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O’Flaherty N, Bryce L, Nolan J, Lambert M. Changing Strategies for the Detection of Bacteria in Platelet Components in Ireland: From Primary and Secondary Culture (2010-2020) to Large Volume Delayed Sampling (2020-2023). Microorganisms 2023; 11:2765. [PMID: 38004776 PMCID: PMC10673373 DOI: 10.3390/microorganisms11112765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Bacterial contamination of platelet components (PC) poses the greatest microbial risk to recipients, as bacteria can multiply over the course of PC storage at room temperature. Between 2010 and 2020, the Irish Blood Transfusion Service (IBTS) screened over 170,000 buffy coat-derived pooled (BCDP) and single-donor apheresis platelets (SDAPs) with the BACT/ALERT 3D microbial detection system (Biomerieux, L'Etoile, France), using a two-step screening protocol which incorporated primary and secondary cultures. Although the protocol was successful in averting septic transfusion reactions (STRs), testing large sample volumes at later time points was reported to improve detection of bacterial contamination. A modified large-volume delayed sampling (LVDS)-type protocol was adopted in 2020, which in the case of SDAP was applied to collections rather than individual splits (2020-2023, 44,642 PC screened). Rates of bacterial contamination for BCDP were 0.125% on Day-2, 0.043% on Day-4 vs. 0.191% in the post-LVDS period. SDAP contamination rates in the pre-LVDS period were 0.065% on Day-1, 0.017% on Day-4 vs. 0.072% in the post-LVDS period. Confirmed STRs were absent, and the interdiction rate for possibly contaminated SDAP was over 70%. In the post-LVDS period, BCDPs had a higher total positivity rate than SDAPs, 0.191% (1:525) versus 0.072% (1:1385), respectively, (chi-squared 12.124, 1 df, p = 0.0005). The majority of organisms detected were skin-flora-type, low pathogenicity organisms, including coagulase-negative staphylococci and Cutibacterium acnes, with little change in the frequency of clinically significant organisms identified over time. Both protocols prevented the issue of potentially harmful components contaminated (rarely) with a range of pathogenic bacteria, including Escherichia coli, Serratia marcesens, Staphylococcus aureus, and streptococci. Culture positivity of outdates post-LVDS whereby 100% of expired platelets are retested provides a residual risk estimate of 0.06% (95% CI 0.016-0.150). However, bacterial contamination rates in expired platelets did not demonstrate a statistically significant difference between the pre-LVDS 0.100% (CI 0.033-0.234) and post-LVDS 0.059% (0.016-0.150) periods (chi-squared = 0.651, 1 df, p = 0.42).
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Affiliation(s)
- Niamh O’Flaherty
- Irish Blood Transfusion Service, National Blood Centre, D08 NH5R Dublin, Ireland; (L.B.); (M.L.)
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2
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Laermans J, Van Remoortel H, Scheers H, Avau B, Georgsen J, Nahirniak S, Shehata N, Stanworth SJ, De Buck E, Compernolle V, Vandekerckhove P. Cost Effectiveness of Different Platelet Preparation, Storage, Selection and Dosing Methods in Platelet Transfusion: A Systematic Review. PHARMACOECONOMICS - OPEN 2023; 7:679-708. [PMID: 37365482 PMCID: PMC10471540 DOI: 10.1007/s41669-023-00427-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Evidence-based guidelines on platelet transfusion therapy assist clinicians to optimize patient care, but currently do not take into account costs associated with different methods used during the preparation, storage, selection and dosing of platelets for transfusion. This systematic review aimed to summarize the available literature regarding the cost effectiveness (CE) of these methods. METHODS Eight databases and registries, as well as 58 grey literature sources, were searched up to 29 October 2021 for full economic evaluations comparing the CE of methods for preparation, storage, selection and dosing of allogeneic platelets intended for transfusion in adults. Incremental CE ratios, expressed as standardized cost (in 2022 EUR) per quality-adjusted life-year (QALY) or per health outcome, were synthesized narratively. Studies were critically appraised using the Philips checklist. RESULTS Fifteen full economic evaluations were identified. Eight investigated the costs and health consequences (transfusion-related events, bacterial and viral infections or illnesses) of pathogen reduction. The estimated incremental cost per QALY varied widely from EUR 259,614 to EUR 36,688,323. For other methods, such as pathogen testing/culturing, use of apheresis instead of whole blood-derived platelets, and storage in platelet additive solution, evidence was sparse. Overall, the quality and applicability of the included studies was limited. CONCLUSIONS Our findings are of interest to decision makers who consider implementing pathogen reduction. For other preparation, storage, selection and dosing methods in platelet transfusion, CE remains unclear due to insufficient and outdated evaluations. Future high-quality research is needed to expand the evidence base and increase our confidence in the findings.
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Affiliation(s)
- Jorien Laermans
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium.
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Hans Scheers
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Bert Avau
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
| | - Jørgen Georgsen
- Department of Clinical Immunology, South Danish Transfusion Service & Tissue Center, Odense University Hospital, Odense, Denmark
| | - Susan Nahirniak
- Faculty of Medicine, University of Alberta, Edmonton, Canada
- Transfusion and Transplantation Medicine, Alberta Precision Laboratories, Alberta, Canada
| | - Nadine Shehata
- Laboratory Medicine and Pathobiology, Department of Medicine, Institute of Health Policy Management and Evaluation, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Emmy De Buck
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Veerle Compernolle
- Blood Services, Belgian Red Cross, Mechelen, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Philippe Vandekerckhove
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
- Belgian Red Cross, Mechelen, Belgium
- Division of Epidemiology and Biostatistics, Department of Global health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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3
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Ness PM. The pursuit of platelet safety. Transfusion 2022; 62:1302-1304. [PMID: 35506509 PMCID: PMC9320799 DOI: 10.1111/trf.16898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 01/01/2023]
Affiliation(s)
- Paul M Ness
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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4
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Kamel H, Ramirez-Arcos S, McDonald C. The international experience of bacterial screen testing of platelet components with automated microbial detection systems: An update. Vox Sang 2022; 117:647-655. [PMID: 35178718 DOI: 10.1111/vox.13247] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/23/2021] [Accepted: 12/04/2021] [Indexed: 12/22/2022]
Abstract
In 2014, the bacterial subgroup of the Transfusion-Transmitted Infectious Diseases working party of ISBT published a review on the International Experience of Bacterial Screen Testing of Platelet Components (PCs) with an Automated Microbial Detection System. The purpose of this review, which is focused on publications on or after 2014, is to summarize recent experiences related to bacterial contamination of PCs and the use of an automated culture method to safeguard the blood supply. We first reviewed septic transfusion reactions after PC transfusion as reported in national haemovigilance systems along with a few reports from various countries on bacterial contamination of blood products. Next, we reviewed PC automated culture protocols employed by national blood services in the United Kingdom, Australia, Canada and large blood collection organization and hospital transfusion services in the United States. Then, we acknowledged the limitations of currently available culture methodologies in abating the risks of transfusion-transmitted bacterial infection, through a review of case reports. This review was neither meant to be critical of the literature reviewed nor meant to identify or recommend a best practice. We concluded that significant risk reduction can be achieved by one or a combination of more than one strategy. No one approach is feasible for all institutions worldwide. In selecting strategies, institutions should consider the possible impact on platelet components availability and entertain a risk-based decision-making approach that accounts for operational, logistical and financial factors.
