Bacterial contamination of cellular blood components

Fetal and neonatal alloimmune thrombocytopenia: evidence based antenatal and postnatal management strategies

INTRODUCTION

Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a relatively rare but potentially lethal disease, leading to severe bleeding complications in 1 in 11.000 newborns. It is the leading cause of thrombocytopenia in healthy term-born neonates. Areas covered: This review summarizes the antenatal as well as postnatal treatment, thus creating a complete overview of all possible management strategies for FNAIT. Expert commentary: The optimal antenatal therapy in order to prevent bleeding complications in pregnancies complicated by FNAIT is non-invasive treatment with weekly intravenous immunoglobulin (IVIG). Based on risk stratification, weekly doses of IVIG of 0.5 or 1.0g/kg should be administered started early in the second in high risk cases or at the end of the second trimester in low risk cases. The optimal postnatal treatment depends on the platelet count and the clinical condition of the newborn. Prompt administration of compatible platelet transfusion is the first treatment of choice in case of severe thrombocytopenia or active bleeding. In case matched platelets are not directly available, random platelets can also be administered initially to gain time until matched platelets are available. In case of persistent thrombocytopenia despite transfusions, IVIG 1.0-2.0g/kg can be administered.

Feasibility of implementing an automated culture system for bacteria screening in platelets in the blood bank routine

Bacterial contamination of blood components is the principal infectious complication linked to transfusion. The aim of the study was to evaluate the applicability of an automated culture system for platelets. 10 141 platelet concentrates were cultured individually and in pools of five on storage days 1 and 7 using Bact/Alert system aerobic bottles. A modified collection bag was used for improved sampling. Five-millilitre samples were cultured at 37 degrees C for 7 days. Only those samples where the same bacteria were identified in reculture were considered true positives (TP). Homogeneity of proportions was tested by Fisher's exact test. The rate of TP was 30 per 100 000 (95% CI, 6.1-86.4) sampling on day 1; 33 per 100 000 (95% CI, 7-96) on day 7; and 40 per 100 000 (95% CI, 1.28-122.4) if the screening was based on taking both samples (day 1 and 7). Only one TP was detected in the pool testing. The time for detection among TPs on day 1 ranged between 30 and 134 h. The system is not considered practical for use as a routine screening method, as the time for detection is too long. Pool testing is insensitive. Faster screening methods or pathogen-inactivation systems are needed.

Platelet transfusions in infants with necrotizing enterocolitis do not lower mortality but may increase morbidity

OBJECTIVE

Necrotizing enterocolitis (NEC), a serious multisystemic inflammatory disease most commonly seen in premature neonates, is often associated with thrombocytopenia. Infants with severe forms of NEC commonly have platelet counts of less than 50,000/mm(3), occasionally less than 10,000/mm(3). Despite an absence of data to support the practice, platelet transfusions are commonly used to maintain a certain arbitrary platelet count in an effort to prevent bleeding. As platelet transfusions contain a variety of bioactive factors including pro-inflammatory cytokines, we hypothesized that a higher number and volume of platelet transfusions would not be associated with an improvement in mortality or morbidity.

STUDY DESIGN

A retrospective cohort analysis was conducted of the medical records of all infants between 1997 and 2001 with Bell's Stage 2 or 3 NEC associated with platelet counts of <100,000/mm(3). The medical records were evaluated for the following variables: platelet counts, number and volume of platelet transfusions, symptoms of bleeding, and hospital course. Mortality and development of short bowel syndrome and/or cholestasis were correlated to the total number and volume (total ml and ml/kg) of platelet transfusions. Differences between the outcome groups were compared using the independent t-test, Fisher's exact test and Mann-Whitney tests.

RESULTS

A total of 46 infants met the study criteria (gestational age 28+/-4 weeks and birth weight 1166+/-756 g, mean+/-SD). There were a total of 406 platelet transfusions administered to the study population. Of these, 151 (37.2%) were given in the presence of active bleeding, with 62% of these resulting in the cessation of bleeding within 24 hours. Other listed indications for platelet transfusions were hypovolemia and severe thrombocytopenia. On analysis of the entire cohort, there was no statistical improvement in either mortality or morbidity (short bowel syndrome and cholestasis) with greater number and/or volume of platelet transfusions. Furthermore, we found that infants who developed short bowel syndrome and/or cholestasis had been given a significantly higher number and volume of platelet transfusions when compared to those who did not have these adverse outcomes [median (minimum - maximum) - number of transfusions : 9 (0 to 33) vs 1.5 (0 to 20), p=0.010; volume of transfusions (ml/kg): 121.5 (0 to 476.6) vs 33.2 (0 to 224.3), p=0.013].

