Transfusion-Transmitted Infections Reported to the National Healthcare Safety Network Hemovigilance Module

Collaboration is key: Case report of suspected Pseudomonas fluorescens transfusion-associated infection

BACKGROUND

We report a case of suspected Pseudomonas fluorescens transfusion-transmitted infection in a 64-year-old female patient with pancreatic adenocarcinoma. The patient developed a biliary obstruction necessitating a drainage catheter, which was complicated by an arterial hemorrhage. Following the transfusion of 1 RBC unit, the patient developed flank pain, chills, and tachycardia.

STUDY DESIGN AND METHODS

The transfusion reaction workup was negative for hemolytic transfusion reaction. However, Gram stains of the implicated RBC unit revealed Gram-negative rods. Fortunately, the patient was already receiving broad-spectrum antibiotics, and preliminary investigation results were available early enough to alert the medical team and adjust antibiotic coverage. The patient was hospitalized in the ICU where she had elevated WBC counts that normalized after the addition of cefepime. The blood collection center was notified.

RESULTS

Both aerobic and anaerobic cultures incubated at 35°C were negative for growth. A subculture and incubation at room temperature (25°C) demonstrated sufficient growth for the identification of Pseudomonas fluorescens by both Vitek-MS MALDI-TOF and Vitek2 biochemical methods.

DISCUSSION

Pseudomonas fluorescens is a Gram-negative rod-shaped bacterium, well-studied as an environmental microbe. It can cause opportunistic infections in humans and was implicated in previous fatal septic transfusion reactions. This report highlights the importance of both standardization in blood product culture protocols and the need for collaboration between microbiology laboratories and transfusion practitioners to optimize the recovery of potentially clinically important fastidious organisms.

Transfusion-transmitted bacterial infection risk due to the proliferation of psychrotrophic bacterial species in RBCs and their difficulty in detection

BACKGROUND

Reports of cases of bacterial infection due to transfusion of red blood cell (RBC) components (RBC-TTBI) are relatively rare. Hence, the possibility of undetectable bacterial contamination in RBCs, especially by psychrotrophic bacteria, must be clarified.

STUDY DESIGN AND METHODS

We assessed nine psychrotrophic bacterial species, including those implicated in bacteremia or RBC-TTBIs. They were cultured on plates from 4 to 37°C to determine their optimal growth temperatures. We also assessed the detection capabilities of the automated culture/alarm system BACT/ALERT VIRTUO (VIRTUO) using BPA (aerobic) and BPN (anaerobic) bottles. In addition, bacteria-inoculated RBCs were incubated at 4°C for 42 days, with samples assessed weekly for bacterial growth using plate culture, VIRTUO, visual inspection, and endotoxin production.

RESULTS

Two Psychrobacter species exhibited weak or no proliferation at temperatures ≥30°C in plate cultures. Three Pseudomonas species, one Psychrobacter species, and one psychrotrophic lactic acid bacteria proliferated in RBCs at 4°C, reaching 104-108 colony-forming units/mL (growth count) and 15-39,230 pg/mL (endotoxin production) by day 14. VIRTUO, operating at 36°C, failed to consistently yield reliable results for any of the tested bacterial species. Notably, visual changes in bag appearance were observed from day 21 in four species that proliferated in RBCs.

DISCUSSION

Each psychrotrophic bacteria demonstrated a specific temperature preference for optimal proliferation. Standard culture tests, typically conducted at 35-37°C, often fail to detect the growth of such bacteria, suggesting they may be overlooked in the cultural analysis of suspected RBC-TTBI cases.

Application of random quality control based on time -series model in ELISA detection of blood donors in Nanjing

This study introduces a completely Random Quality Control (R-QC) method for Enzyme-Linked Immunosorbent Assay (ELISA) tests and compares it with traditional Fixed Quality Control (F-QC) methods across different testing items. A random quality control system was constructed using a Time-series model, enabling fully random positioning of quality control in ELISA tests. The Coefficient of Variation (CV) for R-QC were found to be lower as compared to F-QC in Hepatitis B surface antigen (HBsAg), anti-Human Immunodeficiency Virus (anti-HIV), and Treponema Pallidum (TP) items, and there were significant differences among them. Moreover, the alarm rates and out of control rates in the R-QC groups were notably lower than those in the F-QC groups. The experimentally designed R-QC method demonstrates superior stability, reducing alarm and out of control rates, with has significant implications for improving ELISA testing at the Nanjing Blood Center.

Larger versus smaller red blood cell volume per transfusion in hospitalized adults, children, and preterm neonates

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: The objective of this review is to compare the effectiveness and safety of larger versus smaller RBC volume per transfusion for anemia in hospitalized adults, children, and preterm neonates.

Impact of blood donation biovigilance and transfusion-transmitted infections on organ transplantation

Over 118 million blood donations are collected globally each year. Recipients of blood products include those who experience major trauma or surgery, have acute blood loss and anemia, or impaired bone marrow function. Solid organ transplant recipients often require transfusion of blood products which places them at risk of transfusion-associated adverse events including transfusion-transmitted infection. National hemovigilance networks have documented low rates of transfusion-transmitted infection in the general population. Incidence transfusion-transmitted infection continues to occur in solid organ transplant patients and arises mainly from existing gaps in blood donor biovigilance processes. Emerging infectious diseases have highlighted existing gaps in the donor-recipient pathway to administering safe blood products. This article reviews the current process and regulatory oversight of blood donor biovigilance, including donor screening and microbiological testing, highlights cases of transfusion-transmitted infection documented in the literature, and addresses ways in which biovigilance may be improved, with a focus on the impact of solid organ transplantation.

Comparative genome analyses of Staphylococcus aureus from platelet concentrates reveal rearrangements involving loss of type VII secretion genes

Staphylococcus aureus has been involved in transfusion-transmitted fatalities associated with platelet concentrates (PCs) due to its heightened pathogenicity enhanced by genome-encoded virulence and antibiotic resistance genes. This may be facilitated by mobile genetic elements (MGEs) that can cause rearrangements. Several factors contribute to S. aureus virulence, including the type VII secretion system (T7SS), composed of six core genes conserved across S. aureus strains. In this study, we conducted comparative genome analyses of five S. aureus isolates from PCs (CI/BAC/25/13 /W, PS/BAC/169/17 /W and PS/BAC/317/16 /W were detected during PCs screening with the BACT/ALERT automated culture system, and ATR-20003 and CBS2016-05 were missed during screening and caused septic transfusion reactions). Multiple alignments of the genomes revealed evidence of rearrangements involving phage Sa3int in PS/BAC/169/17 /W and PS/BAC/317/16 /W. While the former had undergone translocation of its immune evasion cluster (IEC), the latter had lost part of the phage, leaving behind the IEC. This observation highlights S. aureus genome plasticity. Unexpectedly, strain CBS2016-05 was found to encode a pseudo-type VII secretion system (T7SS) that had lost five of the conserved core genes (esxA, esaA, essA, esaB and essB) and contained a 5' truncated essC. Since these genes are essential for the function of the T7SS protein transport machinery, which plays a key role in S. aureus virulence, CBS2016-05 probably compensates by recruiting other export mechanisms and/or alternative virulence factors, such as neu-tralizing immunity proteins. This study unravels genome rearrangements in S. aureus isolated from PCs and reports the first S. aureus isolate lacking conserved T7SS core genes.