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Affiliation(s)
- Hany Kamel
- Medical Affairs, Vitalant, Scottsdale, Arizona, USA
| | - Sandra Ramirez-Arcos
- Medical Affairs and Innovation, Canadian Blood Services, Ottawa, Canada.,University of Ottawa, Ottawa, Canada
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5
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Prioli KM, Abersone I, Kopko PM, Herman JH, Custer B, Pizzi LT. Economic implications of FDA platelet bacterial guidance compliance options: Comparison of single-step strategies. Transfusion 2022; 62:365-373. [PMID: 34997763 PMCID: PMC9303536 DOI: 10.1111/trf.16778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bloodborne pathogens pose a major safety risk in transfusion medicine. To mitigate the risk of bacterial contamination in platelet units, FDA issues updated guidance materials on various bacterial risk control strategies (BRCS). This analysis presents results of a budget impact model updated to include 5- and 7-day pathogen reduced (PR) and large volumed delayed sampling (LVDS) BRCS. STUDY DESIGN AND METHODS Model base-case parameter inputs were based on scientific literature, a survey distributed to 27 US hospitals, and transfusion experts' opinion. The outputs include hospital budget and shelf-life impacts for 5- and 7-day LVDS, and 5- and 7-day PR units under three different scenarios: (1) 100% LVDS, (2) 100% PR, and (3) mix of 50% LVDS - and 50% PR. RESULTS Total annual costs from the hospital perspective were highest for 100% LVDS platelets (US$2.325M) and lowest for 100% PR-7 units (US$2.170M). Net budget impact after offsetting annual costs by outpatient reimbursements was 5.5% lower for 5-day PR platelets as compared to 5-day LVDS (US$1.663 vs. US$1.760M). A mix of 7-day LVDS and 5-day PR platelets had net annual costs that were 1.3% lower than for 100% 7-day LVDS, but 1.3% higher than for 100% 5-day PR. 7-day PR platelets had the longest shelf life (4.63 days), while 5-day LVDS had the shortest (2.00 days). DISCUSSION The model identifies opportunities to minimize transfusion center costs for 5- and 7-day platelets. Budget impact models such as this are important for understanding the financial implications of evolving FDA guidance and new platelet technologies.
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Affiliation(s)
- Katherine M Prioli
- Center for Health Outcomes, Policy and Economics, Rutgers University, Piscataway, New Jersey, USA
| | - Ilze Abersone
- Center for Health Outcomes, Policy and Economics, Rutgers University, Piscataway, New Jersey, USA
| | - Patricia M Kopko
- Division of Transfusion Medicine, University of California San Diego, San Diego, California, USA
| | - Jay H Herman
- Division of Transfusion Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian Custer
- Vitalant Research Institute, San Francisco, California, USA.,Department of Laboratory Medicine, UCSF, San Francisco, California, USA
| | - Laura T Pizzi
- Center for Health Outcomes, Policy and Economics, Rutgers University, Piscataway, New Jersey, USA
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Fachini RM, Fontão-Wendel R, Achkar R, Scuracchio P, Brito M, Amaral M, Wendel S. The 4-Year Experience with Implementation and Routine Use of Pathogen Reduction in a Brazilian Hospital. Pathogens 2021; 10:pathogens10111499. [PMID: 34832654 PMCID: PMC8621808 DOI: 10.3390/pathogens10111499] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: We reviewed the logistics of the implementation of pathogen reduction (PR) using the INTERCEPT Blood System™ for platelets and the experience with routine use and clinical outcomes in the patient population at the Sírio-Libanês Hospital of São Paulo, Brazil. (2) Methods: Platelet concentrate (PC), including pathogen reduced (PR-PC) production, inventory management, discard rates, blood utilization, and clinical outcomes were analyzed over the 40 months before and after PR implementation. Age distribution and wastage rates were compared over the 10 months before and after approval for PR-PC to be stored for up to seven days. (3) Results: A 100% PR-PC inventory was achieved by increasing double apheresis collections and production of double doses using pools of two single apheresis units. Discard rates decreased from 6% to 3% after PR implementation and further decreased to 1.2% after seven-day storage extension for PR-PCs. The blood utilization remained stable, with no increase in component utilization. A significant decrease in adverse transfusion events was observed after the PR implementation. (4) Conclusion: Our experience demonstrates the feasibility for Brazilian blood centers to achieve a 100% PR-PC inventory. All patients at our hospital received PR-PC and showed no increase in blood component utilization and decreased rates of adverse transfusion reactions.
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7
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Moore RA, Schmidt RL, Metcalf RA. The impact of the sample time of secondary bacterial culture on the risk of exposure to contaminated platelet components: A mathematical analysis. Transfusion 2021; 61:873-882. [PMID: 33429466 DOI: 10.1111/trf.16258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The US Food and Drug Administration (FDA) issued a guidance for bacterial risk control strategies for platelet components in September 2019 that includes strategies using secondary bacterial culture (SBC). While an SBC likely increases safety, the optimal timing of the SBC is unknown. Our aim was to develop a model to provide insight into the best time for SBC sampling. STUDY DESIGN AND METHODS We developed a mathematical model based on the conditional probability of a bacterial contamination event. The model evaluates the impact of secondary culture sampling time over a range of bacterial contamination scenarios (lag and doubling times), with the primary outcome being the optimal secondary sampling time and the associated risk. RESULTS Residual risk of exposure decreased with increasing inoculum size, later sampling times for primary culture, and using higher thresholds of exposure (in colony-forming units per milliliter). Given a level of exposure, the optimal sampling time for secondary culture depended on the timing of primary culture and on the expiration time. In general, the optimal sampling time for secondary culture was approximately halfway between the time of primary culture and the expiration time. CONCLUSION Our model supports that the FDA guidance is quite reasonable and that sampling earlier in the specified secondary culture windows may be most optimal for safety.
