Septic transfusion case caused by a platelet pool with visible clotting due to contamination with <i>Staphylococcus aureus</i>

Loza-Correa, Maria; Kou, Yuntong; Taha, Mariam; Kaláb, Miloslav; Ronholm, Jennifer; Schlievert, Patrick M.; Cahill, Michael P.; Skeate, Robert; Cserti‐Gazdewich, Christine; Ramirez‐Arcos, Sandra

doi:10.1111/trf.14049

Cited by 26 publications

(48 citation statements)

References 16 publications

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“…A common feature of our near‐miss incidents and by others reporting platelets contaminated with S. aureus is the appearance of visual aggregates in the unit . This serves to underline the importance of visual inspection of all blood components prior to issue, and at the time of transfusion.…”

Section: Discussionmentioning

confidence: 64%

“…These measures decrease the risk of false‐negative screens and contamination rates of both pooled (4 donors) and apheresis (single donor) units and have remained relatively stable over time . False‐negative screening cultures for S. aureus resulting in septic reactions have been reported by others , and suggested explanations include bacterial numbers below detection levels in the sample, sequestration of the bacteria in plasma clots and biofilm formation . We document here four incidents of S. aureus contaminations of platelet units not detected on routine screening, the investigation of contributing donors for skin carriage of S. aureus and the follow‐up and management of these donors together with follow‐up of donors whose donations were confirmed positive for S. aureus contamination.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Failure of bacterial screening to detect Staphylococcus aureus: the English experience of donor follow‐up

et al. 2018

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Section: Discussionmentioning

confidence: 64%

Section: Introductionmentioning

confidence: 99%

Failure of bacterial screening to detect Staphylococcus aureus: the English experience of donor follow‐up

et al. 2018

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“…Thus, visual inspection could theoretically have prevented two‐thirds of TTBIs that might have occurred in the absence of visual inspection. Notably, S. aureus accounted for 63% of bacterially contaminated retrieved PCs, indicating not only the easy aggregability of S. aureus ‐contaminated PC, but also the crucial role of visual inspection, particularly in detecting PC contaminated with S. aureus , one of the most common causes of TTBI . Visual inspection has proceeded at the cost of discarding around 1000 PCs over the past 8 years, although only 2.8% of them were in fact bacterially contaminated.…”

Section: Discussionmentioning

confidence: 99%

Platelet safety strategies in Japan: impact of short shelf life on the incidence of septic reactions

et al. 2020

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BACKGROUND Transfusion‐transmitted bacterial infections (TTBIs) often have serious consequences for patients. The Japanese Red Cross (JRC) has not implemented culture screening for platelet concentrate (PC), but it has maintained a shelf life of 85 hours for PC. STUDY DESIGN AND METHODS The JRC collected reports of suspected TTBI and investigated causal relationships using PC samples and patient blood samples. PCs showing apparent abnormalities were retrieved and cultured and analyzed for bacterial growth. RESULTS The JRC analyzed 86 samples available from 135 transfused PCs with suspected TTBIs that were collected over the past 12 years; 17 (19.8%) were culture‐positive. One, 6, and 10 TTBIs developed in patients on Days 1, 2, and 3 after PC collection, respectively. Assuming that PC is transfused on the day of issue, the TTBI risk was fourfold higher on Day 3 than on Day 2, after adjusting the TTBI incidence for the number of PCs issued per day. Compared with the model of issuing all PCs on Day 3, issuing PCs with the current distribution of storage time could have decreased the TTBI incidence by 56%. During the past 8 years, the JRC retrieved 960 PC units because of apparent abnormalities, 2.8% of which were culture‐positive. CONCLUSION The short shelf life of PC is associated with a low incidence of reported TTBIs, more than half of which occurred on Day 3 relative to earlier time points. Visual inspection of PC before transfusion is crucial in detecting bacterially contaminated PC despite its low positive predictive value.

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“…In many cases, transfusion of microbially contaminated PC was prevented due to visual anomalies, e.g., clot formation, lack of swirling, or color change [47, 50]. …”

Section: Septic Reactions Due To False-negative Resultsmentioning

confidence: 99%

“…The latter is certainly the most controversial approach due to the implicit acceptance of an increased risk of transfusion-associated morbidity and mortality. The decrease in the number of platelet transfusion-transmitted infections, particularly in the last 2 decades, should not divert from the fact that a substantial risk for patients still exists [10, 50]. …”

Section: Discussionmentioning

confidence: 99%

Microbiological Screening of Platelet Concentrates in Europe

Prax

Bekeredjian‐Ding

Krut³

2019

Transfus Med Hemother

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The risk of transfusion-associated sepsis due to transmission of bacteria is a persistent problem in the transfusion field. Despite numerous interventions to reduce the risk, cases of bacterial sepsis following transfusion are repeatedly being reported. Especially platelet concentrates are highly susceptible to bacterial contaminations due to the growth-promoting storage conditions. In Europe, blood establishments and national authorities have implemented individual precaution measures to mitigate the risk of bacterial transmission. To obtain an overview of the different approaches, we compiled information from national authorities, blood establishments, and the current literature. Several aspects such as the shelf life of platelets, time of sampling and the applied control measures are compared between the member states. The analysis of the data revealed a broad heterogeneity of procedures on a national level ranging from platelet release without any safety testing up to mandatory screening of all platelet concentrates prior to transfusion. Despite the substantial progress made in recent years, several bacterial reports on transfusion-associated sepsis indicate that further efforts are needed to increase the safety of blood transfusions in the long term.

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Septic transfusion case caused by a platelet pool with visible clotting due to contamination with Staphylococcus aureus

Abstract: Visual inspection of blood components before transfusion is an essential safety practice to interdict the transfusion of bacterially contaminated units.

Cited by 26 publications

References 16 publications

Failure of bacterial screening to detect Staphylococcus aureus: the English experience of donor follow‐up

Failure of bacterial screening to detect Staphylococcus aureus: the English experience of donor follow‐up

Platelet safety strategies in Japan: impact of short shelf life on the incidence of septic reactions

Microbiological Screening of Platelet Concentrates in Europe

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