DONOR INFECTIVE STATUS AND POTENTIAL IMPACT ON

RECIPIENTSDr. Dino Sgarabotto

Transplant Infectious Diseases UnitPadova General University Hospital

Padova - Italy

Donor-derived Infections

• Bacterial Infections• Fungal Infections• Viral Infections• Mycobacterial infections• Parasitic infections

STAPHYLOCOCCUS AUREUS TRANSMITTED IN TRANSPLANTED KIDNEYS

Doig RL et al: Staphylococcus aureus transmitted in transplanted kidneys. Lancet 1975; 2(7928): 243-5

Staphylococcus aureus septicæmia developed shortly after transplantation in both recipients of transplanted kidneys from a donor who had received electrical burns. In each case the organism appeared initially in the urine. Transplant nephrectomy was necessary in both recipients because of complications of infection, and one recipient died.

Transplantation from Bacteremic Donors

• Retrospective analysis between 1990-96• 5,1% 95 bacteremic donors from a total of 1775, from

whom 212 recipients received organs• 46 Forty-six (48%) of the bacteremic donors had pathogens

in their blood• No evidence of transmission; of the 212 recipients, 193

(91%) received a mean of 3.8±2.5 days of antibiotics postoperatively

• The 30-day graft and patient survival for recipients of organs from bacteremic donors was not significantly different from recipients of organs from nonbacteremic donors

Freeman RB et al: Transplantation 1999; 68(8):1107-11

Microrganisms isolated from donor and recipient therapy

Freeman RB et al: Transplantation 1999; 68(8):1107-11

Graft and patient survival

Donor-to-host transmission of bacterial and fungal infections in lung transplant

• 52% donor infection (103/197)– Graft colonization 63%– Contamination of preservation fluids 29.1%– Bacteremia 7.8%

• 7.6% (15 recipients) donor-to-host transmission – Donor bacteremia (2 cases)– Colonized graft (13 cases)– 2 patients died

• Mediastinitis due to Aspergillus• Pneumonia due to MRSA

Ruiz I et al: Am J Transplant 2006; 6: 178-182

Amoxi/Clav + Aztreonam ev Antibiotics according to the isolated bacteria+

Etiology of graft colonization in donors

Gram + cocci 46 (48.3%)

Gram – bacilli 34 (35.8%)

Fungi 15 (15.8%)

S. aureus 26 H. influenzae 14 C. albicans 10

S. pneumoniae 10 P. aeruginosa 11 A. fumigatus 5

S. viridans 8 K. pneumoniae 4  

E. faecalis 2 E. coli 1  

A. calcoaceticus 2  

S. maltophilia 1  

E. cloacae 1  

Highly resistant bacteria and donor-derived infections: uncharted territory

• ESKAPE organisms or multidrug resistant (MDR) bacteria: Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter species

• Treatment can be challenging because of:– Increasing drug resistance– Limited drug options– Significant drug toxicities– Drug interactions– Therapeutic limitations– Neglected antibiotic developments

AST guidelines 2009Donor screening: Bacterial infections• If the donor has been bacteriemic, the target organs should not

be seeded and the infection should be treated prior to donation• Antibiotic therapy of the recipient for 2-4 weeks if the donor is

known to have been bacteriemic with a virulent organism• No treatment if the infection of the donor was locally restricted• In lung transplants treatment is needed for all colonizing

bacteria• Allograft contamination i.e. organism grown from perfusates or

organ transplant medium should be treated :– Bacilli Gram neg o Staph aureus: 2 weeks– Less virulent organisms: 1 week

Am J Transplant 2009; 9 (Suppl. 4): S7-S18

Risk of transmission of MDR bacterial pathogens

• A growing problem• Optimal management unclear• Antibiotic therapy based on in vitro

susceptibility testing• Sharing information between hospital about

an arising problem from the same donor • Further work is needed to identify when

colonized donors can be safely used

Viral Infections• HIV, HBV and HCV serology and NAT (DNA or

RNA)• West Nile Virus serology and RNA• Other viral test if local epidemics (LCMV, and

others)• Attention to viral meningitis or encephalitis

(some negative etiologies are due to effective treatment, but some are due to uncontrolled viral infections…)

The window period• the window period for a test designed to detect a

specific disease is the time between first infection and when the test can reliably detect that infection. In antibody-based testing, the window period is dependent on the time taken for seroconversion. The window is shorter if using NAT testing

• The window period is important (to epidemiology and safe sex strategies) in organ donation (and in blood donation), because during this time, an infected person or animal cannot be detected as infected but may still be able to infect others.

A challenging clinical case• Candidate donor after a car accident is

39 years old male from Bolivia living in Italy in the last 15 years

• He works as a cleaner in a hotel• Chest xRay and ECG are normal• Shold we consider any additional test

because he comes from Bolivia???

Geographic distribution of Chagas disease

Epidemiology of TB • In Western Europe TB prevalence is 7 cases every

100.000 inhabitants• In USA is 3.5• In East Europe is 100-140; in South America and

North Africa is 80-90• Many parts of Africa have unreliable data (i.e.

>100)• Risk of latent TB in the donors (Quantiferon

positive)

20

80

86

7

8

140

100

A traditional house like this in Bolivia is at risk for Chagas disease

Triatomeor house buginfected by

Tripanosoma cruzi

Your comments NOW• The donor is Quantiferon positive? Can we

harvest the organs? Who is the siutable recipient?

• Do we need to do Tripanosoma cruzi serology? It will take sometime to have the results of an unsual serology! Do we harvest all organs? Even heart??? What risk of infection for the recipient? Acceptable in South America… can it be accepted in Europe…

Conclusion• Determing organ donor suitability is an

inexact science requiring physician judgment• Technological advances will allow improved

organ donor screening: unsual serology like Strongiloides stercoralis or Tripanosoma cruzi and different NATs

• Improved screening will depend on development of a consensus regarding a list of pathogens to essay (different in different areas of the world)

References• AST Infectious Diseases Guidelines 2nd

Edition. December 2009 - Volume 9, Issue Supplement s4 Pages S1–S281 (free download)

• Transplant Infectious Disease 2012; 14: 223-236• Transplant Infectious Disease 2012; 14: 292-298• Transplant Infectious Disease 2011; 13: 58–62

THANKS A LOT FOR YOUR ATTENTION!

NOW QUESTIONS?

Free download from www.slideshare.netHarlequin bow