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Paracoccidioidomycosis is a neglected disease and the most important systemic mycosis in Latin America. This fungal infection is directly linked to activities related to the rural environment, such as agriculture. Despite being a frequently diagnosed disease in Brazil, the real rates of prevalence and incidence are not estimated due to the non-mandatory notification of the disease, which was recently implemented in 2020. We report three interesting cases of Paracoccidioidomycosis in immunocompetent adults, with varied clinical manifestations.

Tiago da Cunha Ferreira,1– 3 Ianick Souto Martins3,4 1Infection Control Division, Policlínica Piquet Carneiro, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil; 2Infectious Diseases Division, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil; 3Faculty of Medicine, Fluminense Federal University, Niterói, RJ, Brazil; 4Infection Control Division, Hospital do Câncer I, Instituto Nacional do Câncer, Rio de Janeiro, RJ, BrazilCorrespondence: Ianick Souto MartinsFaculty of Medicine, Universidade Federal Fluminense, Rua Marquês de Paraná, 303, Centro, Niterói, RJ, CEP 240033-900, BrazilTel +55 21 2629-9000Email Ianicksm@id.uff.brPurpose: The infections caused by ESCPM Enterobacterales (Enterobacter spp., Serratia spp., Citrobacter spp., Providencia spp. and Morganella spp.) have limited therapeutic options. Patients with neoplastic diseases are particularly vulnerable to bloodstream infections (BSIs).Objective: To analyze determinant factors of death in patients with neoplasia complicated with BSI caused by ESCPM Enterobacterales.Patients and Methods: A cohort study of patients aged 18 years or older with neoplasia and BSI due to ESCPM group was conducted at the Cancer Hospital I of the National Cancer Institute, Brazil, from September 2012 to December 2017. The variables associated with death were analyzed using multivariate logistic regression.Results: Of the 103 patients included in the cohort, 67.0% were male, the median age was 63 years and 67.0% had solid tumors. Of the 107 BSI episodes evaluated, 70.1% were hospital-acquired infections, 54.2% were secondary to extravascular focus of infection, gastrointestinal tract (19.6%), mainly. Enterobacter spp. (n: 49, 45.4%) was the most frequent agent isolated followed by Serratia spp. (n: 34, 31.5%), Morganella morganii (n: 16, 14.9%), Citrobacter freundii. (n: 7, 6.5%) and Providencia spp. (n: 2, 1.8%). Ten (9.3%) BSI episodes were caused by multidrug-resistant ESCPM Enterobacterales (MDR-ESCPM). The 7-day and 30-day mortality were 9.3% and 21.5%, respectively. The BSIs caused by MDR-ESCPM were independently associated with 7-day death (OR = 21.62 95% CI: 1.81– 258.51 P = 0.01). Monotherapy with piperacillin-tazobactam tended to be associated with 7-day death (OR = 10.46 95% CI: 0.97– 112.91 P = 0.05) and 30-day death (OR = 2.73 95% CI: 0.96– 7.70 P = 0.05).Conclusion: BSIs due to ESCPM group have high mortality and when caused by MDR-ESCPM are independently associated with 7-day death. The possible association of piperacillin-tazobactam monotherapy for BSI-ESCPM with death needs to be better studied.Keywords: β-lactamases, mortality, cancer, piperacillin-tazobactam

A rare and difficult to diagnose case of subacute infective endocarditis caused by Bacillus cereus in a patient with systemic lupus erythematosus and Libman-Sacks endocarditis has been reported. Our aim is to highlight the importance of molecular methods such as MALDI-TOF and PCR to explain clinical and epidemiological issues about infections caused by unusual pathogen.

