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Platelet Contamination Leads to 3 Deaths

Two separate clusters of platelet transfusion-associated bacterial sepsis in Utah and California resulted in fatalities while proper procedures were followed.


 

Platelet-transmitted bacterial infections persist as a cause of transfusion-associated morbidity and mortality, according to researchers writing in Mortality and Morbidity Weekly Report . They describe 2 separate clusters of platelet transfusion-associated bacterial sepsis reported in Utah and California, in which 3 patients died.

Contamination of blood products most commonly happens when skin microbiota is introduced during needle insertion. Because most platelets are stored at room temperature, bacteria can proliferate to clinically important levels by the time the unit is transfused, the CDC says. About 1 in 5,000 platelet collections are contaminated; 1 in 100,000 platelet transfusions results in bacterial sepsis.

In Utah, 2 patients received contaminated apheresis platelet units. One developed rigors 30 minutes after infusion, but transfusion-transmitted bacterial infection was not considered because of the patient’s complex medical history. He died 4 days later.

Less than a day after the first patient’s infusion, the second patient received the other platelet unit. No immediate symptoms of sepsis followed but later that day routine laboratory testing revealed new intravascular hemolysis. She died 11 hours after transfusion.

In California, a patient developed vomiting, tachycardia, and hypotension within 15 minutes of an infusion that came from an apheresis blood donation. Although the transfusion was stopped, he died within 5 hours. A second patient developed septic shock approximately 9 hours after infusion but recovered.

Subsequent investigation found that both the Utah and California collection facilities followed current practices. However, the CDC report highlights that even when procedures are followed appropriately, the risk remains. The CDC says evidence-based strategies such as pathogen inactivation, rapid detection devices, and modified screen of bacterial culture protocols can help mitigate that risk.

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