Record number:
629
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
7.6% of lung transplants transferred bacterial (12 cases of purulent tracheobronchitis, pneumonia or skin lesions) and fungal (3 cases of Aspergillus tracheobronchitis or mediastinitis) infections.
Time to detection:
up to 30 days
Alerting signals, symptoms, evidence of occurrence:
In a study of lung transplants, there were 15 cases (7.6% cases of all lung transplants) of donor-to-recipient bacterial and fungal transmissions, defined as a recipient infection developing within the first month postop by the same organism with matching antibiotic susceptibility pattern found in the donor blood, donor lung or preservation fluid. Transmission of donor-derived Aspergillus fumigatus caused 2 cases of tracheobronchitis and one fatal case of mediastinitis. One case of pneumonia was caused by donor-derived Klebsiella pneumoniae with E coli. One fatal case of pneumonia was caused by MRSA. Skin lesions were caused by Staph aureus on one patient. Staph aureus also caused tracheobronchitis in 3 other cases and pneumoniae in one case. One case of tracheobronchitis was caused by Stenotrophomonas maltophilia. Three cases of tracheobronchitis were caused by Pseudomonas aeruginosa and one case of pneumonia was caused by Strep viridans.
Demonstration of imputability or root cause:
Level 3, Probable, Likely. Donor-to-recipient bacterial and fungal transmissions, defined as a recipient infection developing within the first month postop by the same organism found in the donor blood, donor lung or preservation fluid with matching antibiotic susceptibility;
Imputability grade:
2 Probable
Keywords:
Reference attachment:
Suggest references:
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Note:
Initially associated with reference ID 1330 about corneas - corrected (EP, 2016-05-30)