OBJECTIVE Over the past few decades, life expectancy in Brazil has increased from 48 years in 1950s to 76 years in 2017. The aim of this study was to investigate the impact of ageing on: (1) the frequency of hospitalisations due to bloodstream infection (BSI); (2) the incidence of hospital-acquired BSI (H-BSI); (3) the incidence of BSI caused by multidrug-resistant (MDR) agents and (4) the mortality rate of BSI in a public hospital. METHODS A hospital-based case-cohort study was conducted between 1 December 2013 and 31 December 2015. The data were analysed using multivariable logistic regression. RESULTS A total of 500 BSI episodes were detected, among 11,102 hospitalizations. The incidence of hospitalisations resulting from BSI was significantly higher in older than younger patients (3.7/100 vs. 2.0/100, p

Klebsiella pneumoniae is an important human pathogen, able to accumulate and disseminate a variety of antimicrobial resistance genes. Resistance to colistin, one of the last therapeutic options for multi-drug-resistant bacteria, has been reported increasingly. Colistin-resistant K. pneumoniae (ColRKp) emerged in two hospitals in Rio de Janeiro state, Brazil in 2016. The aim of this study was to investigate if these ColRKp isolates were clonally related when compared between hospitals, to identify the molecular mechanisms of colistin resistance, and to describe other antimicrobial resistance genes carried by isolates. Twenty-three isolates were successively recovered, and the whole-genome sequence was analysed for 10, each of a different pulsed-field gel electrophoresis (PFGE) type. Although some PFGE clusters were found, none of them included isolates from both hospitals. Half of the isolates were assigned to CC258, three to ST152 and two to ST15. One isolate was pandrug resistant, one was extensively drug resistant, and the others were multi-drug resistant. Colistin resistance was related to mutations in mgrB, pmrB, phoQ and crrB. Eleven new mutations were found in these genes, including two nucleotide deletions in mgrB. All isolates were carbapenem resistant, and seven were associated with carbapenemase carriage (blaKPC-2 in six isolates and blaOXA-370 in one isolate). All isolates had a blaCTX-M, and two had a 16S ribosomal RNA methyltransferase encoding gene (armA and rmtB). ColRKp were composed of epidemic clones, but cross-dissemination between hospitals was not detected. Colistin resistance emerged with several novel mutations amid highly resistant strains, further restricting the number of drugs available and leading to pandrug resistance.

Background Bloodstream infections (BSI) are associated with high morbidity and mortality. This scenario worsens with the emergence of drug-resistant pathogens, resulting in infections which are difficult to treat or even untreatable with conventional antimicrobials. The aim of this study is to describe the epidemiological aspects of BSI caused by multiresistant gram-negative bacilli (MDR-GNB). Methods We conducted a laboratory-based surveillance for gram-negative bacteremia over a 1-year period. The bacterial isolates were identified by MALDI-TOF/MS and the antimicrobial susceptibility testing was performed by VITEK®2. Resistance genes were identified through PCR assays. Results Of the 143 patients, 28.7% had infections caused by MDR-GNB. The risk factors for MDR bacteremia were male sex, age ≥ 60, previous antimicrobial use, liver disease and bacteremia caused by K. pneumoniae. K. pneumoniae was the most frequently observed causative agent and had the highest resistance level. Regarding the resistance determinants, SHV, TEM, OXA-1-like and CTX-M-gp1 were predominant enzymatic variants, whereas CTX-M-gp9, CTX-M-gp2, KPC, VIM, GES, OXA-48-like, NDM and OXA-23-like were considered emerging enzymes. Conclusions Here we demonstrate that clinically relevant antibiotic resistance genes are prevalent in this setting. We hope our findings support the development of intervention measures by policy makers and healthcare professionals to face antibiotic resistance. Electronic supplementary material The online version of this article (10.1186/s12879-019-4265-z) contains supplementary material, which is available to authorized users.