Insight into hazards and control of transfusion-transmitted infections in Egypt: A narrative review

Blood transfusion is a critical life-saving medical intervention, but it carries the risk of transfusion-transmitted infections (TTIs) that can lead to serious consequences. TTIs include viral, bacterial, parasitic, and prion infections, transmitted through asymptomatic donor blood, contamination of stored blood products, or transfusion-related immunosuppression. Recognized global agents posing challenges to blood safety include human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV), Syphilis, etc. Emerging pathogens like SARS-CoV-2, hepatitis E, and others present additional risks. The residual risk of TTIs, representing the likelihood of infected donations passing screening tests, varies globally. High-income countries generally show lower prevalence rates than low-income countries. In Egypt, the estimated prevalence rates for HIV, HBV, HCV, and syphilis markers among the donors are 0.23 %, 0.76 %, 2.33 %, and 0.24 %, respectively. In Egypt, specific residual risk estimates are scarce, but prevalence rates for key infections highlight existing challenges. The World Health Organization promotes a global blood safety strategy, advocating for national blood systems, voluntary non-remunerated donors, and quality-assured testing. Despite these measures, the establishment of a haemovigilance system which is critical for monitoring and preventing adverse events, including TTIs, is reported as lacking in Egypt. This highlights the importance of comprehensive surveillance and safety measures in the blood donation process to ensure universal access to safe blood. Primary health care can play a pivotal role in preventing TTIs.

Ultraviolet light and riboflavin accelerates red blood cell dysfunction in vitro and in a guinea pig transfusion model

BACKGROUND

Quality assessment of modified or processed red blood cell (RBC) components, such as pathogen-reduced RBCs, using only in vitro testing may not always be predictive of in vivo performance. Mouse or rat in vivo models are limited by a lack of applicability to certain aspects of human RBC biology. Here, we used a guinea pig model to study the effects of riboflavin combined with UV light on the integrity of RBCs in vitro and following transfusion in vivo.

MATERIALS AND METHODS

Guinea pig RBCs were collected from whole blood (WB) treated with varying UV doses (10, 20, 40 or 80 J/mL) in the presence of riboflavin (UVR-RBCs). In vitro tests for UVR-RBCs included hemolysis, osmotic fragility, and cellular morphology by scanning electron microscopy. Guinea pigs transfused with one-day post-treatment UVR-RBCs were evaluated for plasma hemoglobin (Hb), non-transferrin bound iron (NTBI), total iron and Perls-detectable hemosiderin deposition in the spleen and kidney, and renal uptake of Hb.

RESULTS

Acute RBC injury was dose dependently accelerated after treatment with UV light in the presence of riboflavin. Aberrant RBC morphology was evident at 20, 40, and 80 J/mL, and membrane lysis with Hb release was prominent at 80 J/mL. Guinea pigs transfused with 40 and 80 J/mL UVR-RBCs showed increased plasma Hb levels, and plasma NTBI was elevated in all UVR-RBC groups (10-80 J/mL). Total iron levels and Perls-hemosiderin staining in spleen and kidney as well as Hb uptake in renal proximal tubules were increased 8 hours post-transfusion with 40 and 80 J/mL UVR-RBCs.

DISCUSSION

UVR-RBCs administered to guinea pigs increased markers of intravascular and extravascular hemolysis in a UV dose-dependent manner. This model may allow for the discrimination of RBC injury during testing of extensively processed RBCs intended for transfusion.

Transfusion transmitted infections among blood donors of Kamenge Teaching Hospital blood bank in Burundi

BACKGROUND

The current risk of contracting a transfusion transmitted infections (TTIs) is unknown in Burundi.

OBJECTIVES

The aim of this study was to assess sociodemographic profiles of blood bank donors at Kamenge Teaching Hospital, the prevalence and associated risk factors of HIV, syphilis, HBV and HCV from 2015 to 2020.

METHODS

We conducted a cross-sectional study including all blood donors of Kamenge Teaching Hospital blood bank. During this study, 1370 blood samples were screened for HIV, Syphilis, HBV and HCV. We calculated prevalence of TTIs and performed logistic regression to know associated risk factors.

RESULTS

Blood donors were males at 77% and 23% females. They were mostly students (54.2%). On screening, 83 blood samples (6.06%) were seropositive for at least one TTI. The overall prevalence rate of HIV, Syphilis, HBV and HCV among blood donors was 1.3%, 0.2% ,1.6%, 2.9% respectively. There was difference in distribution of the four TTIs among blood donors which is statistically significant (x2=33.997, ϱ-value<0.001). Private donors were associated with a high risk of syphilis and being a first-time donor was associated with a high HBV risk factor.

CONCLUSION

The prevalence of TTIs found still to be high; mandatory and continuous screening is necessary.

Navigating Evolving Challenges in Blood Safety

Blood safety remains a paramount public health concern, and health authorities maintain a high level of vigilance to prevent transfusion-transmitted infections (TTIs) [...].

Evaluation of the efficacy and safety of amustaline/glutathione pathogen-reduced RBCs in complex cardiac surgery: the Red Cell Pathogen Inactivation (ReCePI) study-protocol for a phase 3, randomized, controlled trial

BACKGROUND

Red blood cell (RBC) transfusion is a critical supportive therapy in cardiovascular surgery (CVS). Donor selection and testing have reduced the risk of transfusion-transmitted infections; however, risks remain from bacteria, emerging viruses, pathogens for which testing is not performed and from residual donor leukocytes. Amustaline (S-303)/glutathione (GSH) treatment pathogen reduction technology is designed to inactivate a broad spectrum of infectious agents and leukocytes in RBC concentrates. The ReCePI study is a Phase 3 clinical trial designed to evaluate the efficacy and safety of pathogen-reduced RBCs transfused for acute anemia in CVS compared to conventional RBCs, and to assess the clinical significance of treatment-emergent RBC antibodies.

METHODS

ReCePI is a prospective, multicenter, randomized, double-blinded, active-controlled, parallel-design, non-inferiority study. Eligible subjects will be randomized up to 7 days before surgery to receive either leukoreduced Test (pathogen reduced) or Control (conventional) RBCs from surgery up to day 7 post-surgery. The primary efficacy endpoint is the proportion of patients transfused with at least one study transfusion with an acute kidney injury (AKI) diagnosis defined as any increased serum creatinine (sCr) level ≥ 0.3 mg/dL (or 26.5 µmol/L) from pre-surgery baseline within 48 ± 4 h of the end of surgery. The primary safety endpoints are the proportion of patients with any treatment-emergent adverse events (TEAEs) related to study RBC transfusion through 28 days, and the proportion of patients with treatment-emergent antibodies with confirmed specificity to pathogen-reduced RBCs through 75 days after the last study transfusion. With ≥ 292 evaluable, transfused patients (> 146 per arm), the study has 80% power to demonstrate non-inferiority, defined as a Test group AKI incidence increase of no more than 50% of the Control group rate, assuming a Control incidence of 30%.

