*Purpose: Although there is concern about the use of donor organs that are infected or colonized with multidrug-resistant organisms (MDROs), their impact on solid organ transplant recipient (SOTR) outcomes remains unknown. In this study, we evaluated the association between donor MDROs and risk of SOTR infection post-transplant.

*Methods: A retrospective cohort study was conducted at three transplant centers in Philadelphia between 1/1/2015-6/30/2016. All SOTR who underwent transplantation with a local deceased organ donor were included. Exposed SOTRs were categorized into two groups: those whose donor had (1) at least one MDRO on culture, and (2) at least one non-MDRO bacterial or candidal organism on culture. SOTRs were considered unexposed if their donor had no positive cultures. MDROs included methicillin-resistant S. aureus, vancomycin-resistant enterococci, extended-spectrum beta-lactamase or carbapenem-resistant Enterobacterales, multidrug-resistant (MDR) P. aeruginosa, or MDR Acinetobacter species. The primary outcome was any bacterial or invasive candidal infection within three months post-transplant as determined by manual chart review. Donor-derived infections (DDIs) were secondarily evaluated; DDIs were defined as a bacterial or candidal infection within three months post-transplant with the same organism and same susceptibility profile as was present on donor culture. A mixed-effects multivariable frailty model was developed to determine the association between donor culture results and time to first infection (DDI or non-DDI), with a random effect for donor.

*Results: Of 658 total SOTR, 93 (14%) had donors with at least one MDRO on culture, 477 (73%) had donors with at least one non-MDRO positive culture, and 88 (13%) had donors with no positive cultures. On multivariable analysis, donor MDROs were associated with a significantly increased hazard of infection post-transplant (aHR 1.75, 95% CI 1.07-2.87, P=0.03) while non-MDRO positive donor cultures were not (aHR 1.45, 95% CI 0.97-2.16, P=0.07). The association between donor MDROs and SOTR infection was attenuated after removing DDIs from the outcome (aHR 1.64, 95% CI 0.97-2.78, P=0.06), suggesting that DDIs were an important driver of this association.

*Conclusions: SOTR whose donors carry MDROs are at increased risk for early post-transplant bacterial or invasive candidal infection, which is primarily related to increased rates of DDIs. Further studies evaluating methods for reducing this risk are needed.

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