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Affiliation(s)
- Ryleigh A Moore
- Department of Mathematics, University of Utah, Salt Lake City, Utah, USA
| | - Robert L Schmidt
- ARUP Laboratories, Salt Lake City, Utah, USA.,Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Ryan A Metcalf
- ARUP Laboratories, Salt Lake City, Utah, USA.,Department of Pathology, University of Utah, Salt Lake City, Utah, USA
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8
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Fadeyi EA, Wagner SJ, Goldberg C, Lu T, Young P, Bringmann PW, Meier NM, Namen AM, Benjamin RJ, Palavecino E. Fatal sepsis associated with a storage container leak permitting platelet contamination with environmental bacteria after pathogen reduction. Transfusion 2020; 61:641-648. [PMID: 33616945 DOI: 10.1111/trf.16210] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/04/2020] [Accepted: 11/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pathogen reduction technology and enhanced bacterial culture screening promise to significantly reduce the risk of transfusion-associated septic reactions due to contaminated platelets. Recent reports suggest that these interventions lack efficacy for post-collection and processing contamination with environmental organisms if the storage bag integrity is compromised. CASE REPORT We report a fatal septic transfusion reaction in a 63-year-old patient with chronic kidney and liver disease who received a pathogen reduced platelet transfusion in anticipation of surgery. METHODS The residual platelet concentrate was cultured, with the detected microorganisms undergoing 16S genotype sequencing. Separate pathogen reduction studies were performed on the recovered bacteria, including assessment for amotosalen photoproducts. The storage container was subjected to pressure testing and microscopic examination. Environmental culture screening was performed at the hospital. RESULTS Gram negative rods were detected in the platelet unit and cultures of both platelet component and the patient's blood grew Acinetobacter baumannii complex, Leclercia adecarboxylata and Staphylococcus saprophyticus. These strains were effectively inactivated with >7.2, 7.7, and >7.1 log10 kill, respectively. The platelet storage container revealed a leak visible only on pressure testing. Hospital environmental cultures were negative and the contamination source is unknown. A. baumannii complex and S. saprophyticus 16S genotyping sequences were identical to those implicated in a previously reported septic reaction. CONCLUSION Findings are compatible with post-processing environmental contamination of a pathogen reduced platelet concentrate via a non-visible, acquired storage container leak. Efforts are warranted to actively prevent damage to, and detect defects in, platelet storage containers, and to store and transport components in clean environments.
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Affiliation(s)
- Emmanuel A Fadeyi
- Department of Pathology and Laboratory Medicine, Wake Forest University School of Medicine Winston-Salem, Winston-Salem, North Carolina, USA
| | - Stephen J Wagner
- American National Red Cross, Washington, District of Columbia, USA
| | - Corinne Goldberg
- American National Red Cross, Washington, District of Columbia, USA
| | - Thea Lu
- Cerus Corporation, Concord, California, USA
| | - Pampee Young
- American National Red Cross, Washington, District of Columbia, USA
| | | | - Nathaniel M Meier
- Department of Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Andrew M Namen
- Department of Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Elizabeth Palavecino
- Department of Pathology and Laboratory Medicine, Wake Forest University School of Medicine Winston-Salem, Winston-Salem, North Carolina, USA
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9
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O'Brien KL, Chen Y, Uhl L. Assessing inpatient platelet ordering practice: evaluation of computer provider order entry overrides. Vox Sang 2020; 116:702-712. [PMID: 33615489 DOI: 10.1111/vox.13050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Judicious utilization of platelet products protects a limited resource and mitigates risks of transfusion. At many institutions, computer physician order entry systems provide prompts to guide transfusion decisions; many capture the indication for transfusion, and generate metadata when orders are dissonant with guidelines. We conducted a retrospective review to examine adherence to and overrides of hospital guidelines for platelet transfusion to identify opportunities for improved transfusion practice. MATERIALS AND METHODS Physician override reports (1/1/2018-3/31/2019) were examined and physician-entered justification comments accompanying override orders were extracted, in addition to patient-specific data (clinical service, age, sex, and pretransfusion platelet count). Two transfusion medicine physicians independently assessed comments in context of patient data and institutional guidelines and categorized as: indicated, protocol driven, or not indicated. Following adjudication, consensus was reached between the two reviewers. Override keyword frequencies were also determined. RESULTS Over 15-months, 1373 override orders were placed for 558 unique patients (25% of all adult inpatient platelet transfusions). haematology/oncology providers placed 573 (42%) override orders (261 unique patients), 46% of which were categorized as "not indicated", based on consensus review. Overall, 470 (34%) override orders were categorized as "not indicated". Examples of recurring key words included "bleeding/risk of bleeding", "falling platelet count", "platelet goal of XX". CONCLUSIONS A large percentage of override orders for platelet transfusions were determined to be "not indicated" and out of compliance with institutional guidelines. The metadata captured identified concerns regarding clinical transfusion practice and opportunities for revised indications (e.g. threshold for retinal haemorrhage).
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Affiliation(s)
- Kerry L O'Brien
- Department of Pathology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yigu Chen
- Department of Pathology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Lynne Uhl
- Department of Pathology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
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10
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Fenwick AJ, Gehrie EA, Marshall CE, Tobian AAR, Shrestha R, Kacker S, Brunker PAR, Shifflett L, Carroll KC, Gozelanczyk D, Goel R, Ness PM, Bloch EM. Secondary bacterial culture of platelets to mitigate transfusion-associated sepsis: A 3-year analysis at a large academic institution. Transfusion 2020; 60:2021-2028. [PMID: 32750171 PMCID: PMC10007897 DOI: 10.1111/trf.15978] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/16/2020] [Accepted: 05/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND In 2019, the United States Food and Drug Administration published its final recommendations to mitigate bacterial contamination of platelets. We sought to evaluate our secondary bacterial culture (SBC) strategy in light of those recommendations. STUDY DESIGN AND METHODS A retrospective analysis was conducted of SBC data (October 2016-2019) at our institution. SBC was performed upon receipt (Day 3 after collection); 5 mL of platelet product was inoculated aseptically into an aerobic bottle and incubated at 35°C for 3 days. For 8 months, a 10-mL inoculum was trialed. No quarantine was applied. All positive cultures underwent Gram staining and repeat culture of the platelet product (if available). A probable true positive was defined as concordant positive culture between the initial and repeat culture. The incidence of probable true- and false-positive cultures were reported descriptively and differences evaluated by sampling volume. RESULTS Over 3 years, 55 896 platelet products underwent SBC, yielding 30 initial positive results (approx. 1/1863 platelets); 25 (83.3%) signaled within 24 hours of SBC. The rates of probable true positive, false positive, and indeterminate for 5 mL were 0.027% (1/3771), 0.002% (1/45 251) and 0.018% (1/5656), respectively. The respective rates for 10 mL were 0.018% (1/5323), 0.07% (1/1521), and 0%. Seven of eight (87.5%) false-positive SBCs occurred with a 10-mL inoculum. No septic transfusion reactions were reported. CONCLUSION SBC continues to interdict bacterially contaminated units of platelets. Our findings suggest higher rates of false positivity using large-volume inocula.
