Impact of deceased donor multidrug-resistant bacterial organisms on organ utilization

Donor respiratory multidrug-resistant bacteria and lung transplantation outcomes

RATIONALE

Respiratory culture screening is mandatory for all potential lung transplant donors. There is limited evidence on the significance of donor multidrug-resistant (MDR) bacteria on transplant outcomes. Establishing the safety of allografts colonized with MDR bacteria has implications for widening an already limited donor pool.

OBJECTIVES

We aimed to describe the prevalence of respiratory MDR bacteria among our donor population and to test for associations with posttransplant outcomes.

METHODS

This retrospective observational study included all adult patients who underwent lung-only transplantation for the first time at King Faisal Specialist Hospital & Research Centre in Riyadh from January 2015 through May 2022. The study evaluated donor bronchoalveolar lavage and bronchial swab cultures.

MAIN RESULTS

Sixty-seven of 181 donors (37%) had respiratory MDR bacteria, most commonly MDR Acinetobacter baumannii (n = 24), methicillin-resistant Staphylococcus aureus (n = 18), MDR Klebsiella pneumoniae (n = 8), MDR Pseudomonas aeruginosa (n = 7), and Stenotrophomonas maltophilia (n = 6). Donor respiratory MDR bacteria were not significantly associated with allograft survival or chronic lung allograft dysfunction (CLAD) in adjusted hazard models. Sensitivity analyses revealed an increased risk for 90-day mortality among recipients of allografts with MDR Klebsiella pneumoniae (n = 6 with strains resistant to a carbapenem and n = 2 resistant to a third-generation cephalosporin only) compared to those receiving culture-negative allografts (25.0% versus 11.1%, p = 0.04). MDR Klebsiella pneumoniae (aHR 3.31, 95%CI 0.95-11.56) and Stenotrophomonas maltophilia (aHR 5.35, 95%CI 1.26-22.77) were associated with an increased risk for CLAD compared to negative cultures.

CONCLUSION

Our data suggest the potential safety of using lung allografts with MDR bacteria in the setting of appropriate prophylaxis; however, caution should be exercised in the case of MDR Klebsiella pneumoniae.

Optimal Perioperative Antimicrobial Management Strategies of Kidney Transplant Recipients Guided by Metagenomic Next-Generation Sequencing of Deceased Donors' Microbiology Samples

Background

There is no consensus on the optimal use of perioperative antibiotics prophylaxis after kidney transplantation, but there is a common trend to limit the duration of antibiotic use worldwide. Metagenomic next-generation sequencing (mNGS) has emerged as a novel technology for pathogen detection in clinical practice due to its noninvasive, rapid, precise and high susceptibility to detect infectious pathogens. However, data are lacking on whether mNGS analyses could be used to detect pathogens and guide anti-infection regimens in kidney transplant donors and recipients.

Methods

We conducted a retrospective study to review all clinic data of mNGS and traditional laboratory methods (TMs) for pathogen detection in kidney transplant recipients and their corresponding deceased donors from August 1, 2021 to October 30, 2022 in our center.

Results

A total of 57 donors and 112 of their corresponding recipients were included. The antimicrobial strategy mainly depended on mNGS results combined with traditional pathogen culture and clinical conditions. The percentages of positive pathogen detected by mNGS in blood, urine, bronchoalveolar lavage fluid (BALF) and preservation fluids (PFs) were 50.9% (29/57), 35.1% (20/57), 84.2% (48/57) and 54.4% (31/57) respectively, and were 24.6% (14/57), 15.8% (9/57), 57.9% (33/57) and 14.1% (8/57) respectively when using TMs. mNGS could detected all of pathogens which were detected by TMs. However, samples with negative TMs testing can be additionally detected as positive by mNGS (15/43 in blood, 11/48 in urine, 15/24 in BALF and 23/49 in PFs). Drug resistance genes were detected in 9 donors by mNGS,which were consistent with 6 donors by TMs. There was only one case of donor-derived infection in this study.

Conclusion

This study showed that it is effective to combine mNGS with traditional pathogen detection methods and clinical features to develop optimal perioperative antimicrobial management strategies for deceased donor kidney transplantation.

Epidemiology and Prevention of Early Infections by Multi-Drug-Resistant Organisms in Adults Undergoing Liver Transplant: A Narrative Review

Invasive bacterial infections are a leading cause of morbidity and mortality after liver transplant (LT), especially during the first months after LT, and infections due to multi-drug-resistant organisms (MDRO) are increasing in this setting. Most of the infections in patients in intensive care unit arise from the endogenous microflora and, for this reason, pre-LT MDRO rectal colonization is a risk factor for developing MDRO infections in the post-LT. Moreover, the transplanted liver may carry an increased risk of MDRO infections due to organ transportation and preservation, to donor intensive care unit stay and previous antibiotic exposure. To date, little evidence is available about how MDRO pre-LT colonization in donors and recipients should address LT preventive and antibiotic prophylactic strategies, in order to reduce MDRO infections in the post-LT period. The present review provided an extensive overview of the recent literature on these topics, with the aim to offer a comprehensive insight about the epidemiology of MDRO colonization and infections in adult LT recipients, donor-derived MDRO infections, possible surveillance, and prophylactic strategies to reduce post-LT MDRO infections.

