Ready to upload
Adverse Occurrence type:
First case of donor-derived C. auris transmission in SOT.
Time to detection:
Abundant yeasts seen in routine staining of BAL from donors lungs at the time of transplant. Two days for isolation of yeast from donor lungs (pre and post-transplant BAL). Five to six days to onsert of symptoms.
Alerting signals, symptoms, evidence of occurrence:
76 year old male recipient of bilateral lungs who received cefepime, vancomycin, micafungin, inhaled amphotericin B lipid complex, inhaled tobramycin as per routine local protocol. Gram staining and Calcofluor white preparations of the BAL specimens from the donor lungs pre- and post-implantation revealed abundant yeast. Identification of organism grown in culture could not be obtained by matrix-assisted laser desorption/ ionization–time-of-flight mass spectrometry (MALDITOF MS) using the VITEK MS system, version 3.0. Testing with VITEK 2 Yeast Identification Cards version 6.01 (bioMérieux) yielded an identification of Candida haemulonii. Additional testing demonstrated that the yeast grew at 40°C and did not produce pseudohyphae, supporting the identification of C. auris. On post-transplant day (PTD) +5, the patient developed a large pneumothorax, ventricular tachycardia, hypotension, and respiratory arrest. On PTD+6 the patient developed fever (39.2°C) and rise in WBC count at 28 000 cells/μL . Blood cultures were negative and BAL cultures continued to be positive for yeasts. The patient required ECMO, developed heparin -induced thrombocytopaenia and died. The authors do not mention if other organs had been accepted for transplant.
Demonstration of imputability or root cause:
Candida spp detected in BAL collected from donor lungs pre and post-implantation. Identification at species level, as C. auris was difficult and finally confirmed by MALDI-TOF MS using an optimized database (Bruker MALDI Biotyper). Sequencing showed the isolate to be closely related to other C. auris isolates from Illinois. A route cause investigation demonstrated that a premortem respiratory culture from the organ donor, who was from Illinois, had grown a yeast reported as C. haemulonii.
Suggest new keywords:
Donor-Derived Transmission of Candida auris During Lung Transplantation. Marwan M Azar, et al. Clinical Infectious Diseases, Volume 65, Issue 6, 15 September 2017, Pages 1040–1042
Expert comments for publication:
Candida auris is an emerging fungus that can cause invasive infections, is associated with high mortality and is often resistant to multiple antifungal drugs; the impact of positive findings in the donor has to be carefully considered in the context of deceased organ donation. Detection of yeasts from donor surveillance cultures can be interpreted as superficial colonization; broadly speaking it is good practice to identify Candida spp to species level, but in the absence of guidance, this is not uniformily done. Mis-identification of C. auris (frequently as C. haemulonii) is a known problem and warrants awareness and caution. Correct identfication and determination of anti-fungal susceptibility are esential to inform patient management.