Donor-derived filamentous fungal infections in solid organ transplant recipients:

Clinical approach to donor-derived infection in solid organ transplant recipients

Donor-derived infection is an uncommon but potentially devastating complication of solid organ transplantation (SOT). Accurate and timely identification of unexpected infectious disease transmission events has implications not only for the recipient(s) experiencing infection, but also other recipients of organs or tissues from the same donor who may require additional testing or risk mitigation, as well as the broader organ transplant regulatory framework. This narrative review synthesizes data from published reports of symptomatic unexpected donor-derived infections in SOT recipients to provide clinicians with a systematic approach to the evaluation of undifferentiated illnesses that may be of donor origin. Key reasons to consider donor-derived infection include certain microbiologically proven infections in the recipient, especially early after transplant, characteristics of the donor or their management that suggest potential exposure to or infection with specific pathogens prior to organ procurement, and select clinical syndromes that occur in the post-transplant period. Syndromes for which expedited consideration and evaluation of donor-derived infection may be warranted include central nervous system infection, graft or perigraft complications developing in the absence of typical risk factors, and unexplained critical illness/sepsis syndrome in the early post-transplant period. When embarking on an investigation of a suspected donor-derived infection, clinicians should apply knowledge of the entire continuum of the organ procurement and transplant process to ensure unbiased and comprehensive data collection that will facilitate appropriate adjudication of these uncommon but high-consequence events.

Donor-Derived Infection's Prevention and Control in Kidney Transplantation

BACKGROUND

The study aimed to summarize the experience of donor selection and recipient therapy in the face of potential donor-derived infections and improve the quality of donor organ utilization, which would help reduce the risk of infection after recipient operation and decrease the risk of loss or even death of recipient kidney transplantation.

METHODS

In this study, 132 kidneys from 70 donors and their recipients who underwent surgery between July 2017 and January 2021 were studied to perform a retrospective analysis of their etiologic examination results and treatment process.

RESULTS

In the 70 donors, only 25 had negative etiologic examination results, accounting for 35.71%. Among the 132 recipients, 31.82% had positive culture results, 3 (2.27%) experienced donor-derived infections, and one died.

CONCLUSIONS

Although infection in the donor before the donation is quite common, the incidence of donor-derived infections is relatively low. The targeted and preventive application of adequate sensitive antibiotics in the whole course of therapy was the cornerstone for treating recipients at potential risk of potential donor-derived infection. The changes in infection indicators in the recipient should be closely monitored, which would guide medication adjustments timely. These measures could, to a great degree, ensure the prognosis of the recipient, in turn reducing the adverse events caused by donor-derived infections.

Donor heart selection: Evidence-based guidelines for providers

The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.

Infective Artery Rupture of Renal Allografts: A Single-Center Retrospective Study in China

OBJECTIVE

This study investigated the composition of pathogenic microorganisms, clinical features, and therapeutic strategies of infective artery rupture of renal allografts in recipients receiving deceased donor (DD) kidneys.

METHODS

We retrospectively studied the clinical data of the DD kidney transplant recipients with donor-associated infection at Tongji Hospital, Wuhan, China from January 1, 2015 to December 31, 2018, related recipients and corresponding donors. We collected the entire results of pathogenic microorganisms cultured from these related ruptured kidneys and then analyzed their distribution and differences.

RESULTS

A total of 1440 kidney transplants from DD were performed in our center. The total incidence of infective artery rupture in kidney transplants was about 0.76% (11/1440), and the annual incidence ranged from 0.25% to 1.03%. The microbial culture results revealed that 11 recipients suffered from infective artery rupture and 3 recipients who accepted the kidney from same donor had the donor-associated pathogens, including 9 fungal strains (28.1%) and 23 bacterial strains (71.9%). There were 4 recipients infected with multi-drug-resistant Staphylococcus and Klebsiella pneumoniae from the above 11 recipients, of which, 10 recipients underwent graft loss, and one died of septic shock. The microbial cultures of the remaining 3 recipients who received appropriate anti-infective regimens turned negative eventually, and the patients were discharged successfully without significant complications.

CONCLUSION

Renal recipients with infections derived from DDs were at high risk of artery rupture, graft loss, or even death. Appropriate anti-infective treatment is essential to reduce the incidence of artery rupture and mortality.

Nosocomial Infections: Do Not Forget the Parasites!

