Multidrug-resistant donor-derived infections in solid organ transplantation: a systematic review and meta-analysis of transmission risk factors.

Purpose

Donor-derived infections (DDIs) caused by multidrug-resistant organisms (MDROs) are rare but potentially devastating complications of solid organ transplantation (SOT), with limited evidence on transmission risk and clinical outcomes.

Methods

We conducted a systematic review in accordance with PRISMA 2020 guidelines, including case reports, case series, and cohorts describing SOT donors with MDRO that reported recipient's infection outcomes (1999-2025). Individual-level data were extracted when available. Meta-analyses of proportions were performed, and bivariable and multivariable logistic regression models were used to identify factors independently associated with DDI and mortality.

Results

46 studies comprising 435 donors and 544 transplants were included. Kidney (43.8%), lung (29.2%), and liver transplants (22.7%) were the most frequent. Carbapenem-resistant Enterobacterales (38.9%) predominated in donor isolates. The overall transmission rate was 26.6% (IC95%: 14.3-44.2) despite targeted antimicrobial prophylaxis in 86.5% of high-risk recipients. In multivariable analyses, positive preservation fluid (PF) cultures (p < 0.001), high-risk donor's cultures (p < 0.001), and liver transplantation (p = 0.02) were independently associated with increased transmission, whereas positive culture at screening donation (p < 0.001) and carbapenem resistant Acinetobacter baumannii (p = 0.02) isolation was associated with a lower risk of transmission. Respiratory donor cultures (p = 0.006) were independently associated with transmission in lung transplant-specific models.

Conclusions

MDRO in SOT donors are associated with high transmission rates. PF for all SOT and respiratory cultures in lung transplant are key predictors of transmission, supporting organ- and site-specific donor screening and microbiological surveillance to mitigate transmission.