Record number:
370
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Alerting signals, symptoms, evidence of occurrence:
Kidney recipient #1 developed persistent enterococcus urinary tract infection (UTI) on day 27 postop followed by Aspergillus fumigatus UTI on day 43 postop; Nephrectomy showed kidney abscesses and perinephric purulence. Kidney recipient #2 had an asymptomatic UTI due to A fumigatus.
Demonstration of imputability or root cause:
Level 4: certain. The multiorgan donor was a heart recipient that died from what was thought to be an intracerebral bleed on the ninth day postop. Autopsy results showed later an invasive A. fumigatus abscsses in the brain. Both kidney recipients developed A. fumigatus kidney infections.
The liver recipient was treated prophylactically with anti-fungals for 5 months and did not get infected. The islet recipient had A fulmigatus contaminating the islets before transplantation although no clinical infection was developed.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
Suggest references:
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