CONCLUSION

This retrospective analysis suggests that greater number and volume of platelet transfusions in infants with necrotizing enterocolitis are associated with greater morbidity in the form of short bowel syndrome and/or cholestasis without the benefit of lower mortality.

Detection of bacterial contamination of platelet components: six years’ experience with the BacT/ALERT system

BACKGROUND

Hemovigilance has shown that bacteria cause more fatalities than other infections together. Surveillance for detection of bacteria in platelets (PLTs) was initiated. Concomitantly, the storage period for PLTs was extended from 5 to 7 days to reduce cost.

STUDY DESIGN AND METHODS

Analysis was performed of all cases of a positive signal in a screening procedure for contaminated PLTs taking into account results of confirmative cultures and results of culture from blood components including bacteria strains. Records were assessed from patients transfused with blood components issued before the screening culture became positive.

RESULTS

Samples were collected from 22,057 PLT units. An initial reaction was seen in 84 (0.38%). Growth was confirmed in 70 of these. Of the associated PLT units, 26 had been issued or outdated at the time when the culture was found to be reactive, in 27 bacteria were found, and in 17 cultures were negative. The bacteria found were mainly from normal skin flora. Sixty-six patients received 75 blood components issued before the screening system alarmed. None of these patients had a transfusion reaction reported. The outdating fell to less than 5 percent.

CONCLUSION

A screening system for detection of bacterial contamination was implemented without increase in cost owing to extension of storage time to 7 days. Transfusion of several contaminated blood components was prevented.

Implementation of the INTERCEPT Blood System for Platelets into routine blood bank manufacturing procedures: evaluation of apheresis platelets

BACKGROUND AND OBJECTIVES

The INTERCEPT Blood System for Platelets utilizes amotosalen-HCl (S-59) in combination with ultraviolet A (UVA) light to inactivate viruses, bacteria, protozoa and leucocytes that may contaminate platelet concentrates (PCs). To facilitate implementation of this technique into routine blood bank manufacturing procedures, this study evaluated the impact of different time settings of photochemical treatment on in vitro platelet function.

MATERIALS AND METHODS

Platelets derived from apheresis (6.5-7.0 x 10(11) platelets) were resuspended in 240 ml of autologous plasma and 360 ml of platelet additive solution (PAS III) and split into two equal-sized PC units. Whereas one unit was not treated, the other was treated with 150 microm amotosalen and 3 J/cm2 UVA light followed by a compound adsorption device (CAD) step for reduction of residual amotosalen and photoproducts. In a first series of experiments (arm A, n = 7), PC units were photochemically treated after an overnight storage period of 16-23 h followed by a CAD step of 4 h. In a second series (arm B, n = 8), photochemical treatment occurred after a short storage time of 4 h with a subsequent CAD step of 16 h. Platelet function was evaluated by assaying blood gas analysis, glucose and lactate concentration, lactate dehydrogenase (LDH), hypotonic shock response (HSR) and the expression of CD62p, over a period of 7 days.

RESULTS

Neither of the photochemical treatment procedures showed differences for pH, pCO2, pO2, HCO3, glucose consumption or platelet activation until the end of day 7. Increased lactate values detected for the treated units of arm A at the end of the storage period were independent from the PCT time setting.

CONCLUSIONS

Photochemical pathogen inactivation with different initial resting periods between 4 and 23 h, and different CAD steps of 4 and 16 h, had no influence on the platelet in vitro function during 7 days of storage.

Endogenous microbial contamination of cultured autologous preparations in trials of cancer immunotherapy

BACKGROUND

Standardization of the manufacturing and processing of cellular immunotherapy products is necessary to ensure patient safety, establish efficacy, and demonstrate potency. Recognition of the autologous donor as a likely source of microbial contamination of cellular immunotherapy products may improve patient care and reduce expense to the laboratory.

METHODS

Data on 243 immunotherapy products manufactured in the authors' institution between December 1997 and June 2001 were retrospectively reviewed. Also reviewed were the case reports of four patients whose autologous immunotherapy products were contaminated.