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Affiliation(s)
- Alexander J Fenwick
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eric A Gehrie
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christi E Marshall
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ruchee Shrestha
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Seema Kacker
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Patricia A R Brunker
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,American Red Cross Biomedical Services, Greater Chesapeake & Potomac Region, Baltimore, Maryland, USA
| | - Lisa Shifflett
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen C Carroll
- Division of Microbiology, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Donna Gozelanczyk
- American Red Cross Biomedical Services, Greater Chesapeake & Potomac Region, Baltimore, Maryland, USA
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Mississippi Valley Regional Blood Center, Springfield, IL, USA
| | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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11
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Walker BS, White SK, Schmidt RL, Metcalf RA. Residual bacterial detection rates after primary culture as determined by secondary culture and rapid testing in platelet components: A systematic review and meta-analysis. Transfusion 2020; 60:2029-2037. [PMID: 32757411 DOI: 10.1111/trf.16001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Primary culture alone was a bacterial risk control strategy intended to facilitate interdiction of contaminated platelets (PLTs). A September 2019 FDA guidance includes secondary testing options to enhance safety. Our objective was to use meta-analysis to determine residual contamination risk after primary culture using secondary culture and rapid testing. STUDY DESIGN AND METHODS A December 2019 literature search identified articles on PLT bacterial detection rates using primary culture and a secondary testing method. We used meta-analysis to estimate secondary testing detection rates after a negative primary culture. We evaluated collection method, sample volume, sample time, and study date as potential sources of heterogeneity. RESULTS The search identified 6102 articles; 16 were included for meta-analysis. Of these, 12 used culture and five used rapid testing as a secondary testing method. Meta-analysis was based on a total of 103 968 components tested by secondary culture and 114 697 by rapid testing. The residual detection rate using secondary culture (DRSC ) was 0.93 (95% CI, 0.24-0.6) per 1000 components, while residual detection rate using rapid testing (DRRT ) was 0.09 (95% CI, 0.01-0.25) per 1000 components. Primary culture detection rate was the only statistically significant source of heterogeneity. CONCLUSION We evaluated bacterial detection rates after primary culture using rapid testing and secondary culture. These results provide a lower and upper bound on real-world residual clinical risk because these methods are designed to detect high-level exposures or any level of exposure, respectively. Rapid testing may miss some harmful exposures and secondary culture may identify some clinically insignificant exposures.
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Affiliation(s)
| | - Sandra K White
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Robert L Schmidt
- ARUP Laboratories, Salt Lake City, Utah, USA.,Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Ryan A Metcalf
- ARUP Laboratories, Salt Lake City, Utah, USA.,Department of Pathology, University of Utah, Salt Lake City, Utah, USA
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12
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Fridey JL, Stramer SL, Nambiar A, Moayeri M, Bakkour S, Langelier C, Crawford E, Lu T, Lanteri MC, Kamm J, Miller S, Wagner SJ, Benjamin RJ, Busch MP. Sepsis from an apheresis platelet contaminated with Acinetobacter calcoaceticus/baumannii complex bacteria and Staphylococcus saprophyticus after pathogen reduction. Transfusion 2020; 60:1960-1969. [PMID: 32738079 DOI: 10.1111/trf.15951] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Strategies to reduce platelet (PLT) bacterial contamination include donor screening, skin disinfection, sample diversion, bacterial culture, pathogen reduction (PR), and day-of-transfusion tests. We report bacterial sepsis following a pathogen-reduced PLT transfusion. CASE REPORT An adult male with relapsed acute lymphoblastic leukemia was successfully treated for central catheter-associated Staphylococcus aureus bacteremia. A peripherally inserted central catheter (PICC) was placed. Chills, rigors, and flushing developed immediately after PICC-infused pathogen-reduced PLTs, progressing to septic shock requiring intensive care management. METHODS PICC and peripheral blood (PB), transfused bag saline flushes (TBFs), environmental samples, and the pathogen-reduced untransfused co-component (CC) were cultured. Plasma metagenomic and bacterial isolate whole-genome sequencing; PLT mitochondrial DNA (mtDNA) testing of untransfused CC and TBF; CC testing for amotosalen (S-59)/S-59 photoproducts; isolate PR studies (INTERCEPT); and TBF polymerase chain reaction for recipient Y-chromosome DNA were performed. RESULTS PB and PICC cultures grew Acinetobacter calcoaceticus/baumannii complex (ACBC). TBF was gram-positive; mass spectrometry identified ACBC and Staphylococcus saprophyticus (SS). CC Gram stain and cultures were negative. Environmental cultures, some done after decontamination, were ACBC/SS negative. Posttransfusion patient plasma and TBF ACBC sequences were genetically identical. No Y-chromosome signal was detected in TBF. S-59 photoproducts and evidence of mtDNA amplification inhibition were found in the CC. Spiking PR studies showed >5.9-log inactivation for both isolates. Donor skin cultures for Acinetobacter were negative. CONCLUSION CC sterility, PR studies, residual S-59 photoproducts, and mtDNA amplification inhibition suggest successful PR. Unidentified environmental sources and inherent or acquired bag defects may have contributed to postmanufacturing pathogen-reduced PLT contamination.
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Affiliation(s)
- Joy L Fridey
- Southern California Region, American Red Cross, Pomona, California, USA
| | - Susan L Stramer
- Scientific Affairs, American Red Cross, Gaithersburg, Maryland, USA
| | - Ashok Nambiar
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Morvarid Moayeri
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Sonia Bakkour
- Vitalant Research Institute, San Francisco, California, USA
| | - Charles Langelier
- Chan Zuckerberg Biohub, University of California San Francisco, San Francisco, California, USA
| | - Emily Crawford
- Chan Zuckerberg Biohub, University of California San Francisco, San Francisco, California, USA
| | - Thea Lu
- Cerus Corporation, Concord, California, USA
| | | | - Jack Kamm
- Chan Zuckerberg Biohub, University of California San Francisco, San Francisco, California, USA
| | - Steve Miller
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Stephen J Wagner
- Transfusion Innovation, American Red Cross, Rockville, Maryland, USA
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Walker BS, Schmidt RL, Fisher MA, White SK, Blaylock RC, Metcalf RA. The comparative safety of bacterial risk control strategies for platelet components: a simulation study. Transfusion 2020; 60:1723-1731. [PMID: 32632927 DOI: 10.1111/trf.15919] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/07/2020] [Accepted: 05/13/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bacterial contamination of platelets is a problem that can lead to harmful septic transfusion reactions. The US Food and Drug Administration published a guidance in September 2019 detailing several permissible risk control strategies. Our objective was to compare the safety of each bacterial testing strategy for apheresis platelets. STUDY DESIGN AND METHODS We used simulation to compare safety of the nine risk control strategies involving apheresis platelet testing. The primary outcome was the risk of exposure. An exposure event occurred if a patient received platelets exceeding a specific contamination threshold (>0, 103 , and 105 colony-forming units (CFU/mL). We generated a range of bacterial contamination scenarios (inoculum size, doubling time, lag time) and compared risk of exposure for each policy in each contamination scenario. We then computed the average risk difference over all scenarios. RESULTS At the 0 CFU/mL exposure threshold, two-step policies that used secondary culture ranked best (all top three), while single-step 24-hour culture with 3-day expiration ranked last (ninth). This latter policy performed well (median rank of 1) at both the 103 and 105 CFU/mL thresholds, but 48-hour culture with 7-day expiration performed relatively poorly. At these higher thresholds, median ranks of two-step policies that used secondary culture were again top three. Two-step policies that used rapid testing improved at the higher (105 CFU/mL) harm threshold, with median rankings between 1 and 5. CONCLUSION Two-step policies that used secondary culture were generally safer than single-step policies. Performance of two-step policies that used rapid testing depended on the CFU per milliter threshold of exposure used.
