1. DONOR INFECTIVE STATUS AND
POTENTIAL IMPACT ON RECIPIENTS
Dr. Dino Sgarabotto
Transplant Infectious Diseases Unit
Padova General University Hospital
Padova - Italy

6. Donor-derived Infections
•
•
•
•
•
Bacterial Infections
Fungal Infections
Viral Infections
Mycobacterial infections
Parasitic infections

7. STAPHYLOCOCCUS AUREUS TRANSMITTED
IN TRANSPLANTED KIDNEYS
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.
Doig RL et al: Staphylococcus aureus
transmitted in transplanted kidneys.
Lancet 1975; 2(7928): 243-5

8. 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

9. Microrganisms isolated from donor
and recipient therapy
Freeman RB et al: Transplantation 1999; 68(8):1107-11

10. Graft and patient survival

11. 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
Amoxi/Clav + Aztreonam ev
+ Antibiotics according to the isolated bacteria
Ruiz I et al: Am J Transplant 2006; 6: 178-182

12. Etiology of graft colonization in
donors
Gram + cocci
46 (48.3%)
S. aureus 26
Gram – bacilli
34 (35.8%)
Fungi
15 (15.8%)
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

13. Highly resistant bacteria and donorderived 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

14. AST guidelines 2009
Donor 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

15. 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

16. 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…)

17. 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.

18. 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???

19. Geographic distribution
of Chagas disease

20. 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)

21. 8
7
8
140
6
20
80
100

22. A traditional house like this in Bolivia
is at risk for Chagas disease
Triatome
or house bug
infected by
Tripanosoma cruzi

23. 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…

24. 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)

25. 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

26. THANKS A LOT FOR YOUR
ATTENTION!
NOW QUESTIONS?
Harlequin bow
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