Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
Bacteremia and peritontis secondary to vanB Vancomycin Resistant E. faecium was diagnosed 24 hours after transplantation. Recipient died.
Demonstration of imputability or root cause:
Blood cultures and rectal swabs from the donor just before procurement were negative. Two kidney recipients from the same donor were also diagnosed with E. faecium infection. Teams involved in each procedure were different.
Holmes NE, Ballard SA, Lam MMC, Johnson PDR, Grayson ML, Stinear TP, Howden BP. Genomic analysis of teicoplanin resisteance emerging during treatment of vanB vancomycin-resitant Enterococcus faecium infections in solid organ transplant recipients including donor-derived cases.J Antimicorb Chemother 2013;68:2134-9.