DISCUSSION

RBCs are transfused to prevent tissue hypoxia caused by surgery-induced bleeding and anemia. AKI is a sensitive indicator of renal hypoxia and a novel endpoint for assessing RBC efficacy. The ReCePI study is intended to demonstrate the non-inferiority of pathogen-reduced RBCs to conventional RBCs in the support of renal tissue oxygenation due to acute anemia and to characterize the incidence of treatment-related antibodies to RBCs.

Supplemental findings of the 2021 National Blood Collection and Utilization Survey

BACKGROUND

The Department of Health and Human Services' National Blood Collection and Utilization Survey (NBCUS) has been conducted biennially since 1997. Data are used to estimate national blood collection and use. Supplemental data from the 2021 NBCUS not presented elsewhere are presented here.

METHODS

Data on survey participation, donor characteristics, blood component cost, transfusion-associated adverse reactions, and implementation of blood safety measures, including pathogen-reduction of platelets, during 2021, were analyzed. Comparisons are made to 2019 survey data where available (2013-2019 for survey participation).

RESULTS

During 2021, there were 11,507,000 successful blood donations in the United States, a 4.8% increase from 2019. Persons aged 45-64 years accounted for 42% of all successful blood donations. Donations by persons aged 65 years and older increased by 40.7%, while donations among minorities and donors aged <25 years decreased. From 2019 to 2021, the median price hospitals paid per unit of leukoreduced red blood cells, leukoreduced and pathogen-reduced apheresis platelets, and fresh frozen plasma increased. The largest increase in price per unit of blood component in 2021 was for leukoreduced apheresis platelets, which increased by ~$51. Between 2019 and 2021, the proportion of transfusing facilities reporting use of pathogen-reduced platelets increased, from 13% to 60%. Transfusion-related adverse reactions declined slightly between 2019 and 2021, although the rate of transfusion-transmitted bacterial infections remained unchanged.

CONCLUSION

During 2021, blood donations increased nationally, although donations from those aged <25 years and minorities declined. The prices hospitals paid for most blood products increased, as did the use of pathogen-reduced platelets.

Posttransfusion Sepsis Attributable to Bacterial Contamination in Platelet Collection Set Manufacturing Facility, United States

During May 2018‒December 2022, we reviewed transfusion-transmitted sepsis cases in the United States attributable to polymicrobial contaminated apheresis platelet components, including Acinetobacter calcoaceticus‒baumannii complex or Staphylococcus saprophyticus isolated from patients and components. Transfused platelet components underwent bacterial risk control strategies (primary culture, pathogen reduction or primary culture, and secondary rapid test) before transfusion. Environmental samples were collected from a platelet collection set manufacturing facility. Seven sepsis cases from 6 platelet donations from 6 different donors were identified in patients from 6 states; 3 patients died. Cultures identified Acinetobacter calcoaceticus‒baumannii complex in 6 patients and 6 transfused platelets, S. saprophyticus in 4 patients and 4 transfused platelets. Whole-genome sequencing showed environmental isolates from the manufacturer were closely related genetically to patient and platelet isolates, indicating the manufacturer was the most probable source of recurrent polymicrobial contamination. Clinicians should maintain awareness of possible transfusion-transmitted sepsis even when using bacterial risk control strategies.

Transmission of yellow fever vaccine virus through blood transfusion and organ transplantation in the USA in 2021: report of an investigation

BACKGROUND

In 2021, four patients who had received solid organ transplants in the USA developed encephalitis beginning 2-6 weeks after transplantation from a common organ donor. We describe an investigation into the cause of encephalitis in these patients.

METHODS

From Nov 7, 2021, to Feb 24, 2022, we conducted a public health investigation involving 15 agencies and medical centres in the USA. We tested various specimens (blood, cerebrospinal fluid, intraocular fluid, serum, and tissues) from the organ donor and recipients by serology, RT-PCR, immunohistochemistry, metagenomic next-generation sequencing, and host gene expression, and conducted a traceback of blood transfusions received by the organ donor.

FINDINGS

We identified one read from yellow fever virus in cerebrospinal fluid from the recipient of a kidney using metagenomic next-generation sequencing. Recent infection with yellow fever virus was confirmed in all four organ recipients by identification of yellow fever virus RNA consistent with the 17D vaccine strain in brain tissue from one recipient and seroconversion after transplantation in three recipients. Two patients recovered and two patients had no neurological recovery and died. 3 days before organ procurement, the organ donor received a blood transfusion from a donor who had received a yellow fever vaccine 6 days before blood donation.

INTERPRETATION

This investigation substantiates the use of metagenomic next-generation sequencing for the broad-based detection of rare or unexpected pathogens. Health-care workers providing vaccinations should inform patients of the need to defer blood donation for at least 2 weeks after receiving a yellow fever vaccine. Despite mitigation strategies and safety interventions, a low risk of transfusion-transmitted infections remains.

FUNDING

US Centers for Disease Control and Prevention (CDC), the Biomedical Advanced Research and Development Authority, and the CDC Epidemiology and Laboratory Capacity Cooperative Agreement for Infectious Diseases.

Transfusion-Transmitted Disorders 2023 with Special Attention to Bone Marrow Transplant Patients

Transfusion medicine is traditionally a strong/fundamental part of clinical practice, saving hundreds of millions of lives. However, blood-borne or transmitted infections are a well-known and feared possibility, a risk we relentlessly mitigate. Pathogens are continuously and rather quickly changing, so during the last decade, many, sometimes exotic, new pathogens and diseases were recorded and analyzed, and some of them were proved to be transmitted with transfusions. Blood or blood component transfusions are carried out after cautious preparative screening and inactivation maneuvers, but in some instances, newly recognized agents might escape from standard screening and inactivation procedures. Here, we try to focus on some of these proven or potentially pathogenic transfusion-transmitted agents, especially in immunocompromised patients or bone marrow transplantation settings. These pathogens are sometimes new challenges for preparative procedures, and there is a need for more recent, occasionally advanced, screening and inactivation methods to recognize and eliminate the threat a new or well-known pathogen can pose. Pathogen transmission is probably even more critical in hemophiliacs or bone marrow transplant recipients, who receive plasma-derived factor preparations or blood component transfusions regularly and in large quantities, sometimes in severely immunosuppressed conditions. Moreover, it may not be emphasized enough that transfusions and plasma-derived product administrations are essential to medical care. Therefore, blood-borne transmission needs continued alertness and efforts to attain optimal benefits with minimized hazards.

