Record number:
1034
Adverse Occurrence type:
MPHO Type:
Time to detection:
6 hours
Alerting signals, symptoms, evidence of occurrence:
Recipient had HCV driven HCC, no history of colonisation or infection with MRSA and no prostetic devices. Donor was admitted to hospital with a drug overdose, embolic cerebrovascular accient and MRSA mitral valve endocarditis. MRSA was repeatedly isolated from blood cultures; donor received Vancomycin for 4 days until retrieval of the liver (other organs were declined). Recipient received Vancomycin and ertapenem perioperatively but as MRSA was isolated from blood samples drawn 6 h after surgical closure, Vancomycin (1g 12h) was continued for 4 weeks. Repeat blood cultures taken at 27hours post op were negative and remained so. The patient remained well, with good graft function 12 months pots-transplant.
Demonstration of imputability or root cause:
Whole genome sequencing (WGS) and complete de novo assembly of the donor and recipient MRSA isolate genomes confirmed that both isolates were genetically 100% identical.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
References:
Suggest references:
Transmission of Methicillin-Resistant Staphylococcus aureus via Deceased Donor Liver Transplantation Confirmed by Whole Genome Sequencing. Altman DR, Sebra R, Hand J, et al. Am J Transplant. 2014 Nov;14(11):2640-4.
Miceli MH, Gonulalan M, Perri MB, Samuel L, Al Fares MA, Brown K, et al. Transmission of infection to liver transplant recipients from donors with infective endocarditis: lessons learned. Transpl Infect Dis 2015;17:140-6.