
o a speci ic AMS app oach in di e en ansplan
uni s,
59–61,63,64
no ansplan - ela ed complica ions we e
obse ed a e AMS in e en ion, sugges ing ha AMS
p og ammes in he SOT popula ion a e sa e. In addi-
ion, he use o AMS can educe SSI a es by hal , ac-
co ding o he esul s o ou me a-analysis. Howe e ,
his esul is based on h ee p e-pos s udies, mainly
d i en by he s udy by F ene e e al.,
59
so i will be
necessa y o con i m his inding wi h highe -quali y
s udies.
Fo he o he ypes o in e en ions e alua ed, we
did no ind su icien e idence o make a ecommen-
da ion. Mainly o al s ep-down he apy
71
may bene i
SOT , al hough we did no ind enough e idence o
ully suppo his claim. O he in e en ions, such as
pe iope a i e in a esical an ibio ic i iga ion
52,53
and
an imic obial p ophylaxis p io o ERCP in li e ans-
plan a ion,
51
do no appea o be e ec i e in he kidney
and li e ansplan popula ions, espec i ely.
E en i ou sea ch s a egy did no e eal any s udies
on he ole o empi ical ea men , we would like o
highligh wo e ospec i e s udies ha e alua ed his
issue bu we e no included in ou sys ema ic e iew
because o hei design: Lupei e al.
72
and Hamandi
e al.
73
Bo h epo a signi ican ly highe mo ali y a e
in SOT pa ien s whose an imic obial empi ical an i-
mic obial ea men was inadequa e. Al hough we do
no ha e any s udies wi h a con ol g oup e alua ing
empi ical ea men , hese wo s udies sugges he
impo ance o choosing he igh egimen ea ly in he
cou se o in ec ion in SOT .
Nei he did ou sea ch s a egy ind any s udies on
alse-an ibio ic alle gy de-labelling. Howe e , he e a e
some obse a ional s udies
74,75
sugges ing wo se ou -
comes associa ed wi h SOT pa ien s wi h a alse an i-
bio ic alle gy label, including highe C. di icile a es and
g a ailu e. E en in he absence o compa a i e
s udies, his shows he need o p omo e mul idisci-
plina y in e en ions aiming a emo ing in alid alle gy
labels p io o ansplan .
The esul s p esen ed in his sys ema ic e iew a e
in line wi h he a ailable published e idence, hus
showing he need o e alua e he impac o AMS in-
e en ions on SOT by conduc ing u he highe -
quali y s udies,
10,18
mainly in ypes o ansplan o he
han kidney and li e . Some AMS s a egies wi h
p o en bene i s o SOT ha e demons a ed he use-
ulness o ea ing asymp oma ic bac e iu ia beyond
wo mon hs a e kidney ansplan a ion o p e en
UTIs, and he e icacy o an i ungal p ophylaxis o
p e en in asi e ungal in ec ion among li e ans-
plan ecipien s. Howe e , hanks o his sys ema ic
e iew, we we e able o iden i y some a eas o de ici
ha u gen ly need de elopmen and esea ch in he
SOT popula ion: an imic obial p ophylaxis (mainly i s
e icacy and du a ion in o he ypes o SOTs di e en o
kidney) and du a ion o ea men in g a - ela ed in-
ec ions. E icacy o an i ungal p ophylaxis o p e en
mould in ec ions in lung ansplan and e icacy o
ea ing asymp oma ic bac e iu ia in ea ly kidney
ansplan ecipien s also need o be de eloped. O he
a eas, such as he use ulness o de-escala ion, o al
ansi ion and mislabelling o an ibio ic alle gies, also
need u u e esea ch, e en i hey can be in e ed om
da a om he gene al popula ion. Also, none o he
included s udies epo ed in o ma ion abou
an imic obial- ela ed oxici y, which is an in e es ing
a iable o collec in u u e s udies. A summa y o he
cu en e idence and p oposed u u e esea ch needs is
p esen ed in Table 3.
