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Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
DONOR: 36- year- old man, no significant medical background, admitted after near-drowning. Brain death on day 6 after admission. No evidence of active infection. Normal chest X-ray. At the time of organ retrieval, routine bronchoscopy with BAL. Both lungs, both kidneys and liver were transplanted. Two days after organ procurement, a carbapenem-resistant K.pneumoniae (CR-KP), sensitive only to gentamicin, colistin and tigecycline was isolated from donor's BAL. RECIPIENTS: Liver and kidney recipients had no infectious complications (they did not receive antibiotics active against CR-KP). Both lung recipients received perioperative antibiotic prophylaxis with piperacillin-tazobactam; after the report of donor's cultures , both patients received 5 days of IV colistin. Lung recipient #1 did not develop infection (follow up 6 months). Lung recipient #2, a 50 year old male with a history of a previous lung transplant for cystic fibrosis, developed tachypnea, dyspnea and a new lung infiltrate on X-ray 19 days after transplantation. Despite antibiotic therapy, he worsened with wound dehiscence and tracheostomy. At three weeks after surgery, he developed bacteremia with 5 of 5 blood cultures positive for CR-KP. Treatment failed and he died at 4 weeks post-transplant with sepsis and multiorgan failure.
Demonstration of imputability or root cause:
CR-KP infection in the donor and one lung recipient was documented. The CR-KP phenotype (according to antibiotic susceptibility profile) was identical in donor and recipient, but no genotype was performed. The absence of transmission to the lung recipient #2 might have been due to successful prophylaxis.
Goldberg E, Bishara J, Lev S, Singer P, Cohen J. Organ transplantation from a donor colonized with a multidrug-resistant organism: a case report. Transpl Infect Dis. 2012 Jun;14(3):296-9.