Risk Factors for Multidrug-Resistant Organisms Among Deceased Organ Donors

Judith A. Anesi; Emily A. Blumberg; Jennifer H. Han; Dong H. Lee; Heather Clauss; Antonette Climaco; Richard Hasz; Esther Molnar; Darcy Alimenti; Sharon West; Warren B. Bilker; Pam Tolomeo; Ebbing Lautenbach; for the CDC Prevention Epicenters Program

Disclosures

American Journal of Transplantation. 2019;19(9):2468-2478. 

In This Article

Abstract and Introduction

Abstract

Donor infection or colonization with a multidrug-resistant organism (MDRO) affects organ utilization and recipient antibiotic management. Approaches to identifying donors at risk of carrying MDROs are unknown. We sought to determine the risk factors for MDROs among transplant donors. A multicenter retrospective cohort study was conducted at four transplant centers between 2015 and 2016. All deceased donors who donated at least one organ were included. Cultures obtained during the donor's terminal hospitalization and organ procurement were evaluated. The primary outcome was isolation of an MDRO on culture. Multivariable Cox regression was used to determine risk factors associated with time to donor MDRO. Of 440 total donors, 64 (15%) donors grew an MDRO on culture. Predictors of an MDRO on donor culture included hepatitis C viremia (hazard ratio [HR] 4.09, 95% confidence interval [CI] 1.71-9.78, P = .002), need for dialysis (HR 4.59, 95% CI 1.09-19.21, P = .037), prior hematopoietic cell transplant (HR 7.57, 95% CI 1.03-55.75, P = .047), and exposure to antibiotics with a narrow gram-negative spectrum (HR 1.13, 95% CI 1.00-1.27, P = .045). This is the first study to determine risk factors for MDROs among deceased donors and will be important for risk stratifying potential donors and informing transplant recipient prophylaxis.

Introduction

One of the most significant issues facing solid organ transplantation (SOT) is the limited supply of organ donors. Deceased donors with positive bacterial cultures have been utilized inconsistently in the past due to prior reports of SOT donors transmitting bacteria to their organ recipients via the allograft, causing donor-derived bacterial infections (DDBIs).[1–4] DDBIs have been linked to poor outcomes including vascular anastomosis dehiscence, overwhelming infection, and death.[1–4]

One area of particular concern is the organ donor who carries a multidrug-resistant organism (MDRO), because a DDBI due to an MDRO may be more difficult to treat in the recipient. Indeed, there are several case series describing transmission of MDROs from donors to recipients with poor attendant outcomes.[5] Because of this, the current national transplant guidelines recommend exercising caution when considering the use of organs that may carry an MDRO.[6,7] Importantly, however, donor cultures are not uniformly finalized prior to donor evaluation, so the presence of an MDRO on donor culture may be discovered after the decision about organ use has been made.

The presence of an MDRO on donor culture not only affects whether an organ is used but may also affect the perioperative antibiotic regimen administered to the recipient.[6,7] Observational studies have suggested that peri- and postoperative antibiotics for the recipient that are active against donor organisms may reduce the risk for DDBIs.[8,9] Standard perioperative prophylaxis regimens for SOT procedures do not target MDROs, however.[10,11] Thus, the ability to identify donors, prior to transplantation, who are at higher risk of carrying an MDRO would be crucial for determining the antibiotic regimen for the recipient. This would be a preferable strategy to broadening perioperative prophylaxis for all transplant recipients, because the antibiotics required to treat MDROs often confer additional toxicities and may themselves promote emergence of MDROs.

Though risk factors for MDROs in the general population have been well studied, there are no published studies to our knowledge that have determined risk factors associated with MDROs among deceased organ donors specifically. Although all deceased donors are admitted to an intensive care unit (ICU) during their terminal hospitalization (a known risk factor for MDRO colonization[12,13]), deceased organ donors are typically younger, with fewer medical comorbidities, increased rates of injection drug use (IDU), and increased rates of traumatic injuries compared to the general population receiving ICU care.[14,15] In addition, the clinical data available to transplant centers about the organ donor is more limited than that available to clinicians when caring for a hospitalized patient directly.[14] Thus, there is a pressing need to determine the donor factors that are (1) associated with MDROs and (2) can be determined by transplant centers at the time of donor evaluation, so that donors can be risk stratified prior to organ procurement. In this study, we sought to identify risk factors associated with MDROs among deceased SOT donors.

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