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Affiliation(s)
- Brandon S Walker
- Department of Pathology and ARUP Laboratories, University of Utah, Salt Lake City, Utah, USA
| | - Robert L Schmidt
- Department of Pathology and ARUP Laboratories, University of Utah, Salt Lake City, Utah, USA
| | - Mark A Fisher
- Department of Pathology and ARUP Laboratories, University of Utah, Salt Lake City, Utah, USA
| | - Sandra K White
- Department of Pathology and ARUP Laboratories, University of Utah, Salt Lake City, Utah, USA
| | - Robert C Blaylock
- Department of Pathology and ARUP Laboratories, University of Utah, Salt Lake City, Utah, USA
| | - Ryan A Metcalf
- Department of Pathology and ARUP Laboratories, University of Utah, Salt Lake City, Utah, USA
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14
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White SK, Schmidt RL, Walker BS, Metcalf RA. Bacterial contamination rate of platelet components by primary culture: a systematic review and meta-analysis. Transfusion 2020; 60:986-996. [PMID: 32181889 DOI: 10.1111/trf.15762] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Platelets have the highest bacterial contamination risk of all blood components, and septic transfusion reactions remain a problem. A good estimate of contamination rates could provide information about residual risk and inform optimal testing strategies. We performed a systematic review and meta-analysis of platelet contamination rates by primary culture. STUDY DESIGN AND METHODS A literature search in December 2019 identified articles on platelet contamination rates using primary culture. We used meta-analysis to estimate the overall rate of contamination and meta-regression to identify heterogeneity. We studied the following sources of heterogeneity: collection method, sample volume, positivity criteria, and study date. Contamination rate estimates were obtained for apheresis (AP), platelet rich plasma (PRP), and buffy coat (BC) collection methods. RESULTS The search identified 6102 studies, and 22 were included for meta-analysis. Among these 22 studies, there were 21 AP cohorts (4,072,022 components), 4 PRP cohorts (138,869 components), and 15 BC cohorts (1,474,679 components). The overall mean contamination rate per 1000 components was 0.51 (95% CI: 0.38-0.67) including AP (0.23, 95% CI: 0.18-0.28), PRP, (0.38, 95% CI: 0.15-0.70), and BC (1.12, 95% CI: 0.51-1.96). There was considerable variability within each collection method. Sample volume, positivity criteria, and publication year were significant sources of heterogeneity. CONCLUSION The bacterial contamination rate of platelets by primary culture is 1 in 1961. AP and PRP components showed a lower contamination rate than BC components. There is clinically significant between-study variability for each method. Larger sample volumes increased sensitivity, and bacterial contamination rates have decreased over time.
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Affiliation(s)
- Sandra K White
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - Robert L Schmidt
- Department of Pathology, University of Utah, Salt Lake City, Utah
- ARUP Laboratories, Salt Lake City, Utah
| | | | - Ryan A Metcalf
- Department of Pathology, University of Utah, Salt Lake City, Utah
- ARUP Laboratories, Salt Lake City, Utah
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15
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Kundrapu S, Srivastava S, Good CE, Lazarus HM, Maitta RW, Jacobs MR. Bacterial contamination and septic transfusion reaction rates associated with platelet components before and after introduction of primary culture: experience at a US Academic Medical Center 1991 through 2017. Transfusion 2020; 60:974-985. [PMID: 32357261 DOI: 10.1111/trf.15780] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 01/27/2020] [Accepted: 02/20/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The high incidence of septic transfusion reactions (STRs) led to testing being mandated by AABB from 2004. This was implemented by primary culture of single-donor apheresis platelets (APs) from 2004 and prestorage pooled platelets (PSPPs) from 2007. STUDY DESIGN/METHODS Platelet (PLT) aliquots were cultured at issue and transfusion reactions evaluated at our hospital. Bacterial contamination and STR rates (shown as rates per million transfusions in Results) were evaluated before and after introduction of primary culture by blood centers that used a microbial detection system (BacT/ALERT, bioMerieux) or enhanced bacterial detection system (eBDS, Haemonetics). RESULTS A total of 28,457 PLTs were cultured during pre-primary culture periods (44.7% APs; 55.3% at-issue pooled PLTs [AIPPs]) and 97,595 during post-primary culture periods (79.3% APs; 20.7% PSPPs). Forty-three contaminated units were identified in preculture and 34 in postculture periods (rates, 1511 vs. 348; p < 0.0001). Contamination rates of APs were significantly lower than AIPPs in the preculture (393 vs. 2415; p < 0.0001) but not postculture period compared to PSPPs (387 vs. 198; p = 0.9). STR rates (79 vs. 90; p = 0.98) were unchanged with APs but decreased considerably with pooled PLTs (826 vs. 50; p = 0.0006). Contamination (299 vs. 324; p = 0.84) and STR rates (25 vs. 116; p = 0.22) were similar for PLTs tested by BacT/ALERT and eBDS primary culture methods. A change in donor skin preparation method in 2012 was associated with decreased contamination and STR rates. CONCLUSION Primary culture significantly reduced bacterial contamination and STR associated with pooled but not AP PLTs. Measures such as secondary testing near time of use or pathogen reduction are needed to further reduce STRs.
