*Purpose: Transmission risk of microbes present in donor lungs at time of donation to lung transplant recipients (LTR) is unclear. Infection is the second highest cause of 30-day (d) mortality, and the first between 30d-1 year after lung transplant (LT). Guidelines for donor derived infections in transplant recommend 7-14d of antibiotics (ABX) in recipients of bacteremic donors. There are limited data assessing transmission of non-blood donor infections and outcomes post-LT.

*Methods: We reviewed LTR from 2016-2020 with positive donor cultures from any culture site. Patients were excluded if they had cystic fibrosis, a multiorgan or redo LT, or active infection at time of LT. Protocol post-op ABX included vancomycin and cefepime x7d with extension to 14d if positive donor cultures were reported. Our primary outcome was incidence of C. difficile (C. diff) and infections due to multi-drug resistant organisms (MDRO) within 90d post-LT. Secondary outcomes included C. diff and MDRO by 30d, characterization of transmissions, length of stay, ABX regimens, and 90d mortality.

*Results: Of 83 included patients, C. diff and MDRO each occurred in 11% (n=9) of LTR within 90d. Donor cultures were 96% bacterial and 94% were derived from lungs/sputum. Immediate organism clearance (organism identified in donor culture but not found in LTR cultures) occurred in 83% of LTR (n=69). Of the donor-derived organisms from the 14 LTR that grew through post-op ABX, all were bacteria and isolated to respiratory infections (RI); S. aureus accounted for 71% of detected organisms. No RIs progressed to bacteremia. There were no cases of C. diff and 4 cases of MDRO in these positive RI LTR; 2 MDRO were donor-derived. Median duration of post-op ABX was 14d (IQR 11-18) in these positive RI LTR vs 11d (IQR 9-15) in those who demonstrated immediate clearance. Positive RI LTR demonstrated organism clearance after a median of 4d (IQR 3-6). No donor urinary tract or bloodstream infections were transmitted.

*Conclusions: While incidence of C. diff and MDRO within 90d was low and did not appear to be correlated with ABX duration, LTR may still benefit from decreased ABX duration given immediate clearance did occur in 83% of LTR. Because LTR with donor-derived organisms were able to clear them by 4d, an extended duration of ABX may not be necessary. High rates of S. aureus detection may be due to donor colonization presenting as positive assays without apparent disease, and did not appear to affect post-LT outcomes. Our study suggests that extended ABX past 7d may not be necessary in LT patients with gram (+) respiratory cultures or in LT patients with non-respiratory and/or non-bacteremic donor cultures.

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