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Observational Study
. 2025 May-Jun;27(3):e70026.
doi: 10.1111/tid.70026. Epub 2025 Mar 28.

Antibiotic Exposure and Risk of Allograft Rejection and Survival After Liver Transplant: An Observational Cohort Study From a Tertiary Referral Centre

Olivia C Smibert  1   2   3   4   5 , Sara Vogrin  6 , Marie Sinclair  7   8 , Avik Majumdar  7   8 , Mohamed Nasra  4 , Dinesh Pandey  9   10 , Hossein Jahanabadi  9   10 , Jason A Trubiano  3   4   5 , Kate A Markey  11   12   13   14 , Monica A Slavin  1   2   3   5 , Adam Testro  7   8 , Jason C Kwong  4   15
Affiliations
Observational Study

Antibiotic Exposure and Risk of Allograft Rejection and Survival After Liver Transplant: An Observational Cohort Study From a Tertiary Referral Centre

Olivia C Smibert et al. Transpl Infect Dis. 2025 May-Jun.

Abstract

Introduction: Our goal is to understand whether there is an association between Abx exposure-and the inferred downstream damage to the intestinal microbiome-and the key patient outcomes of overall survival and rejection following liver transplant.

Methods: We conducted a retrospective cohort study of 462 liver transplant recipients treated at a multistate liver transplant (LTx) service during a 7-year period. The association between antibiotic exposure and outcome was tested across models that addressed antibiotic spectrum, duration, and timing relative to transplant. Cox proportional hazard regression was used to evaluate the relationship between antibiotics with survival and rejection.

Results: The observed 1-year survival in this cohort was 95% (95% CI: 93%, 97%), and 20.8% of patients (96/462) experienced rejection at 1 year. In multivariable analyses, exposure to anaerobe-targeting antibiotics for longer than 14 days pretransplant (p = 0.055) or posttransplant (p = 0.040) was significantly associated with reduced 1-year survival. In multivariable analyses, exposure to any anaerobe-targeting Abx posttransplant was significantly associated with an increased risk of rejection (p = 0.001).

Conclusions: Exposure to anaerobic spectrum antibiotics either before or after LTx was associated with poor outcomes during the first year posttransplant and provides an impetus to further characterize the relationship between antibiotic use, microbiota disruption, and cellular immunity in liver transplantation.

Keywords: antibiotics; liver transplant; microbiota; rejection; survival.

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Conflict of interest statement

The authors of this manuscript have conflicts of interest to disclose. Kate A. Markey reports that she holds equity and is on the advisory board for Postbiotics Plus and consults for Crestone.

Figures

FIGURE 1
FIGURE 1
Kaplan–Meier of the duration of pretransplant (A) any antibiotic, (B) anaerobic and (C) non‐anaerobic antibiotics and posttransplant exposure to (D) any, (E) anaerobic, and (F) non‐anaerobic antibiotic up to 1‐year and 1‐year survival posttransplant.
FIGURE 2
FIGURE 2
Kaplan‐Meier of the duration of pretransplant (A) any, (B) anaerobic, and (C) non‐anaerobic antibiotics and posttransplant exposure to (D) any, (E) anaerobic, and (F) non‐anaerobic antibiotics up to 1 year and 1‐year incidence of rejection during 1 year posttransplant.
See this image and copyright information in PMC

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