RESULTS

Twenty-five (10%) of the 243 immunotherapy products processed were positive on one or more tests for microbial contamination. In six (24%) of the products, the source of microbial contamination was the autologous donor. In 17 of the remaining 19 products, test results were judged to be false-positive.

DISCUSSION

The unique processing techniques and stringent controls involved in the manufacture of cellular immunotherapy products may result in changes in the sources of microbial contamination routinely encountered. The identification of the autologous donor as a potential source of the microbial contamination of the product may assist the clinician and the laboratory in troubleshooting products with positive results on microbial sterility testing. Also, the number of false-positive results in this study indicates that further research is needed to maximize the specificity of testing while maintaining the present high sensitivity.

Pathogen inactivation of blood components: current status and introduction of an approach using riboflavin as a photosensitizer

Riboflavin is a naturally occurring compound and an essential human nutrient. Studies in the 1960s and 70s showed that it could be effective, when exposed to visible or UV light, in inactivating viruses and bacteria. This suggested to us that it could act as a photosensitizer useful in the inactivation of pathogens found in blood products, because of its nucleic acid specificity and its limited tendency toward indiscriminate oxidation. The riboflavin molecule is a planar, conjugated ring structure with a sugar side chain that confers water solubility. The planar portion is capable of intercalating between the bases of DNA or RNA. Light activated riboflavin oxidizes guanine in nucleic acids, preventing replication of the pathogen's genome. Gambro BCT is developing processes using riboflavin and light to inactivate pathogens in plasma, platelet, and red cell products. We call these Pathogen Eradication Technology (PET) processes. Riboflavin is non-toxic; it must be present in the body for good health. The photo-byproducts formed in the PET processes are lumichrome and protein adducts. The photodegradation of riboflavin in the body is clearly shown by the decrease in its concentration in neonates who are treated with intense visible light to break down circulating bilirubin, which their immature livers cannot yet handle. A definitive lookback study showed no difference in cancer rates between the 55,000 children receiving this therapy in Denmark from 1977 through 1989 and nonirradiated controls. Gambro BCT is developing specific riboflavin-based PET processes for platelet concentrates, fresh frozen plasma, and packed red blood cells. In each, the process is being optimized to achieve high levels of inactivation of specific pathogens, while maintaining acceptable levels of product quality and activity. Extra- and intracellular HIV, BVDV (a model for HCV), and pseudorabies virus (a herpes virus) have been used to guide process development and validation. We have demonstrated 4 to 7 log10 reductions in the titers of these viruses, when they are spiked into blood products and irradiated in the presence of riboflavin. Porcine parvovirus, a tight-capsid, nonenveloped virus is more resistant, a finding in all experimental inactivation approaches. A range of bacteria implicated in platelet and red cell transfusion injuries and deaths, including S. aureus, E. coli, K. pneumoniae, and Y. enterocolitica, are being used to validate antibacterial efficacy. The PET platelet process involves the addition of riboflavin to platelets in plasma, illumination of the product, storage of the product and transfusion without further manipulation. The lack of toxicity of the treatment byproducts permits this ease of use. Quality of the platelets throughout storage has been assessed by pH, PO2, lactate, hypotonic shock response, morphology, glucose, and GMP-140 expression. In vitro function is well maintained. The levels seen are within the range of those reported in commonly transfused products. Radiolabeled transfusion studies of treated platelets have been carried out in primates to determine a preliminary measure of their in-vivo circulation. The in vivo recoveries and survivals of treated and control platelets did not differ. This work suggests that an endogenous photosensitizer, riboflavin, which has an extremely good safety profile, can inactivate high levels of a broad range of viruses and bacteria in platelet concentrates, fresh frozen plasma, and in red blood cells, preserving the activity and functionality of the components. Planned animal and clinical studies are expected to solidify this suggestion into a well-characterized process which can be safely and readily applied to reduce the risks of transfusion transmitted disease.

Detecting bacteria in platelet concentrates by use of reagent strips

BACKGROUND

Iatrogenic infection of immunosuppressed or immunocompromised hosts secondary to receipt of blood components containing bacteria may result in serious adverse outcomes. Measurement of pH and glucose by use of inexpensive reagent strips has been proposed as a practical means of screening for bacteria in platelet concentrate (PC) units.