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Affiliation(s)
- Sirisha Kundrapu
- Department of Pathology and Medicine, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Swati Srivastava
- Department of Pathology and Medicine, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Caryn E Good
- Department of Pathology and Medicine, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Hillard M Lazarus
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robert W Maitta
- Department of Pathology and Medicine, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael R Jacobs
- Department of Pathology and Medicine, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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16
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Kacker S, Katz LM, Ness PM, Bloch EM, Goel R, Gehrie EA, Lokhandwala PM, Tobian AAR. Financial analysis of large-volume delayed sampling to reduce bacterial contamination of platelets. Transfusion 2020; 60:997-1002. [PMID: 32275069 DOI: 10.1111/trf.15773] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/17/2020] [Accepted: 02/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Effective and financially viable mitigation approaches are needed to reduce bacterial contamination of platelets in the US. Expected costs of large-volume delayed sampling (LVDS), which would be performed by a blood center prior to shipment to a hospital, were compared to those of pathogen reduction (PR), point-of-release testing (PORt), and secondary bacterial culture (SBC). METHODS Using a Markov-based decision-tree model, the financial and clinical impact of implementing all variants of LVDS, PR, PORt, and SBC described in FDA guidance were evaluated from a hospital perspective. Hospitals were assumed to acquire leukoreduced apheresis platelets, with LVDS adding $30 per unit. Monte Carlo simulations were run to estimate the direct medical costs for platelet acquisition, testing, transfusion, and possible complications associated with each approach. Input parameters, including test sensitivity and specificity, were drawn from existing literature and costs (2018US$) were based on a hospital perspective. A one-way sensitivity analysis varied the assumed additional cost of LVDS. RESULTS Under an approach of LVDS (7-day), the total cost per transfused unit is $735.78, which falls between estimates for SBC (7-day) and PORt. Assuming 20,000 transfusions each year, LVDS would cost $14.72 million annually. Per-unit LVDS costs would need to be less than $22.32 to be cheaper per transfusion than all other strategies, less than $32.02 to be cheaper than SBC (7-day), and less than $196.19 to be cheaper than PR (5-day). CONCLUSIONS LVDS is an effective and cost-competitive approach, assuming additional costs to blood centers and associated charges to hospitals are modest.
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Affiliation(s)
- Seema Kacker
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Louis M Katz
- Mississippi Valley Regional Blood Center, Davenport, Iowa, USA
| | - Paul M Ness
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Evan M Bloch
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ruchika Goel
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA.,Mississippi Valley Regional Blood Center, Davenport, Iowa, USA
| | - Eric A Gehrie
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Parvez M Lokhandwala
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
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17
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Lu W, Delaney M, Flegel WA, Ness P, Ratcliffe N, Triulzi DJ, Yazer MH, Ziman A, Dunbar NM. How do you… decide which platelet bacterial risk mitigation strategy to select for your hospital-based transfusion service? Transfusion 2020; 60:675-681. [PMID: 32027394 PMCID: PMC7131880 DOI: 10.1111/trf.15693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/07/2020] [Accepted: 01/10/2020] [Indexed: 01/12/2023]
Abstract
The United States Food and Drug Administration Final Guidance for Industry titled, "Bacterial Risk Control Strategies for Blood Collection Establishments and Transfusion Services to Enhance the Safety and Availability of Platelets for Transfusion" provides nine strategies for platelet bacterial risk mitigation. Even if it is assumed all strategies are comparable in terms of safety and efficacy, the decision of which to implement remains challenging. Some additional factors that warrant evaluation before selecting a strategy include the financial impact, process for implementation, logistics upon implementation, institutional acceptance by blood bank staff, administration and clinicians, and effect on platelet availability. To assist with this difficult choice, a panel of transfusion service physicians who have expertise on the topic and have already selected strategies for their transfusion services were recruited to provide varied perspectives. In addition, the use of a decision-making tool that objectively evaluates defined criteria for assessment of the nine strategies is described.
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Affiliation(s)
- Wen Lu
- Robert Tomsich Pathology & Laboratory Medicine
Institute, Cleveland Clinic, Cleveland, Ohio
| | - Meghan Delaney
- Pathology and Laboratory Medicine, Children’s
National Medical Center, Washington, DC
| | - Willy A. Flegel
- Department of Transfusion Medicine, NIH Clinical Center,
National Institutes of Health, Bethesda
| | - Paul Ness
- Department of Pathology, Johns Hopkins University School of
Medicine, Baltimore, Maryland
| | - Nora Ratcliffe
- Pathology & Laboratory Medicine, White River Junction
VA Medical Center, White River Junction, Vermont
| | - Darrell J. Triulzi
- Centralized Transfusion Service, University of Pittsburgh,
Pittsburgh, Pennsylvania
| | - Mark H. Yazer
- Centralized Transfusion Service, University of Pittsburgh,
Pittsburgh, Pennsylvania
| | - Alyssa Ziman
- Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service,
Department of Pathology and Laboratory Medicine, David Geffen School of Medicine,
University of California Los Angeles, Los Angeles, California
| | - Nancy M. Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
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18
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A Fatal Case of Septic Shock Secondary to Acinetobacter Bacteremia Acquired from a Platelet Transfusion. Case Rep Med 2019; 2019:3136493. [PMID: 32089699 PMCID: PMC7029672 DOI: 10.1155/2019/3136493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/04/2019] [Accepted: 12/05/2019] [Indexed: 01/05/2023] Open
Abstract
Background Transfusion of blood products is a frequent and often necessary lifesaving intervention. While changes to blood bank practices over the past several decades have reduced the infectious complications associated with transfusions, risks still exist. Septic transfusion reactions caused by bacterial contamination of blood products, especially platelets, still occur relatively frequently. Unfortunately, clinical recognition of septic transfusion reactions is difficult due to significant symptom, exam, and laboratory abnormality overlap between different types of transfusion reactions, as well as other conditions. Novel methods have been developed to detect blood product contamination but have yet to be widely implemented in the United States. Case Report A 67-year-old male with chronic thrombocytopenia was transfused with platelets prior to a planned procedure. Shortly afterwards, he developed fever and hypotension. He was transferred to the intensive care unit where he was treated with aggressive fluid resuscitation and broad-spectrum antibiotics. The patient went on to develop progressively worsening shock and profound disseminated intravascular coagulation. Blood cultures from the patient and the transfused platelets grew an Acinetobacter species. Despite aggressive resuscitative efforts and appropriate antibiotics, the patient died approximately 48 hours following the transfusion reaction. Conclusion We report a fatal case of septic shock associated with Acinetobacter bacteremia caused by platelet transfusion. Our review of the literature revealed only one other documented platelet transfusion associated fatality caused by Acinetobacter species. Novel pathogen reduction and contamination detection methods have been developed but have yet to be widely adopted in the United States.