Based on he in e p e a ions o he indings o each
o he e alua ed s udies, we can es ablish some c i e ia
o he design o u u e AMS in e en ions in SOT
popula ion, including bo h gene al and speci ic cha -
ac e is ics, o ensu e ha hese p og ammes a e mo e
e ec i e. I is essen ial ha we di ide he in e en ions
acco ding o ype o ansplan , hea , lung, panc eas,
and in es inal ansplan a ion being he a eas whe e we
ha e mo e unce ain y. I is also impo an o de e -
mine ansplan ela ed a iables in each s udy, bo h as
baseline a iables ( ype o immunosupp ession, ea -
men o ejec ion, e c.) and ou comes. In addi ion, we
belie e ha i is impo an o highligh he need o
include SOT popula ion in clinical ials ela ed o
AMS in e en ions, om which hey a e adi ionally
excluded.
In e ms o ou comes, ou me a-analyses we e
pe o med: one assessing he impac o an AMS
A icles
www. helance .com Vol 85 July, 2025 17
app oach in hospi alised SOT , showing i s possible
bene i s; wo me a-analyses o an imic obial p ophy-
laxis in SOT su ge y (li e and kidney), whe e su gical
p ophylaxis was ound o educe su gical si e in ec-
ion a es in SOT pa ien s, bu no addi ional bene i
was ound o ex ended p ophylaxis; and one assess-
ing non-complica ed g a in ec ions, whe e no di -
e ences we e ound in e ms o ecu ence o
in ec ion when compa ing sho and ex ended ea -
men du a ions.
Fu u e s udies o an imic obial op imisa ion in
SOT should include a iables such as mo ali y,
ansplan - ela ed complica ions, de elopmen o an i-
mic obial esis ance, an imic obial consump ion and
hospi al- ela ed ou comes in a s anda dised way o
allow pooled analysis.
This s udy has se e al limi a ions. Fi s , he sea ch
ield was he i le because he wide ange o e ms
included in he sea ch s a egy made he ini ial sea ch
including he abs ac ields un easible. To o se his
disad an age, ci a ions o included e e ences and
ele an sys ema ic e iews we e sea ched o iden i y
addi ional s udies. Second, he low quali y o he s udies
included in he sys ema ic e iew makes i di icul o
d aw i m conclusions abou he e ec s o AMS in-
e en ions in SOT . Also, he he e ogenei y o in-
e en ions included in he e iew inc eases he
di icul y o unde s anding he e ec o each o hem.
Thi d, as he me a-analysis on an imic obial p ophy-
laxis is based on a icles ha in some cases we e pub-
lished mo e han 20 yea s ago, he esul s should be
aken wi h cau ion. The same applies o he me a-
analysis on he e ec o AMS in SSIs, whe e he e-
sul s a e mainly d i en by he s udy by F ene e e al.
59
wi h a la ge numbe o pa ien s e alua ed, bu which is
olde han he o he wo s udies.
AMS in e en ions A ailable s udies Resul s P oposed u u e esea ch
p io i y
a
An imic obial p ophylaxis in e en ions
E icacy o pe iope a i e an ibio ic
p ophylaxis o p e en SSIs in KT
su ge y
To al s udies: 6 A dec ease in SSIs was shown in pa ien s who ecei ed an imic obial p ophylaxis in
ansplan su ge ies, a ou ing an imic obial p ophylaxis
Low
RCTs: 5
To al pa ien s: 390
Sho ening pe iope a i e an ibio ic
p ophylaxis <24 h
To al s udies: 6 No di e ences in SSIs we e ound compa ing sho and ex ended su gical
an imic obial p ophylaxis in kidney and li e ansplan ecipien s
Low o KT and LT
High o lung, hea ,
mul i isce al/in es inal, and
combined ansplan
RCTs: 2
To al pa ien s: 839
E icacy o an i ungal p ophylaxis o
p e en mould in ec ions in lung
ansplan
24,25
To al s udies: 28 No e idence o bene i o an i ungal p ophylaxis s no p ophylaxis, uni e sal
p ophylaxis s p e-emp i e ea men , o p olonged (>6 mon hs) p ophylaxis s <6
mon hs based mainly on obse a ional, high isk o bias s udies.