RND Pump-Mediated Efflux of Amotosalen, a Compound Used in Pathogen Inactivation Technology to Enhance Safety of Blood Transfusion Products, May Compromise Its Gram-Negative Anti-Bacterial Activity

Pathogen inactivation is a strategy to improve the safety of transfusion products. The only pathogen reduction technology for blood products currently approved in the US utilizes a psoralen compound, called amotosalen, in combination with UVA light to inactivate bacteria, viruses, and protozoa. Psoralens have structural similarity to bacterial multidrug efflux pump substrates. As these efflux pumps are often overexpressed in multidrug-resistant pathogens, we tested whether contemporary drug-resistant pathogens might show resistance to amotosalen and other psoralens based on multidrug efflux mechanisms through genetic, biophysical, and molecular modeling analysis. The main efflux systems in Enterobacterales, Acinetobacter baumannii, and Pseudomonas aeruginosa are tripartite resistance-nodulation-cell division (RND) systems, which span the inner and outer membranes of Gram-negative pathogens, and expel antibiotics from the bacterial cytoplasm into the extracellular space. We provide evidence that amotosalen is an efflux substrate for the E. coli AcrAB, Acinetobacter baumannii AdeABC, and P. aeruginosa MexXY RND efflux pumps. Furthermore, we show that the MICs for contemporary Gram-negative bacterial isolates for these species and others in vitro approached and exceeded the concentration of amotosalen used in the approved platelet and plasma inactivation procedures. These findings suggest that otherwise safe and effective inactivation methods should be further studied to identify possible gaps in their ability to inactivate contemporary, multidrug-resistant bacterial pathogens. IMPORTANCE Pathogen inactivation is a strategy to enhance the safety of transfused blood products. We identify the compound, amotosalen, widely used for pathogen inactivation, as a bacterial multidrug efflux substrate. Specifically, experiments suggest that amotosalen is pumped out of bacteria by major efflux pumps in E. coli, Acinetobacter baumannii, and Pseudomonas aeruginosa. Such efflux pumps are often overexpressed in multidrug-resistant pathogens. Importantly, the MICs for contemporary multidrug-resistant Enterobacterales, Acinetobacter baumannii, Pseudomonas aeruginosa, Burkholderia spp., and Stenotrophomonas maltophilia isolates approached or exceeded the amotosalen concentration used in approved platelet and plasma inactivation procedures, potentially as a result of efflux pump activity. Although there are important differences in methodology between our experiments and blood product pathogen inactivation, these findings suggest that otherwise safe and effective inactivation methods should be further studied to identify possible gaps in their ability to inactivate contemporary, multidrug-resistant bacterial pathogens.

Presence of Gram-negative bacteria and Staphylococcus aureus on the skin of blood donors in the Democratic Republic of the Congo

BACKGROUND

Skin bacteria may contaminate blood products but few data are available on sub-Saharan Africa (sSA). We assessed the presence of Gram-negative bacteria and Staphylococcus aureus on blood donor skin and evaluated skin antisepsis in the Democratic Republic of the Congo (DRC).

STUDY DESIGN AND METHODS

Among blood donors at the National Blood Transfusion Center (NBTC) and at a rural hospital, the antecubital fossa skin of the non-disinfected arm (not used for blood collection) was swabbed (25cm² surface) and cultured for total and Gram-negative bacterial counts. Bacteria were identified with MALDI-TOF and tested for antibiotic susceptibility by disk diffusion. For evaluation of the NBTC antisepsis procedure (i.e., ethanol 70%), the culture results of the disinfected arm (used for blood collection) were compared with those of the non-disinfected arm.

RESULTS

Median total bacterial counts on 161 studied non-disinfected arms were 1065 Colony-Forming Units (CFU) per 25 cm² , with 43.8% (70/160) of blood donors growing Gram-negative bacteria and 3.8% (6/159) Staphylococcus aureus (2/6 methicillin-resistant). Non-fermentative Gram-negative rods predominated (74/93 isolates, majority Pseudomonas spp., Acinetobacter spp.). Enterobacterales comprised 19/93 isolates (mostly Pantoea spp. and Enterobacter spp.), 5/19 were multidrug-resistant. In only two cases (1.9%, 2/108) the NBTC antisepsis procedure met the acceptance criterion of ≤2 CFU/25 cm² .

CONCLUSION

Skin bacterial counts and species among blood donors in DRC were similar to previously studied Caucasian populations, including cold-tolerating species and bacteria previously described in transfusion reactions. Prevention of contamination (e.g., antisepsis) needs further evaluation and customization to sSA.

Staphylococcal Enterotoxins Enhance Biofilm Formation by Staphylococcus aureus in Platelet Concentrates

Biofilm formation and slow growth by Staphylococcus aureus in platelet concentrates (PCs) cause missed detection of this bacterium during routine PC screening with automated culture systems. This heightens the chances of false-negative screening transfusions and pre-disposes transfusion patients to an elevated risk of sepsis due to secretion of staphylococcal enterotoxins (SEs) in PCs. A hybrid approach of comparative RNAseq analyses and CRISPR mutagenesis of SE genes was employed to investigate the effect of SEs in S. aureus growth and biofilm formation in PCs. RNAseq data showed no differential expression for key biofilm genes, whereas SE genes were upregulated (>0.5- to 3.6-fold change) in PCs compared to trypticase soy broth (TSB). Remarkably, growth and biofilm formation assays revealed increased growth for the S. aureus SE mutants, while their ability to form biofilms was significantly impaired (−6.8- to −2.4-fold change) in comparison to the wild type strain, in both PCs and TSB. Through the well-established superantigen mechanism of SEs, we propose three roles for SEs during biofilm development in PCs: (1) provide a scaffold for biofilm matrix, (2) mediate cell-to-cell aggregation, and (3) guarantee biofilm survival. Furthermore, SE contribution to both growth and biofilm development seems to be centrally regulated by agr via quorum sensing and by saeSR and sigB. This study reveals new roles for SEs, which enforce their relevance in ensuring PC safety for transfusion patients. It further deciphers the underlying reasons for failed S. aureus detection in PCs during screening with automated culture systems.

Blood Transfusion Reactions-A Comprehensive Review of the Literature including a Swiss Perspective

Blood transfusions have been the cornerstone of life support since the introduction of the ABO classification in the 20th century. The physiologic goal is to restore adequate tissue oxygenation when the demand exceeds the offer. Although it can be a life-saving therapy, blood transfusions can lead to serious adverse effects, and it is essential that physicians remain up to date with the current literature and are aware of the pathophysiology, initial management and risks of each type of transfusion reaction. We aim to provide a structured overview of the pathophysiology, clinical presentation, diagnostic approach and management of acute transfusion reactions based on the literature available in 2022. The numbers of blood transfusions, transfusion reactions and the reporting rate of transfusion reactions differ between countries in Europe. The most frequent transfusion reactions in 2020 were alloimmunizations, febrile non-hemolytic transfusion reactions and allergic transfusion reactions. Transfusion-related acute lung injury, transfusion-associated circulatory overload and septic transfusion reactions were less frequent. Furthermore, the COVID-19 pandemic has challenged the healthcare system with decreasing blood donations and blood supplies, as well as rising concerns within the medical community but also in patients about blood safety and transfusion reactions in COVID-19 patients. The best way to prevent transfusion reactions is to avoid unnecessary blood transfusions and maintain a transfusion-restrictive strategy. Any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system. The initial management of blood transfusion reactions requires early identification, immediate interruption of the transfusion, early consultation of the hematologic and ICU departments and fluid resuscitation.

Blockchain technology: a troubleshooter for blood cold chains

Purpose

Blood cold chain (BCC) represents a system for preserving the blood during its journey from the donor to the ultimate transfusion site. Existing BCCs have many drawbacks related to information transparency and information security. Secured and real-time information sharing in BCC can bring several benefits. The purpose of this paper is to summarise the issues in typical BCCs and to explore the scope of blockchain in the management of BCCs.