STUDY DESIGN AND METHODS

Glucose and pH were measured in 3093 PC units by use of reagent strips (Multistix, Bayer Corp.) to screen for bacterial content. Any PC classified by the reagent strip method as containing bacteria was subsequently cultured to confirm the presence and quantity of bacteria present.

RESULTS

Thirty of 3093 PC units were classified as containing bacteria by the reagent strip method. Two of the 30 PC units positive by the reagent strip method were also positive by standard bacterial culture technique. Bacillus cereus was isolated from both units.

CONCLUSION

Screening PC units by the reagent strip method resulted in 9.7 units per 1000 being wasted, but prevented two patients from receiving a PC unit containing B. cereus.

Platelet transfusion in the management of severe thrombocytopenia in neonatal intensive care unit patients

Platelet transfusions are frequently given to neonatal intensive care unit (NICU) patients with severe thrombocytopenia (platelets less than 50 x 10(9) L(-1)) but no study has assessed whether this is clinically appropriate. To address this we conducted a retrospective review of platelet transfusion practice in patients developing severe thrombocytopenia over 3 years in a single NICU. Out of 901 admissions, 53 (6%) developed severe thrombocytopenia. Twenty-seven neonates received a total of 63 platelet transfusions, the main triggers being: platelet count less than 30 x 10(9) L(-1) (all patients), or less than 50 x 10(9) L(-1) in those with previous haemorrhage or clinical instability. No major haemorrhage occurred during severe thrombocytopenia either in neonates in whom platelet transfusions were withheld (26/53) or in neonates given platelets who survived to discharge (22/27). Five preterm neonates given platelets died but all had overwhelming sepsis or necrotizing enterocolitis and none died directly as a result of haemorrhage. Although the widely used liberal triggers for neonatal platelet transfusion highlighted in this review reflect available guidelines, and represent cautious ('safe') haemostatic practice, they are likely to result in unnecessary transfusion for a significant number of NICU patients. Improved practice requires definition of a safe lower limit for platelet count in stable neonates; effective platelet transfusion strategies for sick neonates; and improved therapies for conditions precipitating severe thrombocytopenia.

New strategies for prophylactic platelet transfusion in patients with hematologic diseases

There is an increasing demand for platelet transfusions due to intensive chemotherapy and blood stem cell or bone marrow transplantation for the treatment of hematologic and oncologic diseases. There has been a long-lasting debate over whether the traditional threshold for prophylactic platelet transfusion of 20,000/microl is really necessary to prevent hemorrhagic complications. During the last 10 years several studies with more than 1,000 patients together have proven the safety of a platelet transfusion trigger of 10,000/microl or even lower when patients are clinically stable without active bleeding. This experience has been mostly gathered in patients with acute leukemia. But this stringent platelet transfusion policy can be used also after blood stem cell and bone marrow transplantation. In stable patients with aplastic anemia and myelodysplasia, prophylactic transfusions should be replaced in most patients by a therapeutic transfusion strategy. Such restrictive platelet transfusion strategies decrease the risk of infectious disease transmission, immunization, and febrile transfusion reactions. Besides reduced hospital visits and a shorter hospital stay for the patients, the costs for platelet transfusions are lowered by 20%-30% compared with traditional transfusion strategies. The decision to administer platelet transfusions should incorporate individual clinical characteristics of the patients and not simply be a reflexive reaction to the platelet count. Further clinical studies are needed to answer the still open question of whether patients with acute leukemia should also be transfused therapeutically rather than prophylactically when they are in stable condition without signs of active bleeding.

Transfusion-transmitted bacterial infection in the United States, 1998 through 2000

BACKGROUND

Bacterial contamination of blood components can result in transfusion-transmitted infection, but the risk is not established.

STUDY DESIGN AND METHODS

Suspected cases of transfusion-transmitted bacteremia were reported to the CDC by participating blood collection facilities and transfusion services affiliated with the American Red Cross, AABB, or Department of Defense blood programs from 1998 through 2000. A case was defined as any transfusion reaction meeting clinical criteria in which the same organism species was cultured from a blood component and from recipient blood, with the organism pair confirmed as identical by molecular typing.

