Guidance

Chapter 13: infections present at the time of donation

Updated 21 May 2024

This section relates to organ and tissue donors only.

At the time a deceased donor is being considered for suitability there may be co-incidental infections which may have a bearing on safety. Diagnosed acute infections, and undiagnosed presumed acute infectious disease, in a potential donor do not necessarily preclude donation, but any such illness should be discussed as early as practicable with the local transplant unit consultant microbiologist or virologist.

Abscesses

Organ donors with abscesses occurring in the preceding 5 days and at a distance from the organ to be retrieved are acceptable for donation if appropriate recipient antibiotic prophylaxis covering the causative organism is given.

Staphylococcus aureus and Streptococcus pyogenes are more likely to spread to distant organs and cause infection in a recipient.

Transmission of infection is unlikely after effective drainage of an abscess and adequate antimicrobial treatment of the donor.

If the clinician caring for the potential donor believes that therapy given for a localised infection has successfully cleared the infection, tissues may be retrieved. Otherwise, the donation of tissues (other than cornea donation) is contraindicated unless life-preserving.

Advice within this document regarding bacteraemia and drug resistant bacteria may also pertain for those potential donors with an abscess.

Malaria

The donation of organs, tissues, other than corneas, from donors with active malarial infection and no curative chemotherapy is contraindicated. Corneal tissue, but not other ocular tissue, is acceptable as corneas are avascular and not considered to be a risk of transmitting protozoal infections.

Acellular or decellularised tissues from a donor with a history of malaria may be accepted for transplantation.

Patients with a history of travel to a malaria-endemic area more than one year ago, but afebrile at the time of assessment, can be accepted as donors.

Febrile donors with a recent travel history to a malaria-endemic country require a malarial screen (blood film) before donation.

If a donor was born or has lived in a malarious area for more than 6 months at any time of life, a validated anti-malarial antibody test should be performed, but in the case of deceased organ donors, donation may proceed pending the results. In very special circumstances - for example, where the donor is the only match for a bone marrow transplant - a validated anti-malarial antibody test should be performed and nucleic acid testing (NAT) applied if antibody is detected or in the scenario described in the next paragraph.

If the return to the UK from a malaria-endemic area is within 4 months, defer the living donor. For deceased donors, the organs may be used but a validated malarial antibody and NAT test of the donor must be done.

If return to the UK from a malaria-endemic area is between 4 months and one year, a validated anti-malarial antibody test should be performed. Organs may be used before the serological result is available. If a positive result for malarial antibodies is obtained, testing for malaria DNA must be done. See below for recipient management.

Gamma irradiation offers a method for tissue sterilisation for those tissues able to withstand this process and offers an alternative to malarial antibody testing of tissue donors with relevant travel history.

Recipient management

When a recipient has been found to have received a donation from a donor who tested positive for malarial antibody and negative for malarial DNA, they should be advised of the potential risk of contracting malaria and clinicians must consider the diagnosis if the recipient subsequently becomes ill with a compatible presentation, including pyrexia, in the first 4 to 6 months post-transplantation. In addition, if the donor tests positive for malarial DNA, a clinician with experience in parasitology and tropical medicine should be contacted to discuss management and commence monitoring.

Fungal infection

Fungal infection should be distinguished from colonisation.

Where there is localised fungal infection, specialist microbiological advice should be sought ahead of careful consideration of the benefits from transplantation and with recipients receiving appropriate antifungal prophylaxis.

Systemic infection defined by fungaemia may be associated with mycotic aneurysm at vascular anastomoses. Ongoing fungaemia is an absolute contraindication to donation of organs and tissues but specialist microbiological advice should be sought for an accurate risk assessment to be made.

Organs and tissues from donors with superficial fungal infection of the skin or mucosa due to candida species are acceptable for donation.

Organs from a patient with a blood stream infection or abscess due to yeast or filamented fungi species are acceptable for donation, providing appropriate recipient antimicrobial prophylaxis covering the donor organism is given. The potential for transmission of fungal infection and the development of a mycotic aneurysm at the vascular anastomoses must be considered.

Aspergillosis

Aspergillosis or other systemic fungal infections are contraindications for transplantation unless a specific risk assessment is carried out and appropriate recipient antifungal prophylaxis is prescribed.

Unusual bacterial, fungal or protozoal infections

Specialist microbiological advice should be sought when considering using organs and tissues from donors who have had unusual infections in the past, including those acquired outside of Western Europe. This should include infections common in immuno-compromised patients (for example, listeriosis or nocardiosis) or infections which lie dormant or may be difficult to eradicate (for example, brucellosis, Lyme disease or typhoid).