Minimizing the Risk of Donor-Derived Events and Maximizing Organ Utilization Through Education and Policy Development

Herein, we review the current knowledge of donor-derived disease and current US Organ Procurement and Transplantation Network policies to minimize the risk. During the process, we also consider actions to further mitigate the risk of donor-derived disease. The overarching goal is to provide an infectious disease perspective on the complex decision of organ acceptance for transplant programs and candidates.

Establishment of a risk prediction model for multidrug-resistant bacteria in deceased organ donors: a retrospective cohort study in China

Background

Multidrug resistance in bacteria is a serious problem in organ transplantations. This study aimed to identify risk factors and establish a predictive model for screening deceased organ donors for multidrug-resistant (MDR) bacteria.

Methods

A retrospective cohort study was conducted at the First Affiliated Hospital of Zhejiang University School of Medicine from July 1, 2019 to December 31, 2022. The univariate and multivariate logistic regression analysis was used to determine independent risk factors associated with MDR bacteria in organ donors. A nomogram was established based on these risk factors. A calibration plot, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) were used to estimated the model.

Results

In 164 organ donors, the incidence of MDR bacteria in culture was 29.9%. The duration of antibiotic use ≥3 days (odds ratio [OR] 3.78, 95% confidence interval [CI] 1.62-8.81, p=0.002), length of intensive care unit (ICU) stay per day(OR 1.06, 95% CI 1.02-1.11, p=0.005) and neurosurgery (OR 3.31, 95% CI 1.44-7.58, p=0.005) were significant independent predictive factors for MDR bacteria. The nomogram constructed using these three predictors displayed good predictive ability, with an area under the ROC curve value of 0.79. The calibration curve showed a high consistency between the probabilities and observed values. DCA also revealed the potential clinical usefulness of this nomogram.

Conclusions

The duration of antibiotic use ≥3 days, length of ICU stay and neurosurgery are independent risk factors for MDR bacteria in organ donors. The nomogram can be used to monitor MDR bacteria acquisition risk in organ donors.

Utility of deceased donor cultures in solid organ transplantation in preventing donor-derived bacterial and fungal infectious diseases transmission

Deceased donor and organ perfusion fluid cultures are obtained in order to inform recipient antimicrobial management and therefore reduce the risk of donor-derived bacterial and fungal infections. However, important heterogeneity exists in laboratory practice across organ procurement organizations and clinical management of culture results across transplant centers. While not standardized, the clinical approach to donors with positive bacterial and/or fungal cultures should be informed by the risk of donor-derived infection (DDI) and the consequence of organ non-utilization and account for potential unintended effects of antimicrobial use in the recipient. In this review, we summarize the literature on bacterial and fungal DDIs, describe the significance of positive cultures by anatomic site, and summarize current guidance on the management of positive cultures from donors or preservation fluids.

Deceased donors with multidrug-resistant organisms: implications and future directions

PURPOSE OF REVIEW

Organ utilization from donors infected or colonized with multidrug-resistant organisms (MDROs) remains inconsistent, and hesitancy to accept organs from these donors may relate to poor outcomes among solid organ transplant recipients with MDRO donor-derived infections (DDIs). An improved understanding of the risk factors for donor MDRO colonization or infection and the risk of MDRO DDI is needed to safely expand the donor pool while minimizing unnecessary organ discard.

RECENT FINDINGS

Recent studies have begun to delineate risk factors for MDRO acquisition among deceased donors and the epidemiology of MDRO DDIs, but additional efforts are warranted to inform optimal approaches to donor evaluation, risk stratification, management, interfacility and interagency data sharing, and approaches to recipient management.

SUMMARY

This review summaries recent data regarding risk factors for MDRO colonization and infection in deceased donors, epidemiology of MDRO DDIs, and current approaches to donors harboring MDROs and provides a framework for future research and collaboration.