Nosocomial infections (NIs) pose an increasing threat to public health. The majority of NIs are bacterial, fungal, and viral infections; however, parasites also play a considerable role in NIs, particularly in our increasingly complex healthcare environment with a growing proportion of immunocompromised patients. Moreover, parasitic infections acquired via blood transfusion or organ transplantation are more likely to have severe or fatal disease outcomes compared with the normal route of infection. Many of these infections are preventable and most are treatable, but as the awareness for parasitic NIs is low, diagnosis and treatment are often delayed, resulting not only in higher health care costs but, importantly, also in prolonged courses of disease for the patients. For this article, we searched online databases and printed literature to give an overview of the causative agents of parasitic NIs, including the possible routes of infection and the diseases caused. Our review covers a broad spectrum of cases, ranging from widely known parasitic NIs, like blood transfusion malaria or water-borne cryptosporidiosis, to less well-known NIs, such as the transmission of Strongyloides stercoralis by solid organ transplantation or nosocomial myiasis. In addition, emerging NIs, such as babesiosis by blood transfusion or person-to-person transmitted scabies, are described.

Infectious complications related to medical tourism

BACKGROUND

Medical tourism has been increasing dramatically globally, with people travelling from developed countries to low-income or middle-income countries, often to avoid high costs or long delays associated with seeking healthcare in their countries of origin. The current review summarizes healthcare-related infections associated with medical tourism, focusing on cosmetic surgery and organ transplantation.

METHODS

A systematic MEDLINE and PubMed search from January 2010 to December 2019 yielded 80 relevant articles, including 49 articles on medical tourism-related infections focusing on cosmetic surgery and organ transplantation, which were included in this reviews.

RESULTS

The literature reveals specific types of cross-border, healthcare-related infections depending on medical intervention. Destinations include low-income countries such as countries of Asia and the Indian subcontinent, middle-income countries including Central and South America, and high-income countries such as the United States and Europe. In terms of type of infections, in 36 (68%) and 15 (28.3%) studies, wound and blood-borne infections were documented, respectively, while in 21 studies (58.3%) non-tuberculous mycobacteria were isolated, including Mycobacterium abscessus, Mycobacterium chelonae, Mycobacterium senegalense and Mycobacterium fortuitum. The choices of medical tourists could have significant consequences for them and their home countries, including infectious complications and importation of pathogens, particularly antibiotic-resistant microorganisms, with public health implications.

CONCLUSIONS

There is a need for public health strategies in order to prevent morbidity and mortality as well as future management and education of patients engaging in medical tourism.

Immunodiagnostic Assays for the Investigation of Fungal Outbreaks

Fungal pathogens can affect humans, animals, and plants, and they can be found in the environment or as part of the host microbiome. Fungal diseases present a broad clinical spectrum, ranging from superficial to invasive infections, and can cause outbreaks. During an outbreak investigation, the laboratory plays an essential role in verifying the diagnosis and helping to confirm the source of the outbreak. Immunodiagnostic assays are important tools and often relied upon for the diagnosis of fungal infections, since the gold standard assays of culture and histopathology are time-consuming and often require invasive procedures. Immunodiagnostic assays range from complement fixation and immunodiffusion to enzyme immunoassays and, most recently, to point-of-care lateral flow devices. In general, these assays provide results faster and offer good analytical performance. These characteristics make immunodiagnostic assays good laboratory tools for outbreak investigations. The aim of this review is to describe the principles, advantages, limitations, and availability of immunodiagnostics assays in outbreak investigations, based on the experience of a reference laboratory.

Donor-derived invasive aspergillosis after kidney transplant

The risk of transmission of infectious diseases from allograft to recipient is well known. Viruses and bacteria are the most frequent causes of transmissible infections. Donor-derived invasive aspergillosis is rare and occurred under particular circumstances. We report 2 cases of kidney transplant recipients who acquired aspergillosis from a single donor.

Trends in pediatric liver transplant donors and deceased donor circumstance of death in the United States, 2002-2015

While much of the discussion regarding expanding the donor pool for pediatric liver transplantation has surrounded the use of technical variant grafts, little attention has been directed toward changes in the deceased donor population. The aim of this study was to investigate trends in the circumstance of the death of deceased donors used for pediatric liver transplantation. All pediatric liver transplant recipients transplanted between 2002 and 2015 were identified in the UNOS database and were categorized based on the donor circumstance of death. There was no significant correlation between year of transplantation and number of pediatric liver transplants performed, pediatric donors, split livers, or living donors. There was a significant downward trend in donors from motor vehicle fatalities and an upward trend in suicide, non-MVA, and death due to natural causes. There was also an upward trend in drowning, one of the most common mechanisms of death among non-MVA in 2015. While the number of donors who died in MVA has fallen, the number of deceased donors who died from suicide, natural causes, and non-MVA, especially drowning, has increased, maintaining the overall number of pediatric deceased donor livers transplanted.

