Fatal group C streptococcal infection due to transfusion of a bacterially contaminated pooled platelet unit despite routine bacterial culture screening

Transfusion

Volumn 48, Issue 10, 2008, Pages 2177-2183

  Lessa, Fernanda ^a   Leparc, German F ^a   Benson, Kaaron ^a   Sanderson, Roger ^a   Van Beneden, Chris A ^a   Shewmaker, Patricia L ^a   Jensen, Bette ^a   Arduino, Matthew J ^a   Kuehnert, Matthew J ^a  

^a MS A 24 ^*

Author keywords

[No Author keywords available]

Indexed keywords

HYPERTENSIVE AGENT; NARCOTIC ANALGESIC AGENT; RNA 16S;

AGED; ARTICLE; BACTERIUM CONTAMINATION; BACTERIUM CULTURE; BACTERIUM DETECTION; BACTERIUM ISOLATE; BLOOD CULTURE; BLOOD DONOR; CASE REPORT; CHILL; CHRONIC MYELOMONOCYTIC LEUKEMIA; COLONY FORMING UNIT; ERYTHROCYTE; FALSE NEGATIVE RESULT; HUMAN; LABORATORY DIAGNOSIS; MALE; PULSED FIELD GEL ELECTROPHORESIS; QUANTITATIVE ANALYSIS; STREPTOCOCCUS DYSGALACTIAE EQUISIMILIS; STREPTOCOCCUS GROUP C; STREPTOCOCCUS INFECTION; THROAT CULTURE; THROMBOCYTE TRANSFUSION;

AGED; BLOOD DONORS; BLOOD PLATELETS; FATAL OUTCOME; HUMANS; MALE; MICROBIOLOGICAL TECHNIQUES; PLATELET TRANSFUSION; STREPTOCOCCAL INFECTIONS; STREPTOCOCCUS;

EID: 52949136226     PISSN: 00411132     EISSN: 15372995     Source Type: Journal    
DOI: 10.1111/j.1537-2995.2008.01802.x     Document Type: Article

References (37)