Endemic mycoses

There are no uniform recommendations for donor screening for endemic mycoses such as histoplasma, blastomycosis and coccidioidomycosis.

Evidence of active systemic fungal infection in the donor is a contraindication to transplantation. Evidence of active infection may include, but is not limited to the detection of antigenemia, antigenuria, H and/or M precipitin bands, and complement fixation titers of greater than or equal to 1:32.

Transmission risk and recipient management

Most reports of infections with these fungi within transplant recipients are in those individuals who have resided in endemic areas. Diagnosis can be difficult as mycotic infection may be dormant.

Transmission of histoplasmosis by transplantation has been described, but most cases appear to be the result of reactivation of past infection in the recipient. In many individuals from the Midwestern United States, calcified pulmonary, hilar and splenic granulomata are the radiographic residua of old Histoplasma infection, but such signs have not traditionally been considered a contraindication to donation. Antifungal prophylaxis is recommended for lung transplant recipients whose donors have positive serology or incidental Histoplasma capsulatum detection in the donor lung. There is currently no consensus on whether recipients of other organs from sero-positive donors should receive prophylaxis.

Transmission of coccidioidomycosis by lung transplantation has been reported in the Southwestern United States. This has also been described in kidney and liver recipients, although reactivation of coccidioidomycosis in the previously infected recipient appears to be far more common. Antifungal prophylaxis is recommended for recipients of sero-positive donors. Post-transplant clinical and serologic monitoring of at-risk patients should be performed periodically to assess for evidence of reactivation infection.

At this time, primary or secondary antifungal prophylaxis for blastomycosis after solid organ transplantation is not recommended.

Trypanosoma cruzi (Chagas disease)

Trypanosoma cruzi antibody screening should be undertaken in donors that meet any of the following criteria:

• born in Latin America (South America, Central America or Mexico)
• received blood components or products while resident in Latin America (South America, Central America or Mexico)
• lived in rural subsistence farming communities for a continuous period of 4 weeks or more in in Latin America (South America, Central America or Mexico)
• individuals whose mothers were born in Latin America (South America, Central America or Mexico)

Presently, Trypanosoma cruzi antibody testing is limited to a small number of laboratories in the United Kingdom and consequently results may not be available at the time of retrieval and implantation of solid organ transplants.

For those potential organ donors meeting any of the above criteria, transplant centres should be made aware at the time of offering of the potential for Trypanosoma cruzi infection in that donor. Organs can be accepted for transplantation provided recipients are appropriately informed and consented as to the risk and consequences of Trypanosoma cruzi infection.

Donors with positive Trypanosoma cruzi serology should not donate tissues other than corneas

Transmission risk and recipient management

If donor serology is subsequently shown to be positive, specialist microbiological advice should be sought and an appropriate post-transplant management plan instituted.

Transmission rates from sero-positive donors to sero-negative recipients have been reported to be approximately:

• 13% to 20% for kidney transplants
• 20% to 29% for liver transplants
• 75% for heart transplants

Transmission rates for other organs (lung, pancreas and intestine) are not well defined.

Strongyloides stercoralis

Asymptomatic carriage with strongyloides stercoralis has been reported most often in donors who were both born in and lived for some while in endemic areas which include most of the Tropics and Subtropics. An eosinophilia may or may not be present. Transmission to immuno-compromised recipients is often associated with significant morbidity and a high mortality rate.

Pre-donation identification from stool sampling and serology, most practicable for a live donor, allows for effective recipient prophylaxis.^{[footnote 1]}

Bacillus anthracis (anthrax)

Infection is an absolute contraindication to solid organ and tissue donation.

Sexually transmitted infections (STIs)

For those pathogens not otherwise specified, STIs are:

• not a contraindication to donation of solid organs for transplantation
• a marker of increased risk of transmissible disease

Influenza

Lungs and bowel should not be used from donors with confirmed influenza infection.

Other organs may be offered, and the final decision lies with the transplanting surgeon weighing the balance of risks for therecipient.

SaBTO has issued advice concerning organ donation and seasonal influenza.

While there is no specific guidance for tissue donors, the criteria for blood donors is outlined in Change Notifications 14 and 15 published by JPAC (the Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee) in 2009.

Tuberculosis

Donation of organs and tissues is contraindicated from donors with active disease or within the first 6 months of anti-tuberculosis treatment.

Current infective endocarditis

Current infective endocarditis is not a contraindication to solid organ transplantation if:

• the organ does not have features of sepsis
• the organism is known
• there has been adequate microbiological treatment - what constitutes adequate microbiological treatment will be dependent on knowledge of the identified organism

Current infective endocarditis a contraindication to tissue donation (cornea donation permitted).