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20
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Towards increasing shelf life and haemostatic potency of stored platelet concentrates. Curr Opin Hematol 2019; 25:500-508. [PMID: 30281037 DOI: 10.1097/moh.0000000000000456] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Platelet transfusion is a widely used therapy in treating or preventing bleeding and haemorrhage in patients with thrombocytopenia or trauma. Compared with the relative ease of platelet transfusion, current practice for the storage of platelets is inefficient, costly and relatively unsafe, with platelets stored at room temperature (RT) for upto 5-7 days. RECENT FINDINGS During storage, especially at cold temperatures, platelets undergo progressive and deleterious changes, collectively termed the 'platelet storage lesion', which decrease their haemostatic function and posttransfusion survival. Recent progress in understanding platelet activation and host clearance mechanisms is leading to the consideration of both old and novel storage conditions that use refrigeration and/or cryopreservation to overcome various storage lesions and significantly extend platelet shelf-life with a reduced risk of pathogen contamination. SUMMARY A review of the advantages and disadvantages of alternative methods for platelet storage is presented from both a clinical and biological perspective. It is anticipated that future platelet preservation involving cold, frozen and/or pathogen reduction strategies in a proper platelet additive solution will enable longer term and safer platelet storage.
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21
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Existing and Emerging Blood-Borne Pathogens: Impact on the Safety of Blood Transfusion for the Hematology/Oncology Patient. Hematol Oncol Clin North Am 2019; 33:739-748. [PMID: 31466601 DOI: 10.1016/j.hoc.2019.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Despite measures to mitigate risk of transfusion-transmitted infections, emerging agents contribute to morbidity and mortality. We outline the epidemiology, risk mitigation strategies, and impact on patients for Zika virus, bacteria, Babesia, and cytomegalovirus. Nucleic acid testing of blood has reduced risk of Zika infection and reduced transfusion-transmitted risk of Babesia. Other collection and testing measures have reduced but not eliminated the risk of sepsis from bacterially contaminated blood components. Cytomegalovirus has almost been eliminated by high-efficiency leukoreduction, but residual transmissions are difficult to distinguish from community-acquired infections and additional antibody testing of blood may confer further safety of susceptible recipients.
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22
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Schulz WL, McPadden J, Gehrie EA, Bahar B, Gokhale A, Ross R, Price N, Spencer BR, Snyder E. Blood Utilization and Transfusion Reactions in Pediatric Patients Transfused with Conventional or Pathogen Reduced Platelets. J Pediatr 2019; 209:220-225. [PMID: 30885645 DOI: 10.1016/j.jpeds.2019.01.046] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/15/2019] [Accepted: 01/29/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To assess the safety and efficacy of a Food and Drug Administration-approved pathogen-reduced platelet (PLT) product in children, as ongoing questions regarding their use in this population remain. STUDY DESIGN We report findings from a quality assurance review of PLT utilization, associated red blood cell transfusion trends, and short-term safety of conventional vs pathogen-reduced PLTs over a 21-month period while transitioning from conventional to pathogen-reduced PLTs at a large, tertiary care hospital. We assessed utilization in neonatal intensive care unit (NICU) patients, infants 0-1 year not in the NICU, and children age 1-18 years (PED). RESULTS In the 48 hours after an index conventional or pathogen-reduced platelet transfusion, respectively, NICU patients received 1.0 ± 1.4 (n = 91 transfusions) compared with 1.2 ± 1.3 (n = 145) additional platelet doses (P = .29); infants 0-1 year not in the NICU received 2.8 ± 3.0 (n = 125) vs 2.6 ± 2.6 (n = 254) additional platelet doses (P = .57); and PEDs received 0.9 ± 1.6 (n = 644) vs 1.4 ± 2.2 (n = 673) additional doses (P < .001). Time to subsequent transfusion and red cell utilization were similar in every group (P > .05). The number and type of transfusion reactions did not significantly vary based on PLT type and no rashes were reported in NICU patients receiving phototherapy and pathogen-reduced PLTs. CONCLUSIONS Conventional and pathogen-reduced PLTs had similar utilization patterns in our pediatric populations. A small, but statistically significant, increase in transfusions was noted following pathogen-reduced PLT transfusion in PED patients, but not in other groups. Red cell utilization and transfusion reactions were similar for both products in all age groups.
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Affiliation(s)
- Wade L Schulz
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
| | - Jacob McPadden
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Eric A Gehrie
- Department of Pathology and Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Burak Bahar
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Amit Gokhale
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT; Department of Pathology, Stony Brook School of Medicine
| | - Rebecca Ross
- Blood Bank, Yale New Haven Hospital, New Haven, CT
| | - Nathaniel Price
- Information Technology Services, Yale New Haven Health, New Haven, CT
| | | | - Edward Snyder
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT.
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23
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Jacquot C, Mo YD, Luban NLC. New Approaches and Trials in Pediatric Transfusion Medicine. Hematol Oncol Clin North Am 2019; 33:507-520. [PMID: 31030816 DOI: 10.1016/j.hoc.2019.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Blood transfusions are frequently lifesaving, but there is growing awareness of their associated infectious and noninfectious adverse events. Patient blood management advocates for judicious use of transfusions and considerations of alternatives to correct anemia or achieve hemostasis. Several transfusion practices, either already implemented or under investigation, aim to further improve the safety of transfusions. An enduring challenge in pediatric and neonatal transfusion practice is that studies typically focus on adults, and findings are extrapolated to younger patients. This article aims to summarize some of the newer developments in transfusion medicine with a focus on the neonatal and pediatric population.
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Affiliation(s)
- Cyril Jacquot
- Division of Laboratory Medicine, Center for Cancer and Blood Disorders, Children's National Health System, Sheikh Zayed Campus for Advanced Children's Medicine, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; Division of Hematology, Center for Cancer and Blood Disorders, Children's National Health System, Sheikh Zayed Campus for Advanced Children's Medicine, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Department of Pathology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Yunchuan Delores Mo
- Division of Laboratory Medicine, Center for Cancer and Blood Disorders, Children's National Health System, Sheikh Zayed Campus for Advanced Children's Medicine, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; Division of Hematology, Center for Cancer and Blood Disorders, Children's National Health System, Sheikh Zayed Campus for Advanced Children's Medicine, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Department of Pathology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Naomi L C Luban
- Division of Laboratory Medicine, Center for Cancer and Blood Disorders, Children's National Health System, Sheikh Zayed Campus for Advanced Children's Medicine, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; Division of Hematology, Center for Cancer and Blood Disorders, Children's National Health System, Sheikh Zayed Campus for Advanced Children's Medicine, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Department of Pathology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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24
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Prevention of transfusion-transmitted infections. Blood 2019; 133:1854-1864. [PMID: 30808637 DOI: 10.1182/blood-2018-11-833996] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 02/03/2019] [Indexed: 01/10/2023] Open
Abstract
Since the 1970s, introduction of serological assays targeting virus-specific antibodies and antigens has been effective in identifying blood donations infected with the classic transfusion-transmitted infectious agents (TTIs; hepatitis B virus [HBV], HIV, human T-cell lymphotropic virus types I and II, hepatitis C virus [HCV]). Subsequently, progressive implementation of nucleic acid-amplification technology (NAT) screening for HIV, HCV, and HBV has reduced the residual risk of infectious-window-period donations, such that per unit risks are <1 in 1 000 000 in the United States, other high-income countries, and in high-incidence regions performing NAT. NAT screening has emerged as the preferred option for detection of newer TTIs including West Nile virus, Zika virus (ZIKV), and Babesia microti Although there is continual need to monitor current risks due to established TTI, ongoing challenges in blood safety relate primarily to surveillance for emerging agents coupled with development of rapid response mechanisms when such agents are identified. Recent progress in development and implementation of pathogen-reduction technologies (PRTs) provide the opportunity for proactive rather than reactive response to blood-safety threats. Risk-based decision-making tools and cost-effectiveness models have proved useful to quantify infectious risks and place new interventions in context. However, as evidenced by the 2015 to 2017 ZIKV pandemic, a level of tolerable risk has yet to be defined in such a way that conflicting factors (eg, theoretical recipient risk, blood availability, cost, and commercial interests) can be reconciled. A unified approach to TTIs is needed, whereby novel tests and PRTs replace, rather than add to, existing interventions, thereby ameliorating cost and logistical burden to blood centers and hospitals.
