Record number:
369
Adverse Occurrence type:
MPHO Type:
Time to detection:
4 days
Alerting signals, symptoms, evidence of occurrence:
65 yr old female developed eye pain and decreased visual acuity 4 days after receiving a corneal transplant that had been stored in MK medium (containing gentamicin) for six hours before transplantation. Donor tissue before and after storage in MK medium cultured positive for A. faecalis. Samples of patient aqueous and vitreous grew A faecalis resisiant to gentamicin. Antibiotics cleared the infection over two weeks but there was a very poor visual outcome.
Demonstration of imputability or root cause:
Likely. Same bacteria in donor tissue before and after storage and in patient aqueous and vitreous when symptomatic. Bacteria from all samples had same resistance to gentamicin.
Imputability grade:
2 Probable
Keywords:
Suggest references:
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