Design/methodology/approach

Issues in the existing BCCs are identified through a narrative review. To explain the potential of blockchain in mitigating these issues, a blockchain-based traceability solution is demonstrated with respect to a particular BCC scenario. The BCC management system discussed in this study makes use of the Ethereum blockchain’s smart contract feature and internet of things (IoT) technology. The smart contract is written in the solidity programming language and tested and validated using the Remix integrated development environment.

Findings

BCCs are concerned with several issues both from technical and non-technical perspectives. Blockchain technology is capable of troubleshooting the issues in the existing BCCs. Combining blockchain and IoT technology enables real-time information sharing among the entities. The demonstration presented in this work depicts how the blockchain-based smart contract can support operations in a typical BCC.

Research limitations/implications

This paper explores the scope of blockchain in BCCs through a demonstration. To get insights into its technical and economical feasibilities, further investigations are needed.

Originality/value

Blockchain-based traceability system presented in this work can be adopted in BCCs to ensure the quality of blood or blood products. Blockchain-based smart contracts can aid the BCCs to achieve a proper balance between blood shortage and outdating.

Freeze-dried platelets are a promising alternative in bleeding thrombocytopenic patients with hematological malignancies

Thrombosomes are trehalose-stabilized, freeze-dried group O platelets with a 3-year shelf life. They can be stockpiled, rapidly reconstituted, and infused regardless of the recipient's blood type. Thrombosomes thus represent a potential alternative platelet transfusion strategy. The present study assessed the safety and potential early signals of efficacy of Thrombosomes in bleeding thrombocytopenic patients. We performed an open-label, phase 1 study of single doses of allogeneic Thrombosomes at three dose levels in three cohorts, each consisting of eight patients who had hematologic malignancies, thrombocytopenia, and bleeding. Adverse events, dose-limiting toxicities (DLTs), World Health Organization (WHO) bleeding scores, and hematology values were assessed. No DLTs were reported. The median age was 59 years (24-71). Most patients had AML (58%) or ALL (29%), followed by MDS (8%) and myeloproliferative neoplasm (4%). The WHO scores of 22 patients who were actively bleeding at a total of 27 sites at baseline either improved (n = 17 [63%]) or stabilized (n = 10 [37%]) through day 6. Twenty-four hours after infusion, 12 patients (50%) had a clinically significant platelet count increase. Of eight patients who received no platelet transfusions for 6 days after Thrombosomes infusion, 5 had a clinically significant increase in platelet count of ≥5000 platelets/μL and 2 had platelet count normalization. Thrombosomes doses up to 3.78 × 10⁸ particles/kg demonstrated safety in 24 bleeding, thrombocytopenic patients with hematological malignancies. Thrombosomes may represent an alternative to conventional platelets to treat bleeding. A phase 2 clinical trial in a similar patient population is underway.

The international experience of bacterial screen testing of platelet components with automated microbial detection systems: An update

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.

Expanded validation of the effect and quality of a pathogen inactivation system based on riboflavin photochemistry on platelet bacterial contamination

Background

Bacterial contamination still poses serious challenges to blood safety. Platelets have the highest bacterial contamination risk of all blood components.

Methods

Twenty units of manual platelets were prepared from blood donated by our hospital, which were inoculated with Staphylococcus aureus and Escherichia coli suspensions. The riboflavin sodium phosphate solution was added into platelets, adjusted to a final concentration of 160 μmol/L. Platelets added into an illumination bag and placed in the inactivation system for riboflavin photochemistry at various doses. The inactivation effect of bacteria was evaluated on a Columbia blood agar plate by the plate counting method. Meanwhile, the blood routine, blood gas analysis, platelet aggregation test, and thromboelastogram of platelets before and after treatment were detected to evaluate the changes of platelet quality after treatment.

Results

the inactivation effect of S. aureus and E. coli at the inactivation dose (16.9 J/cm²) could reach more than 4 logs. After treatment at 16.9 J/cm², the blood routine results showed that the platelet count was significantly different (P<0.05), and the blood gas analysis showed that the oxygen partial pressure (pO₂) and lactic acid concentration (cLac) were also significantly different (P<0.05). After 16.9 J/cm² treatment, there was a significant difference between Arachidonic acid (AA) and Collagen (Cog) activator groups in the platelet aggregation experiment (P<0.05), but there was no significant difference in the main thrombelastogram (TEG) parameters (R value, K value, angle value, MA value) after treatment (P>0.05).

Conclusions

The inactivation effect of this set of blood component pathogen inactivation system on platelet bacterial contamination could be considered to meet actual clinical needs, with the inactivation treatment having little impact on platelet function.

Acquired platelet storage container leaks and contamination with environmental bacteria: A preventable cause of bacterial sepsis

Background

Apheresis platelets (AP) may be contaminated by environmental bacteria via container defects acquired during processing, transport, storage, or transfusion, as highlighted by a recent series of septic reactions related to Acinetobacter spp. and other bacterial strains.

Study design and methods

The frequency and nature of acquired container defect reports to one manufacturer were evaluated from January 2019 to July 2020. The published incidence of contamination and sepsis due to environmental bacteria with culture screened AP in the United States was reviewed for the period of 2010–2019.

Results

Review of a manufacturers' records showed 23 US reports of leaks involving 24 containers attributed to postmanufacturing damage, at a rate of 44 per million distributed storage containers. Analysis of returned containers showed evidence of scratches, impressions, and/or piercings. Literature review of US hemovigilance data revealed that environmental bacteria comprised 7% of confirmed positive primary bacterial culture screens, were responsible for 14%–16% of reported septic, and 8 of 28 (29%) fatal reactions with bacterial‐culture screened AP. Sepsis cases have been reported with culture screened, point‐of‐issue (POI) tested, or pathogen‐reduced AP.

Discussion

Environmental contamination of AP is rare but can cause sepsis. Container damage provides a pathway for contamination after culture screening, POI bacteria testing, or pathogen reduction. Blood collectors and transfusion services should have procedures to ensure proper inspection, handling, storage, and transport of AP to avoid damage and should enhance efforts to detect defects prior to release and to eliminate bacteria from all contacting surfaces to minimize the risk of contamination.

Lack of Cost-Effectiveness of Preoperative Erythropoiesis-Stimulating Agents and/or Iron Therapy in Anaemic, Elective Surgery Patients: A Systematic Review and Updated Analysis

OBJECTIVES

For anaemic elective surgery patients, current clinical practice guidelines weakly recommend the routine use of iron, but not erythrocyte-stimulating agents (ESAs), except for short-acting ESAs in major orthopaedic surgery. This recommendation is, however, not based on any cost-effectiveness studies. The aim of this research was to (1) systematically review the literature regarding cost effectiveness of preoperative iron and/or ESAs in anaemic, elective surgery patients and (2) update existing economic evaluations (EEs) with recent data.

METHODS

Eight databases and registries were searched for EEs and randomized controlled trials (RCTs) reporting cost-effectiveness data on November 11, 2020. Data were extracted, narratively synthesized and critically appraised using the Philips reporting checklist. Pre-existing full EEs were updated with effectiveness data from a recent systematic review and current cost data. Incremental cost-effectiveness ratios were expressed as cost per (quality-adjusted) life-year [(QA)LY] gained.

