What are we waiting for: Serious bacterial infections in children prior to liver transplant are associated with high morbidity but not expedited transplant.

Objectives: Children with end-stage liver disease (ESLD) are at risk for complications including serious bacterial infections (SBI). We used the linkage of the Scientific Registry of Transplant Recipients (SRTR) and Pediatric Health Information System (PHIS) databases to examine frequency and morbidity of SBI and identify patient-specific risk factors.

Methods: We identified children listed for liver transplant between 2003 and 2019 who were hospitalized before transplant. Hospitalizations were characterized by SBI status using International Classification of Diseases (ICD) codes and healthcare utilization was compared using Chi-square and t tests. Univariate and multivariate logistic regression were performed to identify patient variables associated with pre-transplant SBI.

Results: A total of 1849 patients had 7601 hospitalizations and the majority (85%) were without SBI. Hospitalizations with SBI had longer length of stay (p < 0.001) and greater likelihood of needing therapies in the intensive care (p < 0.001). Almost one-third (32%) had hospitalization with SBI; in multivariate analysis, those with ascites (odds ratio [OR] 1.54 95% confidence interval [CI] 1.16-2.03) and nonprivate insurance (OR 1.40 95% CI 1.10-1.78) had higher odds of SBI. Patients with SBI had longer time on the waiting list (p = 0.023) despite being more likely to have approved exception (p = 0.006).

Conclusions: Despite experiencing a life-threatening complication of ESLD, patients with SBI do not undergo more expeditious transplant. They are more likely to have approved exception requests but have longer waitlist time. The current organ allocation system does not effectively prioritize these high-risk patients. SBI risk varies by insurance status, highlighting ongoing health disparities in pediatric transplantation.