Are drowned donors marginal donors? A single pediatric center experience

Drowning, a common cause of death in the pediatric population, is a potentially large donor pool for OLT. Anecdotally, transplant centers have deemed these organs high risk over concerns for infection and graft dysfunction. We theorized drowned donor liver allografts do not portend worse outcomes and therefore should not be excluded from the donation pool. We reviewed our single-center experience of pediatric OLTs between 1988 and 2015 and identified 33 drowned donor recipients. These OLTs were matched 1:2 to head trauma donor OLTs from our center. A chart review assessed postoperative peak AST and ALT, incidence of HAT, graft and recipient survival. Recipient survival at one year between patients with drowned donor vs head trauma donor allografts was not statistically significant (94% vs 97%, P=.63). HAT incidence was 6.1% in the drowned donor group vs 7.6% in the control group (P=.78). Mean postoperative peak AST and ALT was 683 U/L and 450 U/L for drowned donors vs 1119 U/L and 828 U/L in the matched cohort. These results suggest drowned donor liver allografts do not portend worse outcomes in comparison with those procured from head trauma donors.

Confirmed Transmission of Bacterial or Fungal Infection to Kidney Transplant Recipients from Donated After Cardiac Death (DCD) Donors in China: A Single-Center Analysis

Background

We aimed to investigate blood and urine cultures of donated after cardiac death (DCD) donors and report the cases of confirmed (proven/probable) transmission of bacterial or fungal infection from donors to kidney recipients.

Material/Methods

Seventy-eight DCD donors between 2010 and 2016 were included. Sixty-one DCD donors underwent blood cultures and 22 episodes of bacteremias developed in 18 donors. Forty-three donors underwent urine cultures and 14 donors experienced 17 episodes of urinary infections.

Results

Seven of 154 (4.5%) kidney recipients developed confirmed donor-derived bacterial or fungal infections. Inappropriate use of antibiotics in donor was a risk factor for donor-derived infection (p=0.048). The use of FK506 was more frequent in recipients without donor-derived infection than those with donor-derived infection (p=0.033). Recipients with donor-derived infection were associated with higher mortality and graft loss (42.9% and 28.6%, respectively), when compared with those without donor-derived infection (4.8% each). Three kidney recipients with donor-derived infection died; one death was due to multi-organ failure caused by Candida albicans, and two were related to rupture of the renal artery; two of them did not receive appropriate antimicrobial therapy after infection.

Conclusions

Our kidney recipients showed high occurrence rates of donor-derived infection. Recipients with donor-derived infection were associated with higher mortality and graft loss than those without donor-derived infection. The majority of recipients with donor-derived infection who died did not receive appropriate antimicrobial therapy after infection.

Complications of invasive mycoses in organ transplant recipients

INTRODUCTION

Opportunistic mycoses remain a significant complication in organ recipients. Areas covered: This review is an evidence-based presentation of current state-of-knowledge and our perspective on recent developments in the field Expert commentary: Invasive fungal infections are associated with reduced allograft and patient survival, increase in healthcare resource utilization, and newly appreciated but largely unrecognized immunologic sequelae, such as immune reconstitution syndrome. Given adverse outcomes associated with established infections, prophylaxis is a widely used strategy for the prevention of these infections. Currently available biomarkers that detect circulating fungal cell wall constituents i.e., galactomannan and 1, 3-β-D-glucan have not proven to be beneficial as screening tools for employing targeted prophylaxis or as diagnostic assays in this patient population. However, subsets of patients at risk for opportunistic fungal infections can be identified based on clinically identifiable characteristics or events. Preventive strategies targeted towards these patients are a rational approach for optimizing outcomes.

Successful Kidney and Lung Transplantation From a Deceased Donor With Blunt Abdominal Trauma and Intestinal Perforation

The number of organ donors is limited by many contraindications for donation and poor quality of potential organ donors. Abdominal infection is a generally accepted contraindication for donation of abdominal organs. We present a 43-year-old man with lethal brain injury, blunt abdominal trauma, and intestinal perforation. After withdrawal of life-sustaining treatment and circulatory arrest, a minilaparotomy confirmed abdominal contamination with intestinal content. After closure of the abdomen, organs were preserved with in situ preservation with an aortic cannula inserted via the femoral artery. Thereafter, the kidneys were procured via bilateral lumbotomy to reduce the risk of direct bacterial contamination; lungs were retrieved following a standard practice. There was no bacterial or fungal growth in the machine preservation fluid of both kidneys. All organs were successfully transplanted, without postoperative infection, and functioned well after 6 months. We hereby show that direct contamination of organs can be avoided with the use of in situ preservation and retroperitoneal procurement. Intestinal perforation is not an absolute contraindication for donation, although the risk of bacterial or fungal transmission has to be evaluated per case.

