Introduction: Infectious enteritis (IE) in intestinal transplant (ITx) recipients can be a major cause of morbidity including rejection. The overlap in clinical presentation of IE and rejection presents a diagnostic challenge. There are few studies examining IE after ITx. The aim of this study is to evaluate a single center experience with IE after ITx.

Methods: A retrospective review of a prospectively maintained database was completed, including all patients who received ITx between 1/1/2007-12/31/2016. Center protocol included an established set of stool/ostomy studies at the onset of clinical allograft dysfunction. Endoscopy and biopsy was frequently undertaken in addition. IE was defined as positive stool analyses and/or biopsy proven infection. Suspected IE without identification of a specific pathogen was not included. Resolution of infection was determined by symptom improvement/repeat testing.

Results: 60 patients who received 69 ITx were included, [isolated intestine (n=12), liver/intestine (n=28), multivisceral (n=25), modified multivisceral (n=4)]. Mean patient and graft follow up were 51±36 mo and 43±35 mo. Mean age at transplant was 17.6±19.5 yrs and 65% were <18yrs. 47/60 patients (78%) and 52/69 grafts (75%) had at least 1 episode of IE. Mean time from ITx to IE was 28±24 mo. 197 unique episodes of IE occurred, with a mean of 3.3±3.2 per patient (max 12, min 0, median 2). 39% of episodes required hospital admission, 38% occurred in patients already hospitalized, and 23% were managed outpatient. The most frequent IE were C. difficile (n=82), adenovirus (n=57), norovirus (n=26) and rotavirus (n=16). 39 episodes of adenovirus were treated with anti-viral therapy (35 with cidofovir). Children were at significantly higher risk for post-ITx IE (Fischer exact, p <0.0001). 

Conclusion: In this study, the frequency of IE is more common after ITx than previously reported. A majority of ITx patients develop IE during follow up. IE is more common in younger patients, likely due to increased exposures. Standardization of workup up may contribute to the higher rates of detection. Further, the occurrence of IE impacts patient care, requiring more frequent and longer hospitalizations and treatments. These results highlight the importance of systematic testing, careful follow up, treatment as appropriate, and supportive care to minimize risk of precipitating rejection or graft loss.