Machine perfusion combined with antibiotics prevents donor-derived infections caused by multidrug-resistant bacteria

Donor infection affects organ utilization, especially the infections by multidrug-resistant bacteria, which may have disastrous outcomes. We established a rat model, inoculated with Escherichia coli or carbapenem-resistant Klebsiella pneumoniae (CRKP), to investigate whether hypothermic machine perfusion (HMP), normothermic machine perfusion (NMP), or static cold storage (SCS) combined with antibiotic (AB) could eliminate the bacteria. E. coli or CRKP-infected kidneys were treated with cefoperazone-sulbactam and tigecycline, respectively. The HMP+AB and NMP+AB treatments had significant therapeutic effects on E. coli or CRKP infection compared with the SCS+AB treatment. The bacterial load of CRKP-infected kidneys in the HMP+AB (22 050 ± 2884 CFU/g vs. 1900 ± 400 CFU/g, p = .007) and NMP+AB groups (25 433 ± 2059 CFU/g vs. 500 ± 458 CFU/g, p = .002) were significantly reduced, with no statistically significant difference between both groups. Subsequently, the CRKP-infected kidneys of the HMP+AB and SCS+AB groups were transplanted. The rats in the SCS+AB group were severe infected and euthanized on day 4 post-transplant. By contrast, the rats in the HMP+AB group were in good condition. In conclusion, HMP and NMP combined with AB seems to be efficient approaches to decrease bacterial load of infected kidneys. This might lead to higher utilization rates of donors with active infection.

Challenges of Antimicrobial Resistance and Stewardship in Solid Organ Transplant Patients

Purpose of Review

Without effective antimicrobials, patients cannot undergo transplant surgery safely or sustain immunosuppressive therapy. This review examines the burden of antimicrobial resistance in solid organ transplant recipients and identifies opportunities for antimicrobial stewardship.

Recent Findings

Antimicrobial resistance has been identified to be the leading cause of death globally. Multidrug-resistant pathogens are associated with significant morbidity and mortality in transplant recipients. Methicillin-resistant S. aureus affects liver and lung recipients, causing bacteremia, pneumonia, and surgical site infections. Vancomycin-resistant enterococci is a nosocomial pathogen primarily causing bacteremia in liver recipients. Multidrug-resistant Gram-negative pathogens present urgent and serious threats to transplant recipients. Extended-spectrum beta-lactamase-producing E. coli and K. pneumoniae commonly cause bacteremia and intra-abdominal infections in liver and kidney recipients. Carbapenemase-producing Enterobacterales, mainly K. pneumoniae, are responsible for infections early-post transplant in liver, lung, kidney, and heart recipients. P. aeruginosa and A. baumannii continue to be critical threats. While there are new antimicrobial agents targeting resistant pathogens, judicious prescribing is crucial to minimize emerging resistance. The full implications of the COVID-19 global pandemic on antimicrobial resistance in transplant recipients remain to be understood. Currently, there are no established standards on the implementation of antimicrobial stewardship interventions, but strategies that leverage existing antimicrobial stewardship program structure while tailoring to the needs of transplant recipients may help to optimize antimicrobial use.

Summary

Clinicians caring for transplant recipients face unique challenges tackling emerging antimcirobial resistance. Coordinated antimicrobial stewardship interventions in collaboration with appropriate expertise in transplant and infectious diseases may mitigate against such threats.

Kidney Transplantation From Infected Donors With Particular Emphasis on Multidrug-Resistant Organisms: A Single-Center Cohort Study

OBJECTIVES

Prevention of sepsis-related organ dysfunction in septic donors is crucial. In this study, septic donors were followed-up based on donor Sequential Organ Failure Assessment criteria.

MATERIALS AND METHODS

Between January 2014 and 2020 at our center, 29 primary kidney transplant recipients received organs from 20 septic donors. All donors received either pathogen-specific or broad-spectrum antibiotics at least 48 hours before procurement, and all recipients received similar treatment posttransplant for an average of 7 to 14 days. Donor eligibility was determined according to the sum of donor-Sequential Organ Failure Assessment scores obtained from 6 parameters: Pao2/Fio2 ratio; platelet count; serum bilirubin, creatinine, and lactate levels; and presence of hypotension. The cut-off value for bacteremic donor acceptance was below 12 points.

RESULTS

Fever (≥38 °C) persisted in 5 donors in the last 24 hours before organ removal. However, in these 5 donors, the mean donor-Sequential Organ Failure Assessment score was 6.5 ± 1.1, mean arterial pressure was >70 mm Hg, and serum lactate levels were <2 mmol/L. Fifteen donors had systemic inflammatory response syndrome scores of ≤2 with corresponding donor-Sequential Organ Failure Assessment scores of 7.9 ± 1.2; none had systemic inflammatory response syndrome scores >3, which would have indicated severe organ failure. In 28 recipients (97%), no donor-related infections were observed in the perioperative first month and afterwards.

CONCLUSIONS

Treatment of donors and recipients with a common protocol greatly reduced the risk of donor-induced infection transmission. In addition, we found the donor-Sequential Organ Failure Assessment criteria to be a helpful tool in predicting organ failure in infected donors.