Case of early-disseminated Rhizopus microsporus var. microsporus mucormycosis in a renal transplant patient

Mucormycosis is a rare infection caused by the ubiquitous filamentous fungi of the order Mucorales and class Zygomycetes. These species are vasotropic, causing rapid onset of tissue infarctions and necrosis and subsequent thrombosis by invading vascular bed. The disease spectrum ranges from involvement of skin, sinuses, lung, and brain to disseminated and mostly fatal infections, especially in immunocompromised hosts. Here, we present a case of a fatal disseminated mucormycosis in a 56-year-old female who had deceased donor renal allograft transplantation ~2 weeks prior to presentation. She presented with shortness of breath and dry cough. Despite being on broad-spectrum antibiotics/antifungals and proper management by transplant, infectious disease, and primary team, she died within 3 weeks of admission. Autopsy showed disseminated mucormycosis of lungs and thyroid. Disseminated infection within 2 weeks of solid organ transplantation in this patient was one of the rare features of mucormycosis.

Filamentous Fungi

Filamentous mycoses are often associated with significant morbidity and mortality. Prompt diagnosis and aggressive treatment are essential for good clinical outcomes in immunocompromised patients. The host immune response plays an essential role in determining the course of exposure to potential fungal pathogens. Depending on the effectiveness of immune response and the burden of organism exposure, fungi can either be cleared or infection can occur and progress to a potentially fatal invasive disease. Nonspecific cellular immunity (i.e., neutrophils, natural killer [NK] cells, and macrophages) combined with T-cell responses are the main immunologic mechanisms of protection. The most common potential mold pathogens include certain hyaline hyphomycetes, endemic fungi, the Mucorales , and some dematiaceous fungi. Laboratory diagnostics aimed at detecting and differentiating these organisms are crucial to helping clinicians make informed decisions about treatment. The purpose of this chapter is to provide an overview of the medically important fungal pathogens, as well as to discuss the patient characteristics, antifungal-therapy considerations, and laboratory tests used in current clinical practice for the immunocompromised host.

Invasive Fungal Infections After Kidney Transplantation: A Single-center Experience

INTRODUCTION

Invasive fungal infections (IFI) affecting transplant recipients are associated with increased mortality and graft dysfunction.

OBJECTIVE

Describe the frequency, clinical features, and outcomes of IFI (except pneumocystis infection) in kidney transplant recipients.

METHOD

Single-center descriptive study including every kidney transplant recipient with a culture-proven or probable IFI between 2003 and 2013, according to the EORTC-MSG criteria.

RESULTS

We identified 45 IFI. There were 13 cases of invasive candidiasis (C. albicans: 6 and non-C. albicans candidial spp.: 7), 11 cases of pulmonary aspergillosis (A. fumigatus: 9 and A. flavus: 2); 11 cases of subcutaneous mycosis (Alternaria spp.: 9, Paecilomyces spp.: 1, and Pseudallescheria spp.: 1); 7 cases of cryptococcosis; 2 cases of pneumonia by non-Aspergillus molds (Mucor spp.: 1 and Cunninghamella spp.: 1); and 1 case of Geotrichum capitatum pneumonia. All patients were recipients from deceased donors. Six cases occurred in the first 3 months post-transplant, 15 cases between the third and twelfth months, and 21 cases after the twelfth month. Treatment options were fluconazole for Candida infections, voriconazole or caspofungin for aspergillosis, liposomal amphotericin for cryptococcosis, and itraconazole plus excision or cryotherapy for subcutaneous mycosis. Fifteen patients died (33%). Mortality rates were 15% for invasive candidiasis, 45% for aspergillosis, 71% for cryptococcosis, 100% for non-Aspergillus molds and G. capitatum pneumonia, and 0% for subcutaneous mycosis. Six patients who survived (14%) started regular hemodialysis.

CONCLUSION

IFI still have a high mortality and morbidity in kidney transplant recipients, as verified in this report. We reinforce the need for a high index of suspicion and prompt treatment.

