Adverse Occurrence type:
Time to detection:
2 days - 4 weeks
Alerting signals, symptoms, evidence of occurrence:
Fever, pain, arterial anastomosis dehiscence; required removal of transplanted organ; UTI; Day 9 developed spontaneous wound drainage; nephrectomy at day 18; arterial dehiscence; renal abscess
Demonstration of imputability or root cause:
“Contaminated kidney” with mycotic aneurism culture positive for Escherichia coli/Klebsiella pneumoniae; Donor: positive urine culture; recipient with positive urine culture for same organism (Escherichia coli); Donor with positive saline slush culture for same organism as the recipient's blood cultures (Escherichia coli). Details: Donor had urine positive for S. bovis, saline slush positive for Enterococcus/ Escherichia coli. Recipient had positive blood cultures for Escherichia coli (day2) Bacteroides (days 3, 5 & 7) Enterococcus (day 3); Donor: urine, perfusate and renal artery + for Escherichia coli. Recipient cultures were not stated in reference; Donor 1: Preservation fluid infected by Escherichia coli, Enterobacter cloacae, Morganella morganii; recipient demonstrating early wound infection by the same microorganisms. Donor 2: Infection by multi-drug resistant Escherichia coli; both recipients developed pyelonephritis and renal abscess with subsequents graft loss with transmission confirmed by molecular typing.