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Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
A 43-year-old recipient with a history of chronic renal failure, HIV and hepatitis C virus (HCV) positivity developed fever on postoperative day 6; blood culture revealed an extended spectrum beta lactamase (ESBL) producing Klebsiella pneumoniae, resistant to fluoroquinolones (expanded-spectrum cephalosporins, and ertapenem, but susceptible to meropenem, aminoglycosides, colistin, and tigecycline). Treatment was continued with meropenem, with resolution of bactereamia but no clearance from the surgical site. The transplanted kidney did not exhibit functional recovery and was explanted 1 month after transplantation.
Demonstration of imputability or root cause:
The donor was a 52-year-old subject who died after cranial trauma and who (i) had a past history of pulmonary tuberculosis with negative results for acid-fast bacilli in respiratory secretions and no signs of active tuberculosis, (ii) had respiratory tract colonization with a carbapenem-resistant Acinetobacter (CRA). Blood and urine cultures, taken on the same day of organ explantation, were negative. Bacterial culture of the kidney preservation fluid had revealed K. pneumoniae with the same antibiotic resistance profile as the recipient's isolates, and the transplant centre had been informed of this finding.Characterisation of the isolates from the two recipients (kidney and liver) where identical by pulse-field gel electrophoresis (PFGE); multilocus sequencing typing (MLST) assigned all isolates to sequence type 16. OXA-48 producing K. pneumoniae were uncommon in Italy at the time of this event. The authors conclude that the donor was the most likely source but acknolwkedge the fact that this organism was not isolated from the donor.
Cross-infection of solid organ transplant recipients by a multidrug-resistant Klebsiella pneumoniae isolate producing the OXA-48 carbapenemase, likely derived from a multiorgan donor.
Outcomes of transplantation using organs from a donor infected with Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae.
1) Cross-infection of solid organ transplant recipients by a multidrug-resistant Klebsiella pneumoniae isolate producing the OXA-48 carbapenemase, likely derived from a multiorgan donor. Giani T. et al. J Clin Microbiol. 52(7):2702-5, 2014 Jul. 2) A. Mularoni, A. Bertani, G. Vizzini, et al. Outcome of Transplantation Using Organs From Donors Infected or Colonized With Carbapenem- Resistant Gram-Negative Bacteria. American Journal of Transplantation 2015; 15: 2674–2682
Expert comments for publication:
It has been suggested that organs from donors with KPC can be taken in consideration under well-defined conditions, as transmission rate appears to be high and so is the morbidity. There is no international consensus on the predictive value and cost-effectiveness of surveillance culture from donor at the time of donation or culture of the preservation fluid. Clinical experience and epidemiology should be taken into account when designing local policies.