Specialist microbiological advice should be sought.

Drug resistant bacteria

Drug resistant bacteria include:

• methicillin resistant Staphylococcus aureus (MRSA)
• vancomycin resistant Enterococcus (VRE)
• carbapenemase-producing Enterobacteriaceae (CPE)

Drug resistant bacteria can be transmitted from donor to recipient. Transmitted infections are difficult to treat and are associated with poorer outcome in the recipient.

If there is presence of drug resistant bacteria in the donor:

• it is a relative contraindication to solid organ transplantation
• specialist microbiological advice must be sought
• careful consideration of benefits from transplant is required
• it is an absolute contraindication to tissues, unless life preserving

Gamma irradiation offers a method for tissue sterilisation for those tissues able to withstand this process.

Urinary tract infection

A localised urinary tract infection may be transmitted to the recipient in the setting of renal transplantation. Urinary tract infections may also result in a bacteraemia which can lead to transmission of a donor derived infection.

Urinary tract infection is not a contraindication to donation of solid organs for transplantation if:

• the organ is healthy
• the organism is known
• it is treated appropriately in donor
• antibiotics are continued in recipient, especially in renal transplantation

Urinary tract infection:

• is a relative contraindication to tissues unless clinicians caring for patient feel that adequate treatment has been provided
• is not a contraindication to cornea donation

Gamma irradiation offers a method for tissue sterilisation for those tissues able to withstand this process.

Lyme disease

Lyme disease-associated myocarditis is a rare cause of cardiac death in areas where Lyme disease is prevalent.

At the time of writing there were no reported cases of donor-derived transmission in the literature.

Organism can be found in tissues so transplant-related transmission is possible.

Case reports of corneal transplant from donors that were later found to be infected with Borrelia burgdorferi but no evidence of transmission of disease was found.

Specialist microbiological advice must be sought.

Careful consideration must be given to the potential benefits from transplant.

Lyme disease is a relative contraindication for donation of solid organs for transplantation:

• Lyme disease-associated myocarditis in the donor is an absolute contraindication for cardiac transplantation
• Lyme disease-associated myocarditis in the donor is a relative contraindication for other allografts

For acute infection, is an absolute contraindication to tissues unless transplant is life preserving. Can be accepted after infection is resolved.

Dengue virus

Dengue virus is a common insect borne human disease and occurs in tropical and sub-tropical countries worldwide.

The majority of Dengue virus infections are asymptomatic. The possibility of infection should be considered in individuals recently returned (less than 28 days) from countries in which Dengue virus exists. Information regarding infection outbreaks may be found at the websites listed in chapter 5.

Case reports confirm that Dengue virus may be transmitted by solid organ transplants.

Known Dengue virus infection:

• is a contraindication to donation of solid organs for transplantation
• is a contraindication to tissue donation - advice has been given as a position statement by JPAC

Donation may be considered 6 months after recovery from infection with Dengue virus.

For asymptomatic organ donors returning from affected areas, an individual risk assessment is required before donation.

Chikungunya virus

Chikungunya virus may be found worldwide including parts of Europe.

The majority of infections are symptomatic.

Although theoretically possible, transmission from the transplantation of tissues or organs has not been reported.

The possibility of infection should be considered in individuals recently returned from countries in which Chikungunya virus exists. Information regarding infection outbreaks may be found at the websites listed in chapter 5.

Known Chikungunya virus infection:

• is a contraindication to donation of solid organs for transplantation
• is a contraindication to tissue donation - advice has been given as a position statement by JPAC.

Donation may be considered 6 months after recovery from infection with Chikungunya virus.

For asymptomatic organ donors returning from affected areas, an individual risk assessment is required before donation.

Zika virus

Zika virus is a common mosquito borne human disease and occurs in tropical and sub-tropical countries worldwide. Since 2015, an outbreak of Zika virus has been occurring in the Caribbean, Central and South America, Oceania and some parts of Asia. In addition to vector transmitted infection, both sexual and vertical transmission of Zika virus can occur.

The majority of Zika virus infections are asymptomatic. The possibility of infection should be considered in individuals recently returned (less than 28 days) from countries in which Zika virus exists. Information regarding infection outbreaks may be found in the websites listed in chapter 5.

Due to the possibility of sexual transmission by semen, consideration should be given to the possibility of Zika virus infection (asymptomatic or otherwise) in potential donors whose sexual partner has been in an area affected by Zika virus.

Case reports confirm that Zika virus can be transmitted by blood transfusion but to date transmission through solid organ, tissue and cell transplantation has not been reported.