Impact of donor multidrug-resistant organisms on solid organ transplant recipient outcomes

BACKGROUND

The impact of donor colonization or infection with multidrug-resistant organisms (MDROs) on solid organ transplant (SOT) recipient outcomes remains uncertain. We thus evaluated the association between donor MDROs and risk of posttransplant infection, graft failure, and mortality.

METHODS

A multicenter retrospective cohort study was performed. All SOT recipients with a local deceased donor were included. The cohort was divided into three exposure groups: recipients whose donors had (1) an MDRO, (2) a non-MDRO bacterial or candidal organism, or (3) no growth on cultures. The primary outcomes were (1) bacterial or invasive candidal infection within 3 months and (2) graft failure or death within 12 months posttransplant. Mixed effect multivariable frailty models were developed to evaluate each association.

RESULTS

Of 658 total SOT recipients, 93 (14%) had a donor with an MDRO, 477 (73%) had a donor with a non-MDRO organism, and 88 (13%) had a donor with no organisms on culture. On multivariable analyses, donor MDROs were associated with a significantly increased hazard of infection compared to those with negative donor cultures (adjust hazard ratio [aHR] 1.63, 95% CI 1.01-2.62, p = .04) but were not associated with graft failure or death (aHR 0.45, 95% CI 0.15-1.36, p = .16).

CONCLUSIONS

MDROs on donor culture increase the risk of early posttransplant infection but do not appear to affect long-term graft or recipient survival, suggesting organ donors with MDROs on culture may be safely utilized. Future studies aimed at reducing early posttransplant infections associated with donor MDROs are needed.

The time is now: antimicrobial stewardship in solid organ transplantation

PURPOSE OF REVIEW

To provide a summary of complications of antimicrobials and opportunities for antimicrobial stewardship (AS) in solid organ transplant (SOT) patient care.

RECENT FINDINGS

Personalized, precision antimicrobial prescribing in SOT aiming to avoid negative consequences of antimicrobials is essential to improving patient outcomes. The positive impact AS efforts in transplant care has been recognized and bespoke activities tailored to special interests of transplant patients and providers are evolving. Strategies to optimize stewardship interventions targeting antibacterial, antiviral, and antifungal drug selection and dosing in the transplant population have been recently published though clinical integration using a 'handshake' stewardship model is an optimal starting point in transplant care. Other recent studies involving transplant recipients have identified opportunities to shorten duration or avoid antimicrobials for certain commonly encountered clinical syndromes. This literature, informing recent consensus clinical practice guidelines, may help support institutional practice guidelines and protocols. Proposals to track and report stewardship process and outcome measures as a routine facet of programmatic transplant quality reporting have been published. However, developing novel metrics accounting for nuances of transplant patients and programs is critical. Important studies are needed to evaluate organizational transplant prescribing cultures and optimal behavioral science-based interventions relevant to antimicrobial use in this population.

SUMMARY

Consequences of antimicrobial use, such as drug toxicities, and Clostridiodes difficile (CDI) and multidrug-resistant organisms colonization and infection disproportionately affect SOT recipients and are associated with poor allograft and patient outcomes. Stewardship programs encompassing transplant patients aim to personalize antimicrobial prescribing and optimize outcomes. Further studies are needed to better understand optimal intervention strategies in SOT.

Impact of Donor-Derived Multi-drug-Resistant Organism Infections on Abdominal Solid Organ Transplantation Recipients in China

BACKGROUND

Infection with multi-drug-resistant organisms (MDROs) is a life-threatening disease among abdominal solid organ transplantation recipients. Reports of donor-derived (DD) MDRO infections were few, but adverse clinical outcomes were severe, such as death or graft loss.

METHODS

The medical records of 68 donation after citizens' death donors with MDRO infections and 20 recipients transmitted with infections between October 1, 2015, and September 1, 2020, were reviewed according to the Declaration of Helsinki and the Declaration of Istanbul. There were no grafts from prisoners, and no donors were not coerced or paid.

RESULTS

Prevalence and mortality of DD-MDRO infection among abdominal solid organ transplantation recipients were 2.3% and 18.1%, respectively. The prevalence rate of DD-MDR gram-negative bacterial infection was higher than that of gram-positive bacterial infection (1.7% vs 0.6%). Negative culture of specimens occurred in 9 of 68 donors. Recipients with DD-MDR gram-negative bacterial infections had a significantly lower survival rate compared with DD-MDR gram-positive bacterial infections (P = .046).

CONCLUSIONS

Donation after citizens' death donors and recipients had high MDRO infection rates, and gram-negative bacteria were the predominant pathogens. When a possible DD-MDRO infection occurs, there may be adverse outcomes with limited choice of antibiotics. A nationwide surveillance and communication network needs to be established in China.