Sepsis Attributed to Bacterial Contamination of Platelets Associated with a Potential Common Source - Multiple States, 2018
- PMID: 31194723
- PMCID: PMC6613552
- DOI: 10.15585/mmwr.mm6823a2
Sepsis Attributed to Bacterial Contamination of Platelets Associated with a Potential Common Source - Multiple States, 2018
Abstract
During May-October 2018, four patients from three states experienced sepsis after transfusion of apheresis platelets contaminated with Acinetobacter calcoaceticus-baumannii complex (ACBC) and Staphylococcus saprophyticus; one patient died. ACBC isolates from patients' blood, transfused platelet residuals, and two environmental samples were closely related by whole genome sequencing. S. saprophyticus isolates from two patients' blood, three transfused platelet residuals, and one hospital environmental sample formed two whole genome sequencing clusters. This whole genome sequencing analysis indicated a potential common source of bacterial contamination; investigation into the contamination source continues. All platelet donations were collected using apheresis cell separator machines and collection sets from the same manufacturer; two of three collection sets were from the same lot. One implicated platelet unit had been treated with pathogen-inactivation technology, and two had tested negative with a rapid bacterial detection device after negative primary culture. Because platelets are usually stored at room temperature, bacteria in contaminated platelet units can proliferate to clinically relevant levels by the time of transfusion. Clinicians should monitor for sepsis after platelet transfusions even after implementation of bacterial contamination mitigation strategies. Recognizing adverse transfusion reactions and reporting to the platelet supplier and hemovigilance systems is crucial for public health practitioners to detect and prevent sepsis associated with contaminated platelets.
Conflict of interest statement
All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. David Peaper reports equity in and service on the advisory board of Tangen Biosciences; F. Bernadette West was a principal investigator for previous Cerus Corporation studies; Edward Snyder was the principal investigator on two grants from Cerus Corporation to Yale University to conduct PIPER, a Phase IV post-market study of pathogen-reduced platelets, and ReCePI, a randomized controlled trial of pathogen-reduced red cells, (no personal remuneration received for either study); Stephen Wagner reports personal fees from bioMérieux outside the submitted work. No other potential conflicts of interest were disclosed.
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References
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- Food and Drug Administration. Bacterial risk control strategies for blood collection establishments and transfusion services to enhance the safety and availability of platelets for transfusion. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; 2018. https://www.fda.gov/regulatory-information/search-fda-guidance-documents...
