Rise of drug-resistant bugs threatens transplant patients
Communication critical between centers
A catastrophic case of failed kidney transplants in two patients due to a multidrug resistant Escherichia coli infection in the donor underscores the critical role of communication and documentation between health care facilities, the Centers for Disease Control and Prevention emphasizes. In this case, both recipient patients survived, but the transplanted kidneys had to be removed.
"Whatever infection the donor has can potentially be transmitted to the recipient, resulting in very bad consequences such as the loss of the donated organ or even death," says Yenlik Zheteyeva, MD, an investigator with the CDC's Epidemic Intelligence Service. "We are seeing an increasing resistance in hospital infections in general, so we can probably expect an increase in transplant-related infections. It makes the whole issue of communications even more important."
Although transplantation of organs from donors with bacterial infection can be managed, transplant teams need to be aware of all donor test results so that appropriate antimicrobials can be used to treat the recipient and avoid complications of an infected organ.
"Since donated organs are so valuable and are in urgent need this urgency actually outweighs the risk of transmission," she says "But we have to make sure that the transplant centers actually have all of the information about the infection in the donor all of the susceptibilities and the culture results in order to start prophylactic treatment as soon as possible."
According to the CDC, on July 6, 2009, the Organ Procurement and Transplantation Network (OPTN) received notification of possible disease transmission.1 A transplant center in California reported a kidney transplant recipient with E. coli urinary tract infection and sepsis suspected to have been contracted from the donated kidney. Upon further investigation, a transplant center in Texas reported that the recipient of the other kidney from the same donor developed a perinephric abscess caused by E. coli.
Molecular typing studies conducted at CDC showed that the E. coli isolates from both kidney recipients were identical to an isolate from the donor's urine. The donor, a woman aged 56 years, was admitted to the intensive-care unit for a subarachnoid hemorrhage. Attempts to stabilize the patient were unsuccessful, and she was pronounced brain dead 7 days after admission. Organ recovery was performed on the ninth day after admission. However, the patient had developed a urinary tract infection that became resistant when she was prescribed ciprofloxacin empirically.
"The very first culture when she first became febrile was found to be pan-susceptible," Zheteyeva says. "They didn't have this result until some days later because cultures take some time. She was prescribed ciprofloxlin empirically, so it looks like she developed resistance over the course of her stay. Before the culture was collected by the organ procurement organization (OPO) when the donor was already pronounced dead it looks like she had developed resistance to five or six antibiotics by then."
Given onset after admission the infection may have been hospital-acquired, but that was not determined as part of the investigation, she says. "This [E. coli] strain was resistant to ciprofloxacin in the first place," Zheteyeva. "As soon as they got the culture results she was switched to levofloxacin. They saw that she was susceptible to that according to the first culture results. I'm not sure if they could have processed the cultures quicker, but maybe a wider spectrum antimicrobial [than cipro] should have been used in this kind of situation."
In any case, in part because of poor communication about the donor's status, the transplant recipients both developed infections. The left kidney recipient's urine culture results showed the same multidrug-resistant E. coli as was identified in the donor urine 2 days after organ procurement. The right kidney recipient developed a wound infection with multidrug-resistant E. coli with the same resistance pattern as the previous isolates.
The subsequent CDC investigation identified gaps in communicating important donor information that might have adversely affected transplant outcomes. Since transplantation must be done expeditiously to ensure organ viability, the results of some cultures and tests of specimens collected at the time of organ procurement sometimes become available only after the transplant has been performed, the CDC warned. Culture results that are available after organ procurement must be communicated promptly to medical teams in transplant centers so that timely and adequate antimicrobial prophylaxis or treatment is initiated in recipients.
"It is possible to transplant these kind of organs with a known infection in the donor," Zheteyeva says. "Transplant centers have to get informed consent from the recipients. Because this is a situation of urgency they have to indicate adequate antimicrobial prophylaxis in order to prevent transmission. Communication is the key. If the transplant physicians see that the infections can be adequately treated they would probably accept it. Kidneys are in high demand and it is a long wait list. There is pressure to get the organ. "
The combination of pressure for procurement and the rise of multidrug resistant organisms particularly gram-negative pathogens like E. coli create a situation where one lapse could result in transmission.
"The CDC doesn't have a surveillance system to track this kind of situation, but the OPTN requires every suspect or potential transmission to be reported to them by transplant centers," she says. "The number of reports are increasing. [That is] probably not because the number of transmissions are increasing, but because transplant centers are more aware of this kind of situation. Transmission is reported in [about] 1% of donations from disease donors."
What we have here is a...
In this particular investigation, several failures to communicate important information were identified. The results from the donor urine culture performed 5 days before organ recovery were entered incorrectly as negative in both the donor chart that accompanied the donated organs and in DonorNet, a secure web-based computer system that provides donor information to transplant centers. Multiple cultures were still obtained by the various facilities that were positive for multidrug-resistant E. coli. However, because neither the organ procurement organization (OPOs) nor the transplant centers maintained communication logs, no means existed to verify that these culture results were shared among the entities, the CDC reported. In addition, no documentation was entered in the recipients' medical records of E. coli infection in the organ donor, and no change in the recipients' antimicrobial regimen was noted that might have indicated knowledge of this information. A failure was also noted in communicating perfusate culture results from the laboratory to the transplant team in one case, which resulted in delay in initiating appropriate antimicrobial treatment in the right kidney recipient.
"We see in the course of treatment for these two recipients there is nothing indicating that this information was actually received by transplant physicians," Zheteyeva says. "The prophylactic antimicrobials were not adequately initiated. It was definitely a lack of communication. Of course we know that during the transplantation time is an issue. Everything has to be done in a matter of hours and sometimes the OPO collects cultures and they are not available at the time of donation. As soon as [culture results] are available to the OPO they have to immediately be reported to the transplant center. And not to just a random person but to a point of contact that the OPO is sure will convey the message, a person that will contact the transplant physicians caring for this particular recipient."
As a result of the case, this designated "patient safety contact" is specificed in recently revised OPTN policy.
"Now OPOs are expected to have a patient safety contact who would be available 24 hours a day to communicate with all of the labs, follow up the results, and have to send this information as soon as it becomes available," she says. "Within 24 hours the patient safety contact is required to convey the information to the transplant center. They have to record every communication by name and make sure that this information is seen by the people taking care of the patient."
In addition, the CDC recommended the following measures to improve communication during organ procurement from deceased donors.
- In the package of accompanying documents that OPOs prepare for every donated organ, all positive test results (e.g., from urinalysis or blood or urine culture), should be highlighted to draw the attention of physicians in transplant centers.
- To avoid transcription errors, OPOs should consider double-checking (by at least two OPO staff members) critical donor information against medical records in the donor's hospital.
- Any pending tests with results that could affect the organ recipient's safety (e.g., culture results) and the dates when these pending results will become available should be noted in documents accompanying the organ.
- Transplant center case coordinators should contact the OPO on the date of expected availability of laboratory results if the OPO has not already notified the transplant center of these results. All important new donor information should be documented in recipient medical records at transplant centers.
- To avoid internal communication failures, transplant center case coordinators should follow up with hospital laboratories on all culture results. These results must be documented in patient's medical records.
Reference
- Transmission of Multidrug-Resistant Escherichia coli Through Kidney Transplantation California and Texas, 2009. MMWR 2010;59(50);1642-1646.
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