RESULTS

There were 34 cases and 9 deaths. The rate of transfusion-transmitted bacteremia (in events/million units) was 9.98 for single-donor platelets, 10.64 for pooled platelets, and 0.21 for RBC units; for fatal reactions, the rates were 1.94, 2.22, and 0.13, respectively. Patients at greatest risk for death received components containing gram-negative organisms (OR, 7.5; 95% CI, 1.3-64.2; p = 0.009).

CONCLUSION

Bacterial contamination of blood is an important cause of transfusion-transmitted infection; infection risk from platelet transfusion is higher compared with that from RBCs, and, overall, the risk of infection from bacterial contamination now may exceed that from viral agents. Recipients of components containing gram-negative organisms are at highest risk for transfusion-related death. The results of this study may help direct efforts to improve transfusion-related patient safety.

Bacterial contamination of platelet concentrates: incidence, significance, and prevention

Severe transfusion reactions associated with bacteria and/or their products, during or following a blood transfusion, were one of the earliest recognized complications of allogeneic blood transfusions. Bacterial contamination of blood products has thus been a problem for many decades and at present is likely the most common microbiological cause of transfusion-associated morbidity and mortality. Transfusion-associated sepsis due to contaminated platelet concentrates appears to be much more common than that due to contaminated red blood cells. The overall incidence of contaminated cellular blood products is approximately 1 in 3,000. However, transfusion to a recipient of a contaminated platelet unit may not necessarily be associated with clinically apparent morbidity, because the majority of contaminated platelet units contain relatively few organisms. In a minority of instances, contaminated units contain large numbers of potentially virulent bacteria, as well as endotoxins, and their transfusion is often associated with significant recipient morbidity and mortality. The incidence of severe septic episodes has not been clearly established, but is probably of the order of 1 per 50,000 platelet units transfused. With heightened awareness in recent years of the possibility that platelet transfusion-associated septic episodes can occur, a variety of measures have been proposed, and in some cases implemented, to try to prevent and control this transfusion risk.

Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports

OBJECTIVE

To receive and collate reports of death or major complications of transfusion of blood or components.

DESIGN

Haematologists were invited confidentially to report deaths and major complications after blood transfusion during October 1996 to September 1998.

SETTING

Hospitals in United Kingdom and Ireland.

SUBJECTS

Patients who died or experienced serious complications, as defined below, associated with transfusion of red cells, platelets, fresh frozen plasma, or cryoprecipitate.

MAIN OUTCOME MEASURES

Death, "wrong" blood transfused to patient, acute and delayed transfusion reactions, transfusion related acute lung injury, transfusion associated graft versus host disease, post-transfusion purpura, and infection transmitted by transfusion. Circumstances relating to these cases and relative frequency of complications.

RESULTS

Over 24 months, 366 cases were reported, of which 191 (52%) were "wrong blood to patient" episodes. Analysis of these revealed multiple errors of identification, often beginning when blood was collected from the blood bank. There were 22 deaths from all causes, including three from ABO incompatibility. There were 12 infections: four bacterial (one fatal), seven viral, and one fatal case of malaria. During the second 12 months, 164/424 hospitals (39%) submitted a "nil to report" return.

CONCLUSIONS

Transfusion is now extremely safe, but vigilance is needed to ensure correct identification of blood and patient. Staff education should include awareness of ABO incompatibility and bacterial contamination as causes of life threatening reactions to blood.

Transfusion-transmitted diseases: risks, prevention and perspectives

During the past decades major improvements in blood safety have been achieved, both in developed and developing countries. The introduction of donor counseling and screening for different pathogens has made blood a very safe product, especially in developed countries. However, even in these countries, there is still a residual risk for the transmission of several pathogens. For viruses such as the human immunodeficiency virus (HIV), and the hepatitis viruses B and C, this is due mainly to window-period donations. Furthermore, the threat of newly emerging pathogens which can affect blood safety is always present. For example, the implications of the agent causing new variant Creutzfeld-Jakob disease for transfusion practice are not yet clear. Finally, there are several pathogens, e.g. CMV and parvo B19, which are common in the general donor population, and might pose a serious threat in selected groups of immunosuppressed patients. In the future, further improvements in blood safety are expected from the introduction of polymerase chain reaction for testing and from the implementation of photochemical decontamination for cellular blood products. The situation in transfusion medicine in the developing world is much less favorable, due mainly to a higher incidence and prevalence of infectious diseases.