Klebsiella pneumoniae causes a diversity of infections in both healthcare and community settings. This pathogen is showing an increased ability to accumulate antimicrobial resistance and virulence genes, making it a public health concern. Here we describe the whole-genome sequence characteristics of an ST15 colistin-resistant K. pneumoniae isolate obtained from a blood culture of a 79-year-old female patient admitted to a university hospital in Brazil. Kp14U04 was resistant to most clinically useful antimicrobial agents, remaining susceptible only to aminoglycosides and fosfomycin. The colistin resistance in this isolate was due to a ~1.3 kb deletion containing four genes, namely mgrB, yebO, yobH and the transcriptional regulator kdgR. The study isolate presented a variety of antimicrobial resistance genes, including the carbapenemase-encoding gene bla KPC-2, the extended-spectrum beta-lactamase (ESBL)-encoding gene bla SHV-28 and the beta-lactamase-encoding gene bla OXA-1. Additionally, Kp14U04 harboured a multiple stress resistance protein, efflux systems and regulators, heavy metal resistance and virulence genes, plasmids, prophage-related sequences and genomic islands. These features revealed the high potential of this isolate to resist antimicrobial therapy, survive in adverse environments, cause infections and overcome host defence mechanisms.

Central-line bloodstream infection (CLABSI) increases hospital mortality. A cohort study was conducted in a Brazilian hospital to estimate the disability-adjusted life year (DALY) of CLABSI using modified World Health Organization (WHO) methodology. CLABSI DALY was 20.44 per 1,000 inpatients, most were the result of premature death (20.42 per 1,000 inpatients). DALY can be useful to guide and measure the impact of healthcare infection prevention.Infect Control Hosp Epidemiol 2017;38:606–609

Non-diphtheriae Corynebacterium species are usually considered as contaminants of clinical specimens due to their widely environmental distribution and colonization of the human skin and mucous membranes. However, these bacteria have been increasingly recognized as agents of life-threatening infections mainly in individuals in immunosuppressive conditions. These organisms have vast variation in morphology and biochemical reaction, characteristics that make the correct identification of Corynebacterium at the species level extremely difficult using conventional phenotypic methods. The precise identification of C. amycolatum requires approaches rarely available in conventional clinical microbiology laboratories, such as API Coryne system, 16s rRNA and rpoB gene sequencing. In this setting, MALDI-TOF, a quick, accurate, and relatively unexpansive molecular technique, arises as a cost-effective alternative for characterizing these agents. Here, a rare and lethal case of endocarditis caused by C. amycolatum is presented. This is the first case of infective endocarditis due to C. amycolatum reported in Brazil.

The main objective of this study was to assess the frequency and possible sources of colonization and infection by Acinetobacter in the intensive care unit (ICU) of a university hospital in Rio de Janeiro, Brazil, and characterize the isolates for relatedness to internationally and locally disseminated lineages. Patients consecutively admitted to the ICU from April 2007 to April 2008 were screened for colonization and infection. Species were identified by rpoB sequencing. The presence of acquired and intrinsic carbapenemase genes was assessed by polymerase chain reaction (PCR). Strains were typed by random amplification of polymorphic DNA (RAPD)-PCR, pulsed-field gel electrophoresis, and multilocus sequence typing (MLST) using the schemes hosted at the University of Oxford (UO) and Institut Pasteur (IP). Of 234 patients, 98 (42%) had at least one specimen positive for the Acinetobacter isolate, and 24 (10%) had infection. A total of 22 (92%) infections were caused by Acinetobacter baumannii and one each (4%) by Acinetobacter nosocomialis and Acinetobacter berezinae. A. baumannii isolates from 60 patients belonged to RAPD types that corresponded to MLST clonal complexes (CCs) 109/1 (UO/IP scheme, known as International Clone I), CC 110/110 (UO/IP), CC 113/79 (UO/IP), and CC 104/15 (UO/IP). Most CCs were carbapenem resistant and carried the bla(OXA-23)-like gene. Strains were introduced by patients transferred from other wards of the same hospital (11 patients, 18%) or acquired from cross-transmission within the ICU (49 patients, 82%). A. nosocomialis lineage sequence type 260 colonized 10% of the whole study population. A. baumannii have become established in this hospital as a part of a global epidemic of successful clones. Once introduced into the hospital, such clones have become entrenched among patients in the ICU.