High
RCTs: 1
To al pa ien s: 4538
E icacy o an i ungal p ophylaxis o
p e en IFI in LT
26,27
To al s udies: 15 Consis en e idence ac oss RCTs on he bene i o an i ungal p ophylaxis s placebo
o p e en IFIs in high- isk LT. No p o en bene i o o he an i ungals o e
luconazole.
Low
RCT: 15
To al pa ien s: 1853
T ea ing asymp oma ic bac e iu ia in
KT
22,23
To al s udies: 9 No clinical bene i s p o ed o ea ing asymp oma ic bac e iu ia in KT beyond 2
mon hs a e ansplan a ion
Low o la e KT
High o ea ly KT
RCTs: 5
To al pa ien s: 959
An ibio ic ea men op imisa ion in e en ions
Sho ening ea men du a ion o
g a in ec ions
To al s udies: 3 No clinical bene i s p o ed o ea men s >10 days s sho e cou ses o 6–10 days
o non-complica ed g a in ec ions
High
RCTs: 0
To al pa ien s: 335
Sa e y and iming o o al swi ch To al s udies: 1 No di e ences in clinical ou comes o a e o pa ien s wi h BSIs which needed o
es a i ea men o he index in ec ion be ween ully-i ea men s and o al
ansi ions
High
RCTs: 0
To al pa ien s: 162
Assessing he impac o AMS p og ams in SOT uni s
Reducing an ibio ic consump ion To al s udies: 2 All a ailable s udies showed dec eased an ibio ic consump ion a e AMS
implemen a ion
Low
RCTs: 0
Reducing mo ali y, eadmissions, LOS To al s udies: 6 No clinical ou come bene i s ha e been p o ed o AMS in e en ions High
RCTs: 0
Reducing incidence o in ec ions To al s udies: 3 Signi ican educ ion in SSIs a e implemen ing combined AMS + in ec ion con ol
in e en ions in SOT uni s
Mode a e
RCTs: 0
Reducing bac e ial esis ance To al s udies: 3 Limi ed e idence om non-con olled ials showing educ ions in he incidence o
some speci ic MDRO
High
RCTs: 0
Compa ing e ec i eness o di e en
in e en ions o implemen a ion
s a egies
To al s udies: 0 No e idence on which in e en ions and implemen a ion s a egies a e mo e
e ec i e in SOT uni s
High
RCTs: 0
AMS: An imic obial s ewa dship; KT: Kidney ansplan ; LT: Li e ansplan ; IFI: In asi e ungal in ec ion; RCT: Randomised con olled ial; BSIs: Bloods eam in ec ion; SOT: Solid o gan ansplan ; LOS:
Leng h o hospi al s ay; SSIs: Su gical si e in ec ions: MDRO: Mul id ug esis an o ganisms. This able has been elabo a ed acco ding o he da a p oduced by his sys ema ic e iew combined wi h
ecen ly published e iews on speci ic opics.
a
Ranking c i e ia o u u e esea ch p io i y: High p io i y: No a ailable o only low-quali y s udies o a equen clinical p oblem. Mode a e p io i y:
Some mode a e quali y s udies al eady a ailable o in equen clinical p oblems. Low p io i y: High quali y s udies al eady a ailable.
Table 3: Cu en e idence summa y and p oposed u u e esea ch needs.
A icles
18 www. helance .com Vol 85 July, 2025
We should also emphasise ha he ield o solid
o gan ansplan a ion is ela i ely young compa ed o
o he ields o medicine, as is an imic obial s ewa d-
ship, so mo e s udies need o be ca ied ou . I should
be aken in o accoun ha pa ien olumes a y be-
ween cen es and ac oss he wo ld, and ha con-
duc ing p ospec i e RCTs speci ically on in ec ious
diseases and an imic obial s ewa dship has limi a ions
in en olmen o achie e sample sizes wi h su icien
powe . Finally, an imic obial use and ailo ed in-
e en ions also depend on local epidemiology, which
may limi he ex apola ion o local esul s o he global
communi y.
