Adverse Occurrence type:
Time to detection:
2 - 85 days
Alerting signals, symptoms, evidence of occurrence:
This patient received a femoral condyle and meniscus allograft in Illinois from the same infected donor that provided the contaminated femoral condyle to a young man in Minnesota who died of C. sordellii sepsis 4 days after knee surgery. This 17 yr old Illinois man developed fever on postop day 1 and on postop day 8 was readmitted with fever of 39.7C and septic arthritis. Knee cultures did not grow clostridium but tests were not performed that would detect anaerobic bacteria. He recovered after antibiotics.
Demonstration of imputability or root cause:
Level 2. Possible transmission of C. sordellii septic arthritis of the knee despite a negative knee culture. Cultures were not performed in a manner that would detect Clostridium; whereas, a femoral condyle allograft from the same donor implanted in another patient caused C. sordellii septic shock and death and many other tendons and hemicondyles from the same tissue bank caused clostridium infections around the same time period.