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Kacker S, Bloch EM, Ness PM, Gehrie EA, Marshall CE, Lokhandwala PM, Tobian AAR. Financial impact of alternative approaches to reduce bacterial contamination of platelet transfusions. Transfusion 2019; 59:1291-1299. [PMID: 30623459 DOI: 10.1111/trf.15139] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bacterial contamination of platelets remains the leading infectious risk from blood transfusion. Pathogen reduction (PR), point-of-release testing (PORt), and secondary bacterial culture (SBC) have been proposed as alternative risk control strategies, but a comprehensive financial comparison has not been conducted. STUDY DESIGN AND METHODS A Markov-based decision tree was constructed to model the financial and clinical impact of PR, PORt, and SBC, as well as a baseline strategy involving routine testing only. Hospitals were assumed to acquire leukoreduced apheresis platelets on Day 3 after collection, and, in the base case analysis, expiration would occur at the end of Day 5 (PR and SBC) or 7 (PORt). Monte Carlo simulations assessed the direct medical costs for platelet acquisition, testing, transfusion, and possible complications. Input parameters, including test sensitivity and specificity, were drawn from existing literature, and costs (2018 US dollars) were based on a hospital perspective. RESULTS The total costs per unit acquired by the hospital under the baseline strategy, PR, PORt, and SBC were $651.45, $827.82, $686.33, and $668.50, respectively. All risk-reduction strategies decreased septic transfusion reactions and associated expenses, with the greatest reductions from PR. PR would add $191.09 in per-unit acquisition costs, whereas PORt and SBC would increase per-unit testing costs by $31.79 and $17.26, respectively. Financial outcomes were sensitive to platelet dating; allowing 7-day storage with SBC would lead to a cost savings of $12.41 per transfused unit. Results remained robust in probabilistic sensitivity analyses. CONCLUSIONS All three strategies are viable approaches to reducing bacterially contaminated platelet transfusions, although SBC is likely to be the cheapest overall.
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Affiliation(s)
- Seema Kacker
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Eric A Gehrie
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Christi E Marshall
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Parvez M Lokhandwala
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
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Atypical Bacterial Growth within Units of Platelets Challenges Transfusion Medicine Dogma. J Clin Microbiol 2018; 56:JCM.01363-18. [PMID: 30232128 DOI: 10.1128/jcm.01363-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although transfusion-transmitted bacterial infection is relatively rare, mitigation of bacterial contamination of platelet units is arguably the top current transfusion-related safety concern. Several different technologies have been employed to detect or neutralize bacteria in platelet concentrates. However, studies of the efficacy of these systems have been hampered by problematic definitions of what represents a "true-positive" versus a "false-positive" culture result. In the current issue of the Journal of Clinical Microbiology (M. Cloutier, M.-È. Nolin, H. Daoud, A. Jacques, M. J. de Grandmont, É Ducas, G. Delage, and L. Thibault, J Clin Microbiol 56:e01105-18, 2018, https://doi.org/10.1128/JCM.01105-18), it was demonstrated that the growth of Bordetella holmesii is inhibited by the platelet storage environment, which may explain why the results of initial positive platelet cultures are not always confirmed by subsequent cultures later during the storage period. This important finding is at odds with the generally held belief within the field of transfusion medicine that initially positive platelet cultures that are not confirmed on repeat testing are instrumentation-based false positives. The clinical risk profile of organisms demonstrating storage-related low viability is worthy of further study.
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27
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Störmer M, Wood EM, Gathof B. Microbial safety of cellular therapeutics-lessons from over ten years’ experience in microbial safety of platelet concentrates. ACTA ACUST UNITED AC 2018. [DOI: 10.1111/voxs.12452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Melanie Störmer
- Transfusion Medicine; University Hospital Cologne; Cologne Germany
| | - Erica M. Wood
- Transfusion Research Unit; Department of Epidemiology and Preventive Medicine; Monash University; Melbourne VIC Australia
| | - Birgit Gathof
- Transfusion Medicine; University Hospital Cologne; Cologne Germany
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28
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Erony SM, Marshall CE, Gehrie EA, Boyd JS, Ness PM, Tobian AA, Carroll KC, Blagg L, Shifflett L, Bloch EM. The epidemiology of bacterial culture-positive and septic transfusion reactions at a large tertiary academic center: 2009 to 2016. Transfusion 2018; 58:1933-1939. [DOI: 10.1111/trf.14789] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/08/2018] [Accepted: 04/08/2018] [Indexed: 01/21/2023]
Affiliation(s)
- Sean M. Erony
- Johns Hopkins Hospital and Medical Institutions; Baltimore Maryland
| | | | - Eric A. Gehrie
- Johns Hopkins Hospital and Medical Institutions; Baltimore Maryland
| | - Joan S. Boyd
- Johns Hopkins Hospital and Medical Institutions; Baltimore Maryland
| | - Paul M. Ness
- Johns Hopkins Hospital and Medical Institutions; Baltimore Maryland
| | | | - Karen C. Carroll
- Johns Hopkins Hospital and Medical Institutions; Baltimore Maryland
| | - Lorraine Blagg
- Johns Hopkins Hospital and Medical Institutions; Baltimore Maryland
| | - Lisa Shifflett
- Johns Hopkins Hospital and Medical Institutions; Baltimore Maryland
| | - Evan M. Bloch
- Johns Hopkins Hospital and Medical Institutions; Baltimore Maryland
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29
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Kamel H, Goldman M. More than one way to enhance bacterial detection in platelet components. Transfusion 2018; 58:1574-1577. [DOI: 10.1111/trf.14774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 04/24/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Hany Kamel
- Department of Medical AffairsBlood SystemsScottsdale AZ
| | - Mindy Goldman
- Medical, Scientific and Research Affairs, Canadian Blood ServicesOttawa Ontario Canada
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