RESULTS

Only five studies (4 EEs and 1 RCT) were included, one on intravenous iron and four on ESAs + oral iron. The EE on intravenous iron only had an in-hospital time horizon. Therefore, cost effectiveness of preoperative iron remains uncertain. The three EEs on ESAs had a lifetime time horizon, but reported cost per (QA)LY gained of 20-65 million (GBP or CAD). Updating these analyses with current data confirmed ESAs to have a cost per (QA)LY gained of 3.5-120 million (GBP or CAD).

CONCLUSIONS

Cost effectiveness of preoperative iron is unproven, whereas routine preoperative ESA therapy cannot be considered cost effective in elective surgery, based on the limited available data. Future guidelines should reflect these findings.

Platelet transfusion practice and related transfusion reactions in a large teaching hospital

BACKGROUND

Platelet transfusion practice varies widely since many aspects of platelet concentrate (PC) use have not been definitively determined. The objectives of this retrospective study were to present platelet transfusion practice and evaluate PC and patient characteristics, as well as their association with transfusion reaction (TR) rate.

MATERIAL AND METHODS

Platelet transfusions over a 5-year period were analysed regarding PC characteristics (the ABO and RhD compatibility, product type, and storage duration), patient characteristics (most responsible diagnosis, age, and gender), and TR type.

RESULTS

A total of 46,351 PCs were transfused: 76.4% whole blood-derived (WBD) and 23.6% single donor apheresis (SDA). Three thousand seven hundred seventy-six patients received platelet transfusions: 24.7% paediatric and 75.3% adult patients, 79.6% outpatients and 20.4% inpatients. As much as 63.1% of all transfused PCs were fresh (stored for≤3 days), 98.0% ABO-identical, and 87.3% of all PCs given to RhD- patients were RhD-. PCs were mainly transfused to haemato-oncology (76.8%) and cardiovascular surgery patients (6.5%). Overall, 84 (0.18%) TRs were reported, with allergic TRs (ATRs) being the most common. Although PC ABO compatibility and storage duration, as well as patient age and gender, showed differences in TR rate, only the use of PCs in platelet additive solution (PAS) showed a statistically significant reduction of TRs (P<0.001).

CONCLUSION

Transfusion practice at the University Hospital Centre Zagreb resulted in almost all patients receiving ABO and RhD identical PCs, and most of them were fresh PCs. The most important factor affecting the incidence of TRs was platelet storage solution. The use of PAS effectively reduced the rate of TRs, particularly allergic TRs.

Challenging the 30-min rule for thawed plasma

BACKGROUND AND OBJECTIVES

Frozen plasma (FP) is thawed prior to transfusion and stored for ≤5 days at 1-6°C. The effect of temperature excursions on the quality and safety of thawed plasma during 5-day storage was determined.

MATERIALS AND METHODS

Four plasma units were pooled, split and stored at ≤-18°C for ≤90 days. Test units T30 and T60 were exposed to 20-24°C (room temperature [RT]) for 30 or 60 min, respectively, on days 0 and 2 of storage. Negative and positive control units remained refrigerated or at RT for 5 days, respectively. On Day 5, test units were exposed once to RT for 5 h. Quality assays included stability of coagulation factors FV, FVII, FVIII, fibrinogen and prothrombin time. Bacterial growth was performed in units inoculated with ~1 CFU/ml or ~100 CFU/ml of Serratia liquefaciens, Pseudomonas putida, Pseudomonas aeruginosa or Staphylococcus epidermidis on Day 0.

RESULTS

Testing results of all quality parameters were comparable between T30 and T60 units (p < 0.05). Serratia liquefaciens proliferated in cold-stored plasma, while P. putida showed variable viability. Serratia epidermidis and P. aeruginosa survived but did not grow in cold-stored plasma. Positive and negative controls showed expected results. Overall, no statistical differences in bacterial concentration between T30 and T60 units were observed (p < 0.05).

CONCLUSION

Multiple RT exposures for 30 or 60 min do not affect the stability of coagulation factors or promote bacterial growth in thawed plasma stored for 5 days. It is therefore safe to expose thawed plasma to uncontrolled temperatures for limited periods of 60 min.

Transfusion-associated adverse events and implementation of blood safety measures - findings from the 2017 National Blood Collection and Utilization Survey

BACKGROUND

Serious transfusion-associated adverse events are rare in the United States. To enhance blood safety, various measures have been developed. With use of data from the 2017 National Blood Collection and Utilization Survey (NBCUS), we describe the rate of transfusion-associated adverse events and the implementation of specific blood safety measures.

STUDY DESIGN AND METHODS

Data from the 2017 NBCUS were used with comparison to already published estimates from 2015. Survey weighting and imputation were used to obtain national estimates of transfusion-associated adverse events, and the number of units treated with pathogen reduction technology (PRT), screened for Babesia, and leukoreduced.

RESULTS

The rate of transfusion-associated adverse events requiring any diagnostic or therapeutic interventions was stable (275 reactions per 100,000 transfusions in 2015 and 282 reactions per 100,000 transfusions in 2017). In 2017 among US blood collection centers, 16 of 141 (11.3%) reported screening units for Babesia and 28 of 144 (19.4%) reported PRT implementation; 138 of 2279 (6.1%) hospitals reported transfusing PRT-treated platelets. In 2017, 134 of 2336 (5.7%) hospitals reported performing secondary bacterial testing of platelets (50,922 culture-based and 63,220 rapid immunoassay tests); in 2015, 71 of 1877 (3.8%) hospitals performed secondary testing (87,155 culture-based and 21,779 rapid immunoassay tests). Nearly all whole blood/red blood cell units and platelet units were leukoreduced.

CONCLUSIONS

Besides leukoreduction, implementation of most blood safety measures reported in this study remains low. Nationally, hospitals might be shifting from culture-based secondary bacterial testing to rapid immunoassays.

Limitations of current practices in detection of bacterially contaminated blood products associated with suspected septic transfusion reactions

BACKGROUND

In the setting of suspected septic transfusion reactions, bacterial culture of both the transfused patient and the residual blood component is recommended. Primary bacterial contamination can occur at the time of component collection. Clinically insignificant "secondary contamination" can occur during post-transfusion component discard, retrieval for culture, or manipulation of the bag at the time of culture sampling.

STUDY DESIGN AND METHODS

This retrospective, multi-center study analyzes positive residual component culture results and companion patient blood cultures from 15 hospitals, 1 blood center, and all cultured transfusion reactions within the province of Quebec, Canada, over a 5-year period. Imputability was assigned as "definite" (concordant growth), "possible" (discordant growth or lack of growth in patient culture), or "unable to assess" (patient not cultured).

RESULTS

There were 373 positive component cultures from 360 unique transfusion reactions, with 276 (76.7%) companion patient blood cultures performed, of which 10 (2.8%) yielded the pathogen detected in the positive component. Of these 10 definite pathogens, 7 (2 Staphylococcus aureus, 3 other staphylococci, and 1 Streptococcus pyogenes and 1 Bacillus sp.) were associated with platelet and 3 (Aeromonas veronii, Staphylococcus epidermidis, and Enterococcus faecalis) with RBC transfusions. RBC and plasma components comprised 70% of positive component cultures.