We conclude ha , al hough he a ailable e idence
on he impac o AMS in e en ions in he SOT
popula ion is sca ce and o low quali y, some s a e-
gies, such as sho e pe iope a i e an imic obial p o-
phylaxis, sho e ea men du a ion o g a - ela ed
in ec ions and uncomplica ed g am-nega i e BSI in
li e and kidney ansplan ecipien s, and he
implemen a ion o an AMS p og amme in ansplan
uni s, appea o imp o e an imic obial use wi hou
inc easing in ec ion complica ions. Ou pooled da a
om he me a-analyses showed no bene i om p o-
longed an imic obial su gical p ophylaxis in li e and
kidney ansplan ecipien s, and a possible bene icial
e ec on SSIs when an AMS app oach is imple-
men ed in hospi alised SOT pa ien s. Fu he mo e,
sys ema ic e iew o a ailable e idence ound no e i-
dence o inc easing mo ali y, g a - ela ed complica-
ions, inc easing hospi al admissions o an imic obial
esis ance when AMS measu es a e implemen ed.
While he e is no compelling e idence agains , he e
a e, on he con a y, well-g ounded easons in a ou
o implemen ing s a egies o op imise an ibio ic use
and AMS p og ammes in he SOT popula ion,
designed o achie e he bes possible esul s in hese
se ings. This s udy has iden i ied he a eas o AMS
esea ch in SOT ha equi e he highes p io i y,
hose wi h he lowes le el o e idence, and hose
whe e he le el o knowledge is su icien as o be
applied.
Con ibu o s
MPG, ABGG, JMGB, GP, RAM, MEPI, JMC designed he s udy. MPG
and ABGG de eloped he sea ch s a egy wi h eedback om JMGB,
GP, and JMC. MPG and ABGG sc eened and selec ed s udies. MPG
and ABGG ex ac ed he da a and p epa ed he da a o analysis. JMC,
GP, and JMGB had access o and e i ied he s udy da a. ABGG ana-
lysed he da a. MPG w o e he i s d a o he manusc ip , and all
au ho s c i ically e ised he manusc ip . All au ho s had ull access o
all he da a in he s udy and had inal esponsibili y o he decision o
submi o publica ion. All au ho s ead and app o ed he inal e sion
o he manusc ip .
Da a sha ing s a emen
The s udy p o ocol is a ailable a PROSPERO (CRD42024554606). The
da ase s gene a ed and analysed in his me a-analysis a e published in
he Appendix. Addi ional in o ma ion collec ed om s udies is a ailable
om he co esponding au ho on easonable eques .
Decla a ion o in e es s
MPG is suppo ed by he Subp og ama Río Ho ega, Ins i u o de Salud
Ca los III, Subdi ección Gene al de Redes y Cen os de In es igación
Coope a i a, Minis e io de Ciencia, Inno ación y Uni e sidades, Spain
(CM23/00078). ABGG is suppo ed by he Subp og ama Juan Rodés,
Ins i u o de Salud Ca los III, Subdi ección Gene al de Redes y Cen os
de In es igación Coope a i a, Minis e io de Ciencia, Inno ación, y
Uni e sidades, Spain (JR21/00017). GP epo s g an s om he Cen o
de In es igación Biomédica en Red (CIBER), Ins i u o de Salud Ca los
III, Spanish Go e nmen , co- inanced by he Eu opean De elopmen
Regional Fund (A Way o Achie e Eu ope), Mad id, Spain. MEPI is a
esea che belonging o he p og am “Nicolás Mona des” (C1-0038-
2019), Se icio Andaluz de Salud, Jun a de Andalucía, Spain.
Acknowledgemen s
N/A.
Appendix A. Supplemen a y da a
Supplemen a y da a ela ed o his a icle can be ound a h ps://doi.
o g/10.1016/j.eclinm.2025.103310.
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