Status:
Ready to upload
Record number:
2024
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Bacterial contamination of platelets is rare (approximately one in 5,000 platelet units) but poses serious risk, often severe morbidity or mortality, to platelet transfusion recipients.
Time to detection:
Report involved 4 patients in 3 US states.
Patient A: Within minutes of completing the transfusion of pathogen-reduced apheresis platelets, patient briefly experienced rigors, followed 2 hours later by fever and hypotension. Treated for septic shock and recovered.
Patient B: One hour after transfusion began, patient complained of chills and the transfusion was terminated. Two hours after transfusion he became febrile, hypotensive and tachypneic, antibiotics were started; he died of septic shock 2 days later.
Patients C & D: Within two hours of transfusion, both patients became hypotensive and febrile. Both were transferred to the intensive care unit, and both recovered.
Alerting signals, symptoms, evidence of occurrence:
Rigors or chills, fever and hypotension, tachypnea
Demonstration of imputability or root cause:
Posttransfusion cultures were positive for Acinetobacter calcoaceticus-baumannii complex (ACBC) and/or Staphylococcus saprophyticus in all 4 patients when using 'patient posttransfusion blood' and/or testing of 'transfused platelet unit residual". Additionally, ACBC or S. saprophyticus were cultured when sampling the environment at 3 of 4 hospitals (i.e., platelet agitators) and at 1 of 4 facilities of the platelet suppliers ( i.e., a platelet agitator). Pathogen-inactivation technology was used for one unit, a primary culture was 'no growth' for the 3 other units, and 2 of the latter units were also negative when tested using a 'rapid bacterial detection device.'
CDC performed whole genome sequencing (WGS) on collected ACBC and S. saprophyticus isolates using standard methods. Fourteen ACBC isolates from all sources were highly related and appear to represent a novel ACBC taxon. In contrast, ACBC isolates from cases in North Carolina and Michigan were not closely related to isolates from cases in California, Utah, and Connecticut by WGS. WGS analysis revealed two clusters of S. saprophyticus isolates. The root cause of contamination remained unidentified.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
Reference attachment:
Suggest references:
Sydney A. Jones, et al. Sepsis Attributed to Bacterial Contamination of Platelets Associated with a Potential Common Source — Multiple States, 2018. MMWR / June 14, 2019 / Vol. 68 / No. 23
Note:
Should another case # be created to separately report the Staphylococcus saprophyticus contamination/infections?
Yes, the record has been cloned for Staphylococcus saprophyticus (EP)
Expert comments for publication:
Sepsis resulting from bacterial contamination of platelets can occur even with implementation of bacterial mitigation strategies. Whole genome sequencing indicated a potential common source of bacterial contamination among four cases of septic transfusion reactions occurring in three US states. Clinicians need to monitor for sepsis after platelet transfusions even after implementation of bacterial mitigation strategies and immediately report adverse reactions to platelet suppliers and hemovigilance systems.