The epidemiology of urinary tract infections (UTI) by Staphylococcus saprophyticus has not been fully characterised and strain typing methods have not been validated for this agent. To evaluate whether epidemiological relationships exist between clusters of pulsed field gel-electrophoresis (PFGE) genotypes of S. saprophyticus from community-acquired UTI, a cross-sectional surveillance study was conducted in the city of Rio de Janeiro, Brazil. In total, 32 (16%) female patients attending two walk-in clinics were culture-positive for S. saprophyticus. Five PFGE clusters were defined and evaluated against epidemiological data. The PFGE clusters were grouped in time, suggesting the existence of community point sources of S. saprophyticus. From these point sources, S. saprophyticus strains may spread among individuals.

Background Listeriosis occurs mainly in persons at extremes of age and with immunocompromising conditions. It is believed that most cases of listeriosis are acquired in the community. A cluster of listeriosis in hospitalized patients prompted the present investigation. Methods We conducted a case series study of listeriosis from August 21, 2006, to June 1, 2007, in a hospital in the city of Rio de Janeiro, Brazil. Results Six patients with Listeria monocytogenes infection were identified: 5 during hospitalization and 1 at a day clinic. By the time the infection was diagnosed, 5 patients had been in the hospital for a mean of 9 days. All patients were elderly (median age, 80 years) and had immunocompromising conditions. Five (83%) patients died. Four patients developed bloodstream infections, 3 caused by serotype 1/2b. Two patients had peritonitis: one caused by serotype 3b and another by serotype 1/2b. Four L monocytogenes isolates belonged to a single pulse-field gel electrophoresis genotype, suggesting a common source. An epidemiologic investigation pointed to the hospital kitchen as the possible contamination. Conclusion Data suggest a health care-associated outbreak of listeriosis and highlight the importance of developing guidelines for prevention and treatment of health care-associated foodborne diseases, especially in hospitals with immunocompromised adult patients.

Objective. To investigate an outbreak of healthcare-associated Burkholderia cepacia complex (BCC) primary bloodstream infections (BCC-BSI). Design and Setting. Case-crossover study in a public hospital, a university hospital and a private hospital in Rio de Janeiro, Brazil, from March 2006 to May 2006. Patients. Twenty-five patients with BCC-BSI. Design. After determining the date BCC-BSI symptoms started for each patient, 3 time intervals of data collection were defined, each one with a duration of 3 days: the case period, starting just before BCC-BSI symptoms onset; the control period, starting 6 days before BCC-BSI symptoms onset; and the washout period, comprising the 3 days between the case period and the control period. Exposures evaluated were intravascular solutions and invasive devices and procedures. Potential risk factors were identified by using the McNemar χ2 adjusted test. Cultures of samples of potentially contaminated solutions were performed. BCC strain typing was performed by pulsed-field gel electrophoresis using Spel. Results. The statistical analysis revealed that the use of bromopride and dipyrone was associated with BCC-BSI. A total of 21 clinical isolates from 17 (68%) of the 25 patients and an isolate obtained from the bromopride vial were available for strain typing. Six pulsotypes were detected. A predominant pulsotype (A) accounted for 11 isolates obtained from 11 patients (65%) in the 3 study hospitals. Conclusion. Our investigation, using a case-crossover design, of an outbreak of BCC-BSI infections concluded it was polyclonal but likely caused by infusion of contaminated bromopride. The epidemiological finding was validated by microbiological analysis. After recall of contaminated bromopride vials by the manufacturer, the outbreak was controlled.

