Record number:
1008
Adverse Occurrence type:
MPHO Type:
Time to detection:
1 day
Alerting signals, symptoms, evidence of occurrence:
Recipient 1: perinephric collection; Recipent 2: uncomplicated cystitis. Both secondary to vanB Vancomycin Resistant E. faecium. Recipient 2 died.
Demonstration of imputability or root cause:
Blood cultures and rectal swabs from the donor just before procurement were negative. The other kidney and the liver recipients from the same donor were also diagnosed with E. faecium infection. Teams involved in each procedure were different.
Imputability grade:
2 Probable
Suggest references:
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.