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Molecular Evidence of Nosocomial Pneumocystis jirovecii Transmission among 16 Patients after Kidney Transplantation

Sabine Schmoldt,^1, Regina Schuhegger,^2, Thorsten Wendler,³ Ingrid Huber,² Heidelore Söllner,² Michael Hogardt,¹ Helmut Arbogast,⁴ Jürgen Heesemann,¹ Lutz Bader,^1, and Andreas Sing^2,*

Max von Pettenkofer-Institute for Hygiene and Medical Microbiology, University of Munich, Marchioninstrasse 17, 81377 Munich, Germany,¹ Bavarian Health and Food Safety Authority (Bavarian LGL), Veterinaerstrasse 2, 85764 Oberschleissheim, Germany,² Department I of Internal Medicine, Nephrology Division, University Hospital, Munich-Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany,³ Division of Transplantation Surgery, University Hospital, Munich-Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany⁴

Received 15 October 2007/ Returned for modification 12 December 2007/ Accepted 9 January 2008

In recent years, clusters of Pneumocystis jirovecii (formerly Pneumocystis carinii) pneumonia (PCP) among immunocompromised individuals have been reported. Mostly, the source of infections was suspected to be within the clinical settings when transplant recipients and PCP patients shared hospital facilities. We report on a cluster of 16 renal transplant recipients positive for P. jirovecii. None of them received anti-Pneumocystis prophylaxis prior to P. jirovecii detection. Epidemiological studies revealed that 15 of them had received kidney transplants at a German university hospital and attended the same inpatient and outpatient clinic from January through September 2006. Multilocus sequence typing (MLST) was performed on the following genes: ITS1, β-tub, 26S, and mt26S. P. jirovecii DNA was available from 14 patients and showed identical MLST types among these renal transplant recipients. Surprisingly, one patient who was treated at a different nephrological center and reported no personal contact with patients from the renal transplantation cluster harbored an identical P. jirovecii MLST type. Three HIV-positive patients and one bone-marrow-transplanted hematologic malignancy patient—treated at different medical centers—were used as controls, and different MLST types were revealed. Interestingly, in three of the four previously described regions, new alleles were detected, and one new polymorphism was observed in the mt26S region. The epidemiological data and the genotyping results strongly suggest a nosocomial patient-to-patient transmission of P. jirovecii as the predominant transmission route. Therefore, strict segregation and isolation of P. jirovecii-positive/suspected patients in clinical settings seems warranted.

Published ahead of print on 23 January 2008.

Sabine Schmoldt and Regina Schuhegger contributed equally to this work.

Lutz Bader and Andreas Sing contributed equally to this work.