The virus has a clear neurotropism, as evidenced by congenital Zika Syndrome and other CNS presentations, but the course of Zika virus infection in the immunocompromised host has not been well documented thus far. It is not known whether there is a risk of prolonged viraemia or virus compartmentalization after disappearance in blood.

Known Zika virus infection:

• is a contraindication to donation of solid organs for transplantation except in exceptional circumstances
• is a contraindication to tissue donation

Donation may be considered 6 months after recovery from infection with Zika virus.

For asymptomatic organ donors returning from affected areas, an individual risk assessment is required before donation.

West Nile virus

West Nile Virus is a mosquito borne zoonotic infection that is currently not indigenous to the UK at present, but is endemic in many countries in Southern Europe, North America and Australia.

The majority of West Nile virus infections are asymptomatic, although a minority can develop neuroinvasive disease. The possibility of infection should be considered in individuals recently returned (less than 28 days) from countries in which West Nile virus exists. Information regarding infection outbreaks may be found in the websites listed in chapter 5.

Known West Nile virus infection:

• is a contraindication to donation of solid organs for transplantation
• is a contraindication to tissue donation

For asymptomatic donors returning from affected areas, an individual risk assessment is required before donation.

Donor transmission may occur from an asymptomatic individual or from a donor who died of unrecognised and therefore undiagnosed West Nile neuroinvasive disease. SaBTO has considered the implications should an organ and tissue donor test positive for West Nile virus infection posthumously following the transplantation of an organ and published guidance: West Nile virus and solid organ transplantation: SaBTO statement.

Progressive multifocal leukoencephalopathy

Progressive multifocal leukoencephalopathy is a rare, progressive central nervous system disorder caused by the JC virus.

Previous JC virus infection is not a contraindication to donation of tissues or organs.

A confirmed diagnosis of progressive multifocal leukoencephalopathy is an absolute contraindication to donation of tissues or organs.

Listeria monocytogenes

Listeria monocytogenes may cause meningitis or septicaemia.

Although the potential for disease transmission exists there are no reported cases.

Listeria monocytogenes is a relative contraindication to donation of solid organs for transplantation. Donation may be considered if there is adequate antimicrobial treatment in the donor.

Specialist microbiological advice must be sought.

Careful consideration of benefits from transplant is required.

For acute infection, Listeria monocytogenes is an absolute contraindication to donation of tissues unless life preserving. Can be accepted once infection is resolved

Mumps, measles and rubella

No reported transmission.

Acute disease is a relative contraindication to donation of solid organs for transplantation.

Specialist microbiological advice must be sought.

Careful consideration of benefits from transplant is required.

Acute disease is an absolute contraindication to donation of tissues unless life preserving.

Middle East Respiratory Syndrome - coronavirus (MERS-CoV)

Where acute disease is confirmed, there is no evidence base to support safe use of substances of human origin.

MERS-CoV:

• is an absolute contraindication to donation of solid organs for transplantation
• is an absolute contraindication to donation of tissues

MPox (formerly called Monkeypox)

There are no reports to date of transmission of Mpox through transplantation but there remains a theoretical risk of transmission if the donor was viraemic with asymptomatic infection or contact with Mpox in the previous 21 days.

Acute illness, if confirmed, is an absolute contraindication to donation of tissues and solid organs for transplantation.

Donation can be accepted following exposure to Mpox more than 21 days before, with no signs or symptoms of Mpox.

Donation can be accepted after complete recovery from Mpox at least 14 days previously.

Severe acute respiratory syndrome (SARS)

Where acute disease is confirmed, there is no evidence base to support safe use of substances of human origin.

SARS:

• is an absolute contraindication to donation of solid organs for transplantation
• is an absolute contraindication to donation of tissues

Rabies

Rabies:

• is an absolute contraindication to donation of solid organs for transplantation
• is an absolute contraindication to donation of tissues

Yellow fever

Yellow fever:

• is an absolute contraindication to donation of solid organs for transplantation
• is an absolute contraindication to donation of tissues

Viral haemorrhagic fevers (VHF)

In general:

• acute disease is an absolute contraindication to donation of solid organs for transplantation
• acute disease is an absolute contraindication to donation of tissues

See a list of all chapters in this guidance

1. Abanyie FA, Gray EB, Delli Carpini KW, Yanofsky A, McAuliffe I, Rana M,Chin-Hong PV, Barone CN, Davis JL, Montgomery SP and Huprikar S. Donor-derived Strongyloides stercoralis infection in solid organ transplant recipients in the United States, 2009 to 2013 American Journal of Transplantation: volume 15(5), pages 1,369-75, May 2015. ↩