Chapter 35
Donor-derived Infections
35.1 Potential infections that may be transmitted from donor to recipient [1,2]
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CNS, central nervous system; EBV, Epstein–Barr virus; HIV, human immunodeficiency virus; HSV, herpes simplex virus; HTLV, human T-cell lymphotrophic virus; SARS, severe acute respiratory syndrome.
Notes:
1. Expected transmissions are those, such as EBV, cytomegalovirus, hepatitis B virus (HBV), hepatitis C virus (HCV), and toxoplasmosis, in which routine screening tests detect the latent infection of the donor. These expected infections are transmitted regularly by transplanted organs and their impact is mitigated through monitoring recipients for early infection or the use of universal prophylaxis.
2. Unexpected transmissions occur from a pathogen that was either unrecognized or not screened for in the donor, e.g. Chagas, HIV, HCV, lymphocytic choriomeningitis virus, Mycobacterium tuberculosis, rabies, and West Nile virus. Many of the unexpected transmissions have resulted in clinically significant morbidity and mortality.
References (in square brackets): [1] Adv Chronic Kidney Dis 2009;16:234; [2] American Transplant Congress (ATC) 2008 abst LB-02.
35.2 Management of specific donor scenarios
| Scenario | Actions | Comments |
| Bacteremia in donor | Assess pathogen and susceptibility pattern If probable infection (coagulase-negative Staphylococcus may be contaminant – must contextualize with number of positive cultures and clinical picture of donor), would provide 2 weeks of active therapy, based on susceptibility patterns, in each recipient |
Catastrophic outcomes, including mycotic aneurysms of the anastomosis site, graft loss, or sepsis can occur if bacteremia is not treated with an active antimicrobial [1, 4] |
| Bacterial meningitis in donor | Patients with culture-proven bacterial meningitis can be used safely as an organ donor if:
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Culture-negative patients with a clinical picture consistent with bacterial meningitis have resulted in disease transmission, including a case of lymphoma [1, 4] Patient and graft survival similar in meningitis donors and non-infected donors [5] |
| Encephalitis | In general, donors with encephalitis should not be used unless there is a culture-positive bacterial cause If a donor with encephalitis is considered, the local transplant infectious diseases expert should be consulted before acceptance of the donor |
Transmission of Balamuthia, LCMV, rabies, and West Nile virus are a few examples of infections transmitted from patients who died of non-bacterial encephalitis [1, 4] There are several reports of people with Naegleria fowleri encephalitis being successfully used as donors. If such donors are used, consent of the recipient must be obtained pre-transplant and infectious diseases expert should be consulted as early as possible [6] |
| Donor with pneumonia | Presence of pneumonia is typically a contraindication to lung transplantation; lungs that have completed a course of active antibacterial therapy may considered on a case-by-case basis If bacterial colonization is recognized on procurement cultures, pathogen-directed treatment should be considered for lung transplant recipients while treatment of other recipients is typically unnecessary unless there is evidence of bacteremia or fungemia |
Fungal pneumonia is a contraindication to transplantation; Candida species typically do not cause pneumonia and positive respiratory cultures typically represent upper airway colonization |
| Donor with influenza | Influenza is typically an infection limited to the respiratory tract except in the setting of severe influenza or novel influenza virus infections. As such, risk is highest among lung recipients. Most recommend not using the lungs from donors with confirmed influenza (seasonal or pandemic) unless they have completed a standard course of therapy. Use of other organs could be considered on a case-by-case basis | There have been at least two confirmed cases of donor-derived influenza transmission involving infected lungs If virus is transmitted from an organ other than the lung, an atypical presentation may be expected – including fever and local symptoms; respiratory symptoms may be absent. Collection of alternative samples, including blood, urine, and stool, should be considered |
| All recipients of organs from a donor with confirmed influenza should receive empiric treatment (not prophylaxis) with an active antiviral for at least 5 days post-transplant | ||
| Donor with UTI | Presence of a UTI does not rule out a donor; donors with pyelonephritis may be at higher risk of transmitting infection and the condition should be discussed with the accepting nephrologist | – |
| Typically, kidney transplant recipients would need to receive a 3–7 day course of antibiotics active against the uropathogen; treatment of other recipients is likely unnecessary unless there is evidence of bacteremia or fungemia | ||
| Donor with positive syphilis screen | People with positive syphilis serology can safely be used as donors. Confirmatory testing with Treponema-specific test (such as FTA-ABS) should be done to r/o a false-positive screening test Prior history of treated STDs, including syphilis, in the donor should be obtained. Irrespective of donor STD history, all recipients of donors with confirmed positive syphilis serology should receive appropriate therapy for syphilis of unclear duration – typically penicillin G 2.4 million units IM weekly for 3 weeks |
If the recipient is penicillin allergic, consult local infectious diseases expert for appropriate therapy |
| Donor with Chagas | Any donor with a positive Chagas serology should be confirmed by secondary testing (typically a RIPA) because of poor specificity of the test Any recipient of organs from a donor confirmed to be infected with Chagas by serology should be monitored for evidence of Chagas replication and treated with the first evidence of replication |
In the US, medication for Chagas is available only through CDC (http://www.cdc.gov/chagas/) In the US, the CDC should be contacted as soon as Chagas is recognized in the donor |
| Donor with Strongyloides | Although Strongyloides serology is rarely obtained on donors, if it is positive or if an O&P examination of stool reveals Strongyloides, the recipient should receive two doses of ivermectin 0.2 mg/kg 1 week between doses | – |
| Donor with tuberculosis [7] | Active tuberculosis is a contraindication to transplantation | – |
| Management of donors with latent TB or granulomatous disease is more complicated (see Chapter 39) | ||
| Donor with positive HTLV serology [3] | Any positive donor HTLV-1/2 serology needs to have confirmation because of poor specificity. If the donor is confirmed to be HTLV-1-infected, the recipient should have baseline HTLV serology drawn (if not already done) Optimal monitoring and management protocols have not been established; would consult local infectious diseases expert |
Current serologic tests lack significant specificity and cannot differentiate between HTLV-1, which may be associated with disease in humans, and HTLV-2, which may not be associated with clinical disease |
| Donor with other documented infections | Discuss the donor and his/her specific issues with the OPO medical director and the accepting clinician [2] | – |
FT-ABS, fluorescent treponemal antibody absorbed; HTLV, human T-cell lymphotrophic virus; IM, intramuscular; LCMV, lymphocytic choriomeningitis virus; O&P, ova and parasite; OPO, organ procurement organization; RIPA, radioimmune precipitation assay; STD, sexually transmitted disease.
In all cases of donor infection, consult with your local transplant infectious diseases or infectious diseases expert. Always obtain an infectious diseases consult on the recipient immediately post-transplant if there is any concern for a donor-derived infection.
References (in square brackets): [1] Adv Chronic Kidney Dis 2009; 16: 234; [2] OPTN Policy 4; [3] Am J Transplantation 2010; 10(2): 207; [4] ATC 2008 abst LB-02; [5] Transplantation 2001; 72: 1108; [6] Am J Transplantation 2008; 8: 1334; [7] Clin Infect Dis 2009; 48: 1276.