Respiratory Failure due to Possible Donor-Derived Sporothrix schenckii Infection in a Lung Transplant Recipient

Background. De novo and donor-derived invasive fungal infections (IFIs) contribute to morbidity and mortality in solid organ transplant (SOT) recipients. Reporting of donor-derived IFIs (DDIFIs) to the Organ Procurement Transplant Network has been mandated since 2005. Prior to that time no systematic monitoring of DDIFIs occurred in the United States. Case Presentation. We report a case of primary graft dysfunction in a 49-year-old male lung transplant recipient with diffuse patchy bilateral infiltrates likely related to pulmonary Sporothrix schenckii infection. The organism was isolated from a bronchoalveolar lavage on the second day after transplantation. Clinical and radiographic responses occurred after initiation of amphotericin B lipid formulation. Conclusion. We believe that this was likely a donor-derived infection given the early timing of the Sporothrix isolation after transplant in a bilateral single lung transplant recipient. This is the first case report of sporotrichosis in a lung transplant recipient. Our patient responded well to amphotericin induction therapy followed by maintenance therapy with itraconazole. The implications of donor-derived fungal infections and Sporothrix in transplant recipients are reviewed. Early recognition and management of these fungi are essential in improving outcomes.

Transplant tourism: understanding the risks

Transplant tourism is commonly defined as travel abroad for the purpose of transplantation, but the term evokes ethical and legal concerns about commercial transplantation. Due to the mismatch in supply and demand for organs, transplant tourism has increased over the last several decades and now accounts for 10 % of transplants worldwide. Patients from the USA who pursue transplantation abroad do so most commonly for renal transplantation, and travel mostly to China, the Philippines, and India. Transplant tourism puts the organ recipient at risk for surgical complications, poor graft outcome, increased mortality, and a variety of infectious complications. Bacterial, viral, fungal, and parasitic infections have all been described, and most concerning are the high rates of blood-borne viral infections and invasive, often fatal, fungal infections. Transplant and infectious diseases physicians should have a high degree of suspicion for infectious complications in patients returning from transplantation abroad.

Fatal scedosporiosis in multiple solid organ allografts transmitted from a nearly-drowned donor

Scedosporium spp. is the most common mold infection in pneumonia resulting from near-drowning. Three fatal scedosporiosis cases developed after solid organ transplantation, probably transmitted from the nearly-drowned donor. One heart transplant recipient and two kidney transplant recipients developed fatal scedosporiosis following deceased donor transplantation from the same donor, a nearly-drowned victim of a suicide attempt. Genotypically, indistinguishable strains of Scedosporium auratiacum were recovered from the three recipients. Two liver transplant recipients from the same donor received prophylactic voriconazole without any subsequent signs of infection. To determine the safety of donation from nearly-drowned donors, a national traceback investigation was also performed of the causes of deaths in all transplant recipients who received organs from drowned donors between 2001 and 2013. Over 13 years, 2600 deceased donor transplants were performed in Korea. Among these 2600 deceased donor transplants, 27 (1%) victims of drowning donated their organs. From these 27 donors, 84 patients received organ transplants and 18 died, including the above three. We found no microbiologic evidence of invasive mold transmission from the nearly-drowned donors to the other 15 recipients. Although disseminated infection in the donor could not be demonstrated by culture, undiagnosed disseminated donor infection and transmission of Scedosporium spp. should be considered in near-drowning events.

Fatal Scopulariopsis infection in a lung transplant recipient: lessons of organ procurement

Seventeen days after double lung transplantation, a 56-year-old patient with idiopathic pulmonary fibrosis developed respiratory distress. Imaging revealed bilateral pulmonary infiltrates with pleural effusions and physical examination demonstrated sternal instability. Broad-spectrum antibacterial and antifungal therapy was initiated and bilateral thoracotomy tubes were placed. Both right and left pleural cultures grew a mold subsequently identified as Scopulariopsis brumptii. The patient underwent pleural irrigation and sternal debridement three times but pleural and wound cultures continued to grow S. brumptii. Despite treatment with five antifungal agents, the patient succumbed to his illness 67 days after transplantation. Autopsy confirmed the presence of markedly invasive fungal disease and pleural rind formation. The patient's organ donor had received bilateral thoracostomy tubes during resuscitation in a wilderness location. There were no visible pleural abnormalities at the time of transplantation. However, the patient's clinical course and the location of the infection, in addition to the lack of similar infection in other organ recipients, strongly suggest that Scopulariopsis was introduced into the pleural space during prehospital placement of thoracostomy tubes. This case of lethal infection transmitted through transplantation highlights the unique risk of using organs from donors who are resuscitated in an outdoor location.