A prospective cohort study was undertaken to describe the epidemiology of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBLKp) acquisition at an intensive care unit (ICU) in a non-outbreak setting. Surveillance for ESBLKp colonization and infection was performed in patients admitted at the ICU from January, 2000, to May, 2001. Screening for ESBLKp intestinal colonization was done by culturing rectal swab specimens at admission, 72 hr after admission and weekly until discharge or detection of ESBLKp. The incidence of ESBLKp intestinal colonization was 5.8/1,000 patient-days (95%CI, 3.4-10.1), and of ESBLKp infection was 1.7/1,000 patient-days (95%CI, 0.7-4.2). Use of vancomycin (OR 6.6; 95%CI, 1.73-25.28), amphotericin B (OR 12.0; 95%CI, 1.79-80.51), metronidazole (OR 5.3; 95%CI, 1.10-25.65), and ciprofloxacin (OR 0.1; 95%CI, 0.01-0.97) were independently associated with ESBLKp intestinal colonization. Previous ESBLKp colonization (OR 60.6; 95%CI, 56.33-578.73) was independently associated with ESBLKp infection. Each ICU-acquired ESBLKp isolate belonged to a different genotype by ERIC-PCR or pulsed-field gel electrophoresis (PFGE) and had a different plasmid profile, suggesting that cross transmission was not the main source for ESBLKp acquisition. Factors associated with ESBLKp in the non-outbreak setting were different from those previously reported during outbreaks. Intestinal ESBLKp colonization was confirmed as a risk factor for infection by this pathogen.

Maghsoudi, Behzad/0000-0002-1279-8799; Kritsotakis, Evangelos/0000-0002-9526-3852; Yalcin, Ata Nevzat/0000-0002-7243-7354; Mikaszewska-Sokolewicz, Malgorzata A/0000-0002-1148-7817; ALDEMIR KOCABAS, Bilge/0000-0002-6396-5243; Masjedi, Mohammad Reza/0000-0002-6871-382X; Masjedi, Mansoor/0000-0001-6175-9289; Gan, Chin Seng/0000-0002-6758-4798; Oncul, Oral/0000-0002-1681-1866; Sabetian, Golnar/0000-0001-8764-2150; YAMAN, Ayhan/0000-0002-5651-1286; Ozdemir, Halil/0000-0002-7318-1688; Leon, Hector Armando Rincon/0000-0003-0715-200X; Delia, Muntean/0000-0001-9100-4530; Atasay, Fatma Begum/0000-0002-9114-5293; Zand, Farid/0000-0003-3489-3372; Kuchenbecker, Ricardo/0000-0002-4707-3683; Medeiros, Eduardo A/0000-0002-6205-259X; ROMERO LOPEZ-ALBERCA, CRISTINA/0000-0001-5856-8668; Salomao, Reinaldo/0000-0003-1149-4598; ozdemir, sonay incesoy/0000-0003-2863-901X; Meco, Basak Ceyda/0000-0003-2951-9634; Horoz, Ozden Ozgur/0000-0001-7590-650X; Horhat, Florin George/0000-0001-6133-0204; Kazi, Mohammad Mukhit/0000-0003-3824-5540; Ciftci, Ergin/0000-0002-4955-160X; Abouqal, Redouane/0000-0002-6117-4341; Leblebicioglu, Hakan/0000-0002-6033-8543; Garcell, Humberto Guanche/0000-0001-7279-0062; Kendirli, Tanil/0000-0001-9458-2803; de Souza, Maria Cecilia B V/0000-0003-0318-3087; Sanaei Dashti, Anahita/0000-0002-2827-3575; UNAL, SERHAT/0000-0003-1184-4711; alvarez Moreno, carlos Arturo/0000-0001-5419-4494; Barahona G., Nayide/0000-0003-3559-6900; Rodriguez Ferrer, Marena Luz/0000-0002-8053-8454; Karabay, Oguz/0000-0003-0502-432X; Kaya, Sehnaz/0000-0003-0002-1517; ERDEVE, OMER/0000-0002-3193-0812; Gonzalez Martinez, Marisela del Rocio/0000-0003-1474-736X; Gikas, Achilleas/0000-0002-8455-9631; Baylan, Orhan/0000-0002-6529-7824; Mitrev, Zan/0000-0001-7859-8821; yildizdas, dincer/0000-0003-0739-5108; Ngo, Quy Chau/0000-0002-6787-2757; Duszynska, Wieslawa/0000-0002-5880-4904; KAYA, ZEYNEP/0000-0002-8468-2103; Dragan, Barbara/0000-0003-3108-4211; Gupta, Umesh/0000-0001-7717-1404; Navarro Fuentes, Karla Reyna/0000-0002-6894-8872; zali, Mohammadreza/0000-0002-9027-4560; Morocho Tutillo, Diego Rolando/0000-0002-4974-7856; El Kholy, Amani/0000-0002-0645-7664; Kanj, Souha/0000-0001-6413-3396; Assiri, Abdullah/0000-0002-5605-2876; Unal, Necmettin/0000-0002-9440-7893; Jayatilleke, Kushlani/0000-0002-3931-6630; KARABAY, OGUZ/0000-0003-1514-1685 WOS: 000341307100001 PubMed: 25179325 We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line-associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U. S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN. Copyright (C) 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Background Infection with carbapenem-resistant Acinetobacter baumannii has been associated with high morbidity and mortality in solid organ transplant recipients. The main objective of this study was to assess the influence of carbapenem resistance and other potential risk factors on the outcome of A. baumannii infection after kidney and liver transplantation. Methods Retrospective study of a case series of A. baumannii infection among liver and renal transplant recipients. The primary outcome was death associated with A. baumannii infection. Multivariate logistic regression was used to assess the influence of carbapenem resistance and other covariates on the outcome. Results Forty-nine cases of A. baumannii infection affecting 24 kidney and 25 liver transplant recipients were studied. Eighteen cases (37%) were caused by carbapenem-resistant isolates. There were 17 (35%) deaths associated with A. baumannii infection. In unadjusted analysis, liver transplantation (p = 0.003), acquisition in intensive care unit (p = 0.001), extra-urinary site of infection (p A. baumannii infection. The number of deaths associated with A. baumannii infection was higher among patients infected with carbapenem-resistant isolates, but the difference was not significant (p = 0.28). In multivariate analysis, the risk of A. baumannii-associated mortality was higher in patients with infection acquired in the intensive care unit (odds ratio [OR] = 34.8, p = 0.01) and on mechanical ventilation (OR = 15.2, p = 0.04). Appropriate empiric antimicrobial therapy was associated with significantly lower mortality (OR = 0.04, p = 0.03), but carbapenem resistance had no impact on it (OR = 0.73, p = 0.70). Conclusion These findings suggest that A. baumannii-associated mortality among liver and kidney transplant recipients is influenced by baseline clinical severity and by the early start of appropriate therapy, but not by carbapenem resistance.