DISCUSSION

The process of performing residual component culture is vulnerable to secondary contamination. The significance of microorganisms recovered from component culture cannot be interpreted in isolation. In the context of low prevalence of primary contamination of blood components, the positive predictive value of a positive component culture result is very low.

Platelet Transfusion-Insights from Current Practice to Future Development

Since the late sixties, therapeutic or prophylactic platelet transfusion has been used to relieve hemorrhagic complications of patients with, e.g., thrombocytopenia, platelet dysfunction, and injuries, and is an essential part of the supportive care in high dose chemotherapy. Current and upcoming advances will significantly affect present standards. We focus on specific issues, including the comparison of buffy-coat (BPC) and apheresis platelet concentrates (APC); plasma additive solutions (PAS); further measures for improvement of platelet storage quality; pathogen inactivation; and cold storage of platelets. The objective of this article is to give insights from current practice to future development on platelet transfusion, focusing on these selected issues, which have a potentially major impact on forthcoming guidelines.

Transfusion-related adverse reactions: Data from the National Healthcare Safety Network Hemovigilance Module - United States, 2013-2018

BACKGROUND

Despite current blood safety measures, transfusion recipients can experience transfusion-related adverse reactions. Monitoring these reactions can aid in understanding the effectiveness of current transfusion safety measures. Data from the National Healthcare Safety Network Hemovigilance Module were used to quantify adverse reaction risk.

METHODS

Facilities reporting at least one month of transfused blood components and transfusion-related adverse reactions during January 2013-December 2018 were included. Adverse reaction rates (number per 100,000 components transfused) were calculated for transfused components stratified by component type, collection, and modification methods.

RESULTS

During 2013-2018, 201 facilities reported 18,308 transfusion-related adverse reactions among 8.34 million blood components transfused (220/100,000). Adverse reactions were higher among apheresis (486/100,000) and pathogen-reduced platelets (579/100,000) than apheresis red blood cells (197/100,000). Allergic reactions (41%) were most common. There were 23 fatalities and 9% of all adverse reactions were serious (severe, life-threatening, or fatal). Reactions involving pulmonary complications (transfusion-associated circulatory overload, transfusion-related acute lung injury and transfusion-associated dyspnea) accounted for 35% of serious reactions but 65% of fatalities. Most (76%) of the 37 transfusion-transmitted infections were serious; none involved pathogen-reduced components.

CONCLUSIONS

One in 455 blood components transfused was associated with an adverse reaction although the risk of serious reactions (1 in 6224) or transfusion-transmitted infections (1 in 225,440) was lower. Some serious reactions identified were preventable, suggesting additional safety measures may be beneficial. Higher reaction rates identified among pathogen-reduced platelets require further study. These findings highlight the importance of monitoring reactions through national hemovigilance to inform current safety measures and the need for strategies to increase healthcare facility participation.

Fatal sepsis associated with a storage container leak permitting platelet contamination with environmental bacteria after pathogen reduction

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.

The current state of the platelet supply in the US and proposed options to decrease the risk of critical shortages

Due to circumstances such as increased demand and an aging donor pool, the likelihood of critical platelet shortages is increasing. The platelet supply could be improved through the expansion of the donor pool, the identification and sustained utilization of high-quality donors, and changes in component processing and storage that result in a longer platelet shelf-life. Refrigerated platelets, stored at 1° to 6°C, have the potential to improve patient safety by decreasing the risk of bacterial contamination while concurrently allowing for a longer storage period (eg, 14 days) and improved hemostatic effectiveness in actively bleeding patients. An approach utilizing remuneration of apheresis platelet donors combined with pathogen reduction of the platelet components could be used as a means to increase the donor pool and identify and sustain safe, reliable, high-quality donors. Remuneration might provide an incentive for underutilized populations (eg, individuals <30 years old) to enter the apheresis platelet donor population resulting in a significant expansion of the platelet donor pool. Over time, approaches such as the use of refrigerated platelets, platelet donor remuneration, and the application of pathogen reduction technology, might serve to attract a large, reliable, and safe donor base that provides platelet collections with high yields, longer shelf-lives and, excellent hemostatic function.

Platelet transfusion for neonates with thrombocytopaenia: protocol for a systematic review

INTRODUCTION

Thrombocytopaenia is one of the most common haemostatic abnormalities among neonates. It affects approximately one-quarter of neonates admitted into neonatal intensive care units and may lead to a high risk of bleeding and mortality, which are substantial causes for concern by neonatologists. Platelet transfusion (PT) is a specific treatment for thrombocytopaenia. To date, PT thresholds are diverse since the associations between low platelet count and negative outcomes are not clear. We propose this protocol for a systematic review to collect and assess evidence concerning the best PT threshold to reduce mortality, bleeding and major morbidity among neonates with thrombocytopaenia.

METHODS AND ANALYSIS

The systematic review will be performed according to the Cochrane Handbook for Systematic Review of Interventions, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and the Grading of Recommendations Assessment, Development and Evaluation system. Two independent researchers will perform the study selection, data extraction/coding, quality assessment and further analyses of the included studies, with disagreements being resolved by a third researcher. A systematic search of the literature will be conducted in the PubMed, Cochrane Library and Embase databases from database inception through 13 October 2020. All randomised controlled trials, cohort studies and case-control studies will be included without any restrictions regarding publication date or language. The primary outcomes will comprise in-hospital mortality and bleeding episodes. Endnote X9 and Review Manager V.5.3 software will be used to manage the selection process and statistical analysis, respectively. If the included studies are sufficient and homogeneous for any of the outcomes, a quantitative synthesis (meta-analysis) may be performed. Otherwise, we will conduct a narrative systematic review of the results.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study because the data will be obtained from published studies and will not include individual patient data. The results of this study are anticipated to be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020169262.

A consideration of convalescent plasma and plasma derivatives in the care of Severely-ill patients with COVID-19

The pathogenesis and immunopathological damage of severe forms of COVID-19 resemble acute autoimmune disease sparked by SARS-CoV-2, including an early systemic overproduction of proinflammatory cytokines. Such immunopathological features provide a rationale for the use of passive immunotherapy with convalescent plasma as a source of neutralizing anti-viral antibodies and of anti-inflammatory plasma components. While convalescent plasma therapy is now being evaluated in prospective clinical trials, we further consider the therapeutic potential of human hyper immune globulins, and of heterologous, engineered and monoclonal neutralizing antibodies as anti-viral agents to treat COVID-19. Good medical practice procedures are still needed and is why we also discuss the potential use of polyclonal polyspecific immunoglobulins (IVIG), a therapeutic plasma derivative, with potent anti-inflammatory activity, in severe forms of Covid-19.

Sepsis from an apheresis platelet contaminated with Acinetobacter calcoaceticus/baumannii complex bacteria and Staphylococcus saprophyticus after pathogen reduction

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.

Current advances in transfusion medicine: a 2019 review of selected topics from the AABB Clinical Transfusion Medicine Committee

BACKGROUND

The AABB Clinical Transfusion Medicine Committee (CTMC) compiles an annual synopsis of the published literature covering important developments in the field of transfusion medicine (TM) for the board of director's review. This synopsis is now made available as a manuscript published in TRANSFUSION.

