Pseudomonas aeruginosa

Record number: 
Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
100% of organ recipients infected with same donor-derived bacterium. Four of four organ recipients from the same donor developed MDR P. aeruginosa infection.
Time to detection: 
2 weeks
Alerting signals, symptoms, evidence of occurrence: 
DONOR: 21-year-old man with a single gunshot wound to the right buttock with an exit wound at the left upper quadrant of the abdomen. He underwent "damage control" laparotomy and was treated with piperacillin-tazobactam and fluconazole. Abdomen was packed and treated with a vacuum assisted closure (VAC) device. On POD +2 he underwent (3) Definite/(3) Definite/Certain resection with subtotal gastrectomy. VAC device was placed again, secondary to inability to close the abdomen because of bowel edema. Patient was declared brain dead on day 5 after admission. No signs of active infection were noted along the 5 days since admission; vancomycin, piperacillin-tazobactam, fluconazole were administered before procuration. No evidence of intra-abdominal infection was observed during procuration, but peritoneal swabs were taken. Heart, liver and kidneys were obtained for transplantation. The following day, Gram stain from peritoneal swabs culture was positive for Gram negative rods. Imipenem or meropenem was initiated in all recipients. Three days later, peritoneal cultures were confirmed for MDR P.aeruginosa. Blood and sputum cultures taken pre-procurement grew the same organism. RECIPIENTS:HEART: 49 -year-old man with a non-ischemic dilated myocardiopathy.PO course complicated by initial poor graft function, K.pneumoniae pneumonia, and pulmonary infarction. He recovered and was discharged home. 6 weeks after transplantation, he developed dyspnea. He had loculated right pleural effusion, cultures from pleural fluid were positive for P.aeruginosa with the same resistance pattern as seen on the donor cultures. He was treated with tube thoracostomy and IV meropenem for 2 weeks, with full recovery. LIVER: Recipient developed intrabdominal infection with MDR P.aeruginosa. He died on POD 38+ from causes unrelated to MDR P.aeruginosa infection. /KIDNEY 1: Recipient developed 2 weeks after transplantation a subcutaneous collection comunicated with retroperitoneal space. Treated with meropenem and drainage, he died because of pulmonary embolism. Abdominal wound and blood cultures were positive for MDR P.aeruginosa and vancomycin-resistant E.faecalis. KIDNEY 2: Positive blood cultures for MDR P.aeruginosa and Enterococcus. Perinephric collection. Final outcome not known.
Demonstration of imputability or root cause: 
Same MDR-Pseudomona aeruginosa (according to antibiotic susceptibility profile) in donor and all 4 recipients
Imputability grade: 
3 Definite/Certain/Proven
Suggest references: 
Watkins AC et al. The deceased organ donor with an "open abdomen":proceed with caution. Transpl Infect Dis. 2012 Jun;14(3):311-5