Conserved structural features in eukaryotic and prokaryotic fucosyltransferases

Fucosyltransferases are the enzymes transferring fucose from GDP-Fuc to Gal in an alpha1,2-linkage and to GlcNAc in alpha1,3-, alpha1,4-, or alpha1,6-linkages. Since all fucosyltransferases utilize the same nucleotide sugar, their specificity will probably reside in the recognition of the acceptor and in the type of linkage formed. A search of nucleotide and protein databases yielded more than 30 sequences of fucosyltransferases originating from mammals, chicken, nematode, and bacteria. On the basis of protein sequence similarities, these enzymes can be classified into four distinct families: (1) the alpha-2-fucosyltransferases, (2) the alpha-3-fucosyltransferases, (3) the mammalian alpha-6-fucosyltransferases, and (4) the bacterial alpha-6-fucosyltransferases. Nevertheless, using the sensitive hydrophobic cluster analysis (HCA) method, conserved structural features as well as a consensus peptide motif have been clearly identified in the catalytic domains of all alpha-2 and alpha-6-fucosyltranferases, from prokaryotic and eukaryotic origin, that allowed the grouping of these enzymes into one superfamily. In addition, a few amino acids were found strictly conserved in this family, and two of these residues have been reported to be essential for enzyme activity for a human alpha-2-fucosyltransferase. The alpha-3-fucosyltransferases constitute a distinct family as they lack the consensus peptide, but some regions display similarities with the alpha-2 and alpha-6-fucosyltranferases. All these observations strongly suggest that the fucosyltransferases share some common structural and catalytic features.

A system for the supply of platelets suspended in a storage medium including buffy-coat-derived platelet concentrates in combination with "split" apheresis platelets

Our objective was to create a system for the supply of platelet concentrates (PCs) based on leukocyte-filtered PCs suspended in a storage medium (PAS-II) including: (1) pooled buffy-coat-derived (BC) PCs and (2) "split" apheresis PCs. The same standards were intended for the two preparations with regard to composition and blood cell counts. In preliminary studies, similar in vitro data were found for leukocyte-filtered and non-filtered reference BC PCs. Slightly inferior in vitro results than for BC PCs restricted the shelf-life of apheresis PCs to 5 days compared to 7 days for BC PCs. With the present platelet supply system in use as a routine service for one year, the experience was very satisfactory, meeting the demands for PCs very efficiently and resulting in a low out-dating rate (5%).

Current methods for the preparation of platelet concentrates: laboratory and clinical aspects

Modern blood transfusion services are striving to attain the highest standards through continual quality improvement and ensure that a formalised quality system is in place in the organisation for time management and waste reduction. With respect to the production of platelet concentrates (PCs), semi-automated and automated procedures are now available which are convenient and allow the processing of multiple packs simultaneously or the production of multiple doses of PCs with low leucocyte content. Nevertheless, PCs are highly heterogeneous on the basis of cellular content and storage stability. Statistical process control (SPC) is essential to ensure that optimal quality is maintained. In the light of new developments in platelet production, their clinical effect should be reappraised. This article highlights some of the key features in the production of PCs, focusing on basic concepts and quality indicators which reflect in vivo functions. The potential for bacteriological contamination and future production strategies are briefly mentioned.

Transfusion transmitted Yersinia enterocolitica infection in New Zealand

AIMS

To update and summarise cases of transfusion-transmitted Yersinia enterocolitica infection in New Zealand and to evaluate critically suggested methods to reduce this rare but frequently fatal complication of blood transfusion.

METHODS

Case reports of four recent transfusion-transmitted Y. enterocolitica infections in New Zealand are given and previous reports reviewed. Literature review and evaluation of proposed methods to decrease the incidence of transfusing yersinia contaminated blood.

RESULTS

There have been eight cases of transfusion-transmitted Y. enterocolitica infection in New Zealand in the past five years. Four of the five deaths have been directly caused by the transfusion. This gives a transfusion incidence rate of one:65,000 and a fatality rate of one:104,000 units transfused. This fatality rate is more than 80 times higher than that reported in the United States.

CONCLUSIONS

Why the incidence of transfusion-transmitted yersinia is so high is not clear, since we do not store blood as long as many other countries, particularly the United States. In Auckland, however, the cases came at a time when the number of yersinia isolates from the community is reported to be rising. Many suggestions for the prevention of this problem have been put forward reflecting the fact that there is as yet no perfect solution. Those which are easy to implement and cheap to perform are largely already in place and investigation is continuing into the other alternatives.