1. Roth VR, Kuehnert MJ, Haley R, Gregory KR, Schreiber GB, Arduino MJ, Holt SC, Carson LA, Elder KV, Jarvis WR. Evaluation of a reporting system for bacterial contamination of blood components in the United States. Transfusion 2001 41 : 1486 92.
2. Schrezenmeier H, Walther-Wenke G, Muller TH, Weinauer F, Younis A, Holland-Letz T, Geis G, Asmus J, Bauerfeind U, Burkhart J, Deitenbeck R, Förstemann E, Gebauer W, Höchsmann B, Karakassopoulos A, Liebscher UM, Sänger W, Schmidt M, Schunter F, Sireis W, Seifried E. Bacterial contamination of platelet concentrates: results of a prospective multicenter study comparing pooled whole blood-derived platelets and apheresis platelets. Transfusion 2007 47 : 644 52.
3. AABB Standard 5.4.21. Standards for blood banks and transfusion services. 24th ed. Bethesda : American Association of Blood Banks 2006.
4. Hillyer CD, Josephson CD, Blajchman MA, Vostal JG, Epstein JS, Goodman JL. Bacterial contamination of blood components: risks, strategies, and regulation: joint ASH and AABB educational session in transfusion medicine. Hematology (Am Soc Hematol Educ Program) 2003 575 89.
5. Kuehnert MJ, Roth VR, Haley NR, Gregory KR, Elder KV, Schreiber GB, Arduino MJ, Holt SC, Carson LA, Banerjee SN, Jarvis WR. Transfusion-transmitted bacterial infection in the United States, 1998 through 2000. Transfusion 2001 41 : 1493 9.
6. Centers for Disease Control and Prevention. Fatal bacterial infections associated with platelet transfusions - United States, 2004. Morb Mortal Wkly Rep 2005 54 : 168 70.
7. Eder AF, Kennedy JM, Dy BA, Notari EP, Weiss JW, Fang CT, Wagner S, Dodd RY, Benjamin RJ American Red Cross Regional Blood Centers. Bacterial screening of apheresis platelets and the residual risk of septic transfusion reactions: the American Red Cross experience (2004-2006). Transfusion 2007 47 : 1134 42.
8. Palavecino EL, Yomtovian RA, Jacobs MR. Detecting bacterial contamination in platelet products. Clin Lab 2006 52 : 443 56.
9. Hogman CF, Fritz H, Sandberg L. Posttransfusion Serratia marcescens septicemia. Transfusion 1993 33 : 189 91.
10. AuBuchon JP, Pickard C, Herschel L. Sterility of plastic tubing welds in components stored at room temperature. Transfusion 1995 35 : 303 7.
11. Sazama K. Bacteria in blood for transfusion. A review. Arch Pathol Lab Med 1994 118 : 350 65.
12. Facklam RR, Elliott JA. Identification, classification, and clinical relevance of catalase-negative, gram-positive cocci, excluding the streptococci and enterococci. Clin Microbiol Rev 1995 8 : 479 95.
13. Freeny J, Bland S, Etienne J, Desmonceaux M, Boeufgras JM, Fleurette J. Description and evaluation of the semiautomated 4-h Rapid ID 32 Strep method for identification of streptococci and members of related genera. J Clin Microbiol 1992 30 : 2657 61.
14. Facklam R. What happened to the streptococci: overview of taxonomic and nomenclature changes. Clin Microbiol Rev 2002 15 : 613 30.
15. Shewmaker PL, Steigerwalt AG, Morey RE, Carvalho Mda G, Elliott JA, Joyce K, Barrett TJ, Teixeira LM, Facklam RR. Vagococcus carniphilus, sp. nov., isolated from ground beef. Int J Syst Evol Microbiol 2004 54 : 1505 10.
16. Wrestler JC, Lipes BD, Birren BW, Lai E. Pulsed-field gel electrophoresis. Methods Enzymol 1996 270 : 255 72.
17. Tenover FC, Arbeit RD, Goering RV, Mickelsen PA, Murray BE, Persing DH, Swaminathan B. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing. Clin Microbiol 1995 33 : 2233 9.
18. Malone T, Williams D, Leparc GF. Validation and product performance qualification of a blood culture method for the bacterial detection of whole blood derived platelets. Transfusion 2004 44 Suppl : AP85.
19. Malone TP, Williams DA, Haines PC, Leparc GF. Bacterial detection of whole blood-derived platelets tested from a pooled sample using a 37°C lag phase; two years of data. Transfusion 2006 46 Suppl : A7 020B.
20. Efstratiou A, Colman G, Hahn G, Timoney JF, Boeufgras JM, Monget D. Biochemical differences among human and animal streptococci of Lancefield group C or group G. J Med Microbiol 1994 41 : 145 8.
21. Bradley SF, Gordon JJ, Baumgartner DD, Marasco WA, Kauffman CA. Group C streptococcal bacteremia: analysis of 88 cases. Rev Infect Dis 1991 13 : 270 80.
22. Kumar A, Sandoe J, Kumar N. Three cases of vertebral osteomyelitis caused by Streptococcus dysgalactiae subsp. equisimilis. J Med Microbiol 2005 54 : 1103 5.
23. Turner JC, Hayden FG, Lobo MC, Ramirez CE, Murren D. Epidemiologic evidence for Lancefield group C beta-hemolytic streptococci as a cause of exudative pharyngitis in college students. J Clin Microbiol 1997 35 : 1 4.
24. Haidan A, Talay SR, Rohde M, Sriprakash KS, Currie BJ, Chhatwal GS. Pharyngeal carriage of group C and group G streptococci and acute rheumatic fever in an Aboriginal population. Lancet 2000 356 : 1167 9.
25. Kalia A, Enright MC, Spratt BG, Bessen DE. Directional gene movement from human-pathogenic to commensal-like streptococci. Infect Immun 2001 69 : 4858 69.
26. Davies MR, McMillan DJ, Beiko RG, Barroso V, Geffers R, Sriprakash KS, Chhatwal GS. Virulence profiling of Streptococcus dysgalactiae subspecies equisimilis isolated from infected humans reveals 2 distinct genetic lineages that do not segregate with their phenotypes or propensity to cause diseases. Clin Infect Dis 2007 44 : 1442 54.
27. Turner JC, Hayden GF, Kiselica D, Lohr J, Fishburne CF, Murren D. Association of group C beta-hemolytic streptococci with endemic pharyngitis among college students. JAMA 1990 264 : 2644 7.
28. Ekelund K, Skinhoj P, Madsen J, Konradsen HB. Invasive group A, B, C and G streptococcal infections in Denmark 1999-2002: epidemiological and clinical aspects. Clin Microbiol Infect 2005 11 : 569 76.
29. Laupland KB, Ross T, Church DL, Gregson DB. Population-based surveillance of invasive pyogenic streptococcal infection in a large Canadian region. Clin Microbiol Infect 2006 12 : 224 30.
30. Benjamin RJ, Wagner SJ. The residual risk of sepsis: modeling the effect of concentration on bacterial detection in two-bottle culture systems and an estimation of false-negative culture rates. Transfusion 2007 47 : 1381 9.
31. Acrodose™ PL system for pre-storage pooling and testing of leukoreduced whole blood derived platelets. East Hill (NY) : Pall Medical 2008. Available at http://www.pall.com/39378_39467.asp (accessed March 23, 2008).
32. Brecher ME, Hay SN, Rose AD, Rothenberg SJ. Evaluation of BacT/ALERT plastic culture bottles for use in testing pooled whole blood-derived leukoreduced platelet-rich plasma platelets with a single contaminated unit. Transfusion 2005 45 : 1512 7.
33. Silva MA, Gregory KR, Carr-Greer MA, Holmberg JA, Kuehnert MJ, ME B, Task F. Summary of the AABB interorganizational task force on bacterial contamination of platelets: fall 2004 impact survey. Transfusion 2006 46 : 636 41.
34. Brecher ME, Hay SN. Investigation of an isolate of Staphylococcus lugdunensis implicated in a platelet fatality: a possible advantage of the use of an anaerobic bottle. Transfusion 2007 47 : 1390 4.
35. Food and Drug Administration. Platelet PGD Test. Available at http://www.fda.gov/bbs/topics/NEWS/2007/NEW01702.html (accessed October 4, 2007).
36. Ramirez-Arcos S, Chin-Yee I, Hume H, Fearon M, Goldman M, Eckert K, Martincic I, Peters G, Kovach D, Richardson SE. Fatal septic shock associated with transfusion-transmitted Serratia marcescens. Transfusion 2006 46 : 679 81.
37. Civitelli F, Guglielmetti P, Partini N. Comparison of methods for isolation of beta-hemolytic streptococci. Quad Sclavo Diag 1987 23 : 225 7.