Texto completo. Acesso restrito. p. 241-244 Submitted by Santiago Fabio (fabio.ssantiago@hotmail.com) on 2013-06-13T19:46:03Z No. of bitstreams: 1 2222222222ddddd.pdf: 69650 bytes, checksum: c02f1d35741677f480343e714c3e6526 (MD5) Made available in DSpace on 2013-06-13T19:46:03Z (GMT). No. of bitstreams: 1 2222222222ddddd.pdf: 69650 bytes, checksum: c02f1d35741677f480343e714c3e6526 (MD5) Previous issue date: 2013 The study aim was to describe the emergence of carbapenem resistance and clonal complexes (CC), defined by multilocus sequence typing (MLST), in Acinetobacter baumannii in a surveillance system for meningitis. Starting in 1996 in an urban setting of Brazil, surveillance detected meningitis by Acinetobacter sp for the first time in 2002. Up to 2008, 35 isolates were saved. Carbapenem resistance emerged in 2006, reaching 70% of A. baumannii isolates in 2008, including one that was colistin resistant. A. baumannii belonged to CC113/79 (University of Oxford/Institute Pasteur schemes), CC235/162 and CC103/15. Dissemination of infections resistant to all antimicrobial agents may occur in the future. Salvador

We describe a case of proven donor transmission of carbapenem-resistant Acinetobacter baumannii, which resulted in severe infectious complications after lung transplantation. A single bla(OXA-23) positive strain, belonging to a new multilocus sequence type (ST231), was isolated from donor and recipient, who died 65 days after transplantation. This report highlights the current challenges associated with the potential transmission of multidrug-resistant infections through organ transplantation.