Allogeneic transfusion risks in the surgical patient

The risk of blood transfusion-associated complications has been reduced in the past 10 years through technical advances in testing of blood, viral inactivation of noncellular blood components, enforcement of stringent donor selection criteria, and the use of alternatives to allogeneic transfusion. Even so, a zero-risk blood supply is unfeasible. The general public perceives infectious complications to be the most significant risk: although the greatest fear is associated with transmission of human immunodeficiency virus (HIV), at least three hepatitis viruses are transmissible by all blood components. Human immunodeficiency virus accounts for < 20 cases per year of transfusion-related acquired immunodeficiency syndrome in the United States. The three important noninfectious complications are alloimmunization, which is common but clinically insignificant; immunosuppression, the clinical significance of which is controversial; and graft-versus-host disease, a lethal complication most likely to affect patients who are immunosuppressed, have cancer, or are recipients of bone marrow transplants.

Retrograde transmission of Proteus mirabilis during platelet transfusion and the use of arbitrarily primed polymerase chain reaction for bacteria typing in suspected cases of transfusion transmission of infection

BACKGROUND

When bacteria are found, after a platelet transfusion, in the recipient's blood as well as in the platelet concentrate (PC), a causal relationship is normally suspected, with the PC as the causative agent. The other alternative, that the patient has bacteremia and contaminated the PC, is less well documented in the literature.

CASE REPORT

Arbitrarily primed polymerase chain reaction (AP-PCR) was used for testing strains of Proteus mirabilis isolated from a patient's blood before and after a platelet transfusion and from the PC. Because of a febrile reaction after a platelet transfusion, bacterial culture was performed on the PC used, showing growth of P. mirabilis. The same species was found in the patient's blood after the transfusion. Posttransfusion sepsis caused by a contaminated PC was suspected, and anti-sepsis treatment was given to the recipient. Later, it became apparent that the patient had had bacteremia before the transfusion and that P. mirabilis was one of the species in the isolate. With AP-PCR, the identity of the three P. mirabilis isolates could be distinguished.

CONCLUSION

AP-PCR is a useful technique for distinguishing the identity of bacterial isolates from patients and blood components. A patient with bacteremia can contaminate a PC in conjunction with a platelet transfusion. With AP-PCR, the PC could be ruled out as the cause of the posttransfusion sepsis.

Buffy-coat-derived platelet concentrates prepared from half-strength citrate CPD and CPD whole-blood units. Comparison between three additive solutions: in vitro studies

The in vitro effects of storage of platelets prepared from 4 or 6 pooled buffy coat (BC) units and stored in a platelet storage medium consisting of 30-40% of CPD plasma or alternatively half-strength citrate CPD (0.5 CPD) plasma and 60-70% of different alternative platelet additive solutions (PASs) were evaluated. Measurements of mean platelet volume, pH, pO2, pCO2, bicarbonate, glucose, lactate, ATP, total adenine nucleotide content, extracellular lactate dehydrogenase or adenylate kinase activity, as markers for disintegration of platelets, and extracellular beta-thromboglobulin, as a marker for activation of platelets, were included in the in vitro studies. Previous studies indicated that a reduction of the citrate concentration from the standard 21 to 8 mmol/l is associated with a significant reduction of the consumption of glucose and production of lactate. Alternatively, similar effects can be obtained by the addition of acetate. In a preliminary paired study, the effects of different concentrations of acetate were tested. In an additional paired study, the effects of CPD plasma in combination with either saline or a PAS containing NaCl (115.5 mmol/l), citrate (10 mmol/l), and acetate (30 mmol/l), pH 7.2 (PAS-2) were evaluated. 0.5CPD plasma in combination with either PAS-2 or a nonacetate PAS (PAS-1) were also tested. The storage of platelets in 0.5CPD plasma was used as a reference. The conclusions are: (1) A minimum acetate concentration of 30 mmol/l is needed to counteract the effects of citrate on the production of lactate. (2) pH and the bicarbonate buffering capacity are significantly better maintained in PAS-2 than in PAS-1.(ABSTRACT TRUNCATED AT 250 WORDS)