STUDY DESIGN AND METHODS

CTMC committee members review original manuscripts including TM-related topics published in different journals between late 2018 and 2019. The selection of topics and manuscripts are discussed at committee meetings and are chosen based on relevance and originality. After the topics and manuscripts are selected, committee members work in pairs to create a synopsis of the topics, which is then reviewed by two committee members. The first and senior authors of this manuscript assembled the final manuscript. Although this synopsis is comprehensive, it is not exhaustive, and some papers may have been excluded or missed.

RESULTS

The following topics are included: infectious risks to the blood supply, iron donor studies, pre-transfusion testing interference and genotyping, cold agglutinin disease (CAD), HLA alloimmunization in platelet transfusions, patient blood management, updates to TACO and TRALI definitions, pediatric TM, and advances in apheresis medicine.

CONCLUSION

This synopsis provides easy access to relevant topics and may be useful as an educational tool.

New strategies for the control of infectious and parasitic diseases in blood donors: the impact of pathogen inactivation methods

Around 70 infectious agents are possible threats for blood safety.

The risk for blood recipients is increasing because of new emergent agents like West Nile, Zika and Chikungunya viruses, or parasites such as Plasmodium and Trypanosoma cruzi in non-endemic regions, for instance.

Screening programmes of the donors are more and more implemented in several Countries, but these cannot prevent completely infections, especially when they are caused by new agents.

Pathogen inactivation (PI) methods might overcome the limits of the screening and different technologies have been set up in the last years.

This review aims to describe the most widely used methods focusing on their efficacy as well as on the preservation integrity of blood components.

Pseudomonas poae-Associated Fatal Septic Transfusion Reaction, Peoria, Illinois, USA, 2017

In the United States, fatal transfusion-transmitted infections from red blood cell units are rare. Although this pattern mostly reflects how inhospitable refrigerated red blood cell units are to contaminant growth, fatalities caused by microorganisms that can grow at storage temperature (4°C), but not in standard clinical blood cultures at 37°C, are probably underestimated. We analyzed a fatal red blood cell transfusion in Peoria, Illinois, USA, that occurred in 2017. Samples from the patient's whole blood and the red blood cell unit remained culture-negative during the investigation, despite direct visualization of gram-negative bacilli within the unit immediately after transfusion. We identified the bacteria as Pseudomonas poae, a nonpathogenic pseudomonad carrying multiple cold-shock domain protein genes, and confirmed its cold tolerance and inability to grow at 37°C. Our work indicates transfusion reaction workups need to include testing for psychrophilic organisms, which could explain the cause of other apparently culture-negative transfusion reactions.

A suspected septic transfusion reaction associated with posttransfusion contamination of a platelet pool by vancomycin-resistant Enterococcus faecium

BACKGROUND

Vancomycin-resistant enterococci (VRE) are antibiotic-resistant organisms associated with both colonization and serious life-threatening infection in health care settings. Contamination of platelet concentrates (PCs) with Enterococcus can result in transfusion-transmitted infection.

CASE PRESENTATION

This report describes the investigation of a septic transfusion case involving a 27-year-old male patient with relapsed acute leukemia who was transfused with a 5-day-old buffy coat PC pool and developed fever and rigors.

DISCUSSION

Microbiology testing and pulse-field gel electrophoresis (PFGE) was done on patient blood cultures obtained from peripheral and central lines. Microbiology and molecular testing were also performed on the remaining posttransfusion PC pool, which was refrigerated for 24 hours before microbiology testing. Red blood cell (RBC) and plasma units associated with the implicated PCs were screened for microbial contamination. Patient blood cultures obtained from peripheral and central lines yielded vancomycin-resistant Enterococcus faecium. Gram stain of a sample from the platelet pool was negative but coagulase-negative Staphylococcus (CNST) and VRE were isolated on culture. Antibiotic sensitivity and PFGE profiles of several VRE isolates from the patient before and after transfusion, and the PC pool, revealed that all were closely related. Associated RBC and plasma components tested negative for microbial contamination.

CONCLUSIONS

Microbiological and molecular investigations showed a relationship between VRE isolated from the patient before and after transfusion, and therefore it is postulated that a patient-to-PC retrograde contamination (from either blood or skin) occurred. As the CNST isolated from the PC pool was not isolated from patient samples, its implication in the transfusion event is unknown.

Ensuring safety of the blood supply in the United States: Donor screening, testing, emerging pathogens, and pathogen inactivation

Safety of the blood supply has been a critical aspect of the transfusion medicine field since its inception, including infections that can be passed to a blood product recipient. Reactive efforts to identify potentially infected blood products are used throughout the blood donation process and afterward. Before donation, potential donors are provided educational materials about infection risks, examined and then screened through a series of questions that help temporarily, permanently, or indefinitely defer donors who could harbor acute and/or chronic infections. During donation, aseptic technique and diversion pouches reduce the potential to introduce bacteria into the blood product. Before transfusion, the blood products are tested for several infectious diseases by serology, nucleic acid testing, or a combination. During transfusion, the patient is monitored closely, and suspected transfusion reactions should be reported and investigated. The FDA regularly publishes guidance documents to incorporate knowledge gained regarding transfusion-transmitted infections, so that information can be shared and practices updated so that transfusion-related patient care can be optimized over time. Pathogen reduction processes are being developed and deployed that provide a proactive approach to both recognized and emerging pathogens.

Review of current transfusion therapy and blood banking practices

Transfusion Medicine is a dynamically evolving field. Recent high-quality research has reshaped the paradigms guiding blood transfusion. As increasing evidence supports the benefit of limiting transfusion, guidelines have been developed and disseminated into clinical practice governing optimal transfusion of red cells, platelets, plasma and cryoprecipitate. Concepts ranging from transfusion thresholds to prophylactic use to maximal storage time are addressed in guidelines. Patient blood management programs have developed to implement principles of patient safety through limiting transfusion in clinical practice. Data from National Hemovigilance Surveys showing dramatic declines in blood utilization over the past decade demonstrate the practical uptake of current principles guiding patient safety. In parallel with decreasing use of traditional blood products, the development of new technologies for blood transfusion such as freeze drying and cold storage has accelerated. Approaches to policy decision making to augment blood safety have also changed. Drivers of these changes include a deeper understanding of emerging threats and adverse events based on hemovigilance, and an increasing healthcare system expectation to align blood safety decision making with approaches used in other healthcare disciplines.

Blood utilisation and transfusion reactions in adult patients transfused with conventional or pathogen-reduced platelets

Pathogen-reduced (PR) platelets are routinely used in many countries. Some studies reported changes in platelet and red blood cell (RBC) transfusion requirements in patients who received PR platelets when compared to conventional (CONV) platelets. Over a 28-month period we retrospectively analysed platelet utilisation, RBC transfusion trends, and transfusion reaction rates data from all transfused adult patients transfused at the Yale-New Haven Hospital, New Haven, CT, USA. We determined the number of RBC and platelet components administered between 2 and 24, 48, 72 or 96 h. A total of 3767 patients received 21 907 platelet components (CONV = 8912; PR = 12 995); 1,087 patients received only CONV platelets (1578 components) and 1,466 patients received only PR platelets (2604 components). The number of subsequently transfused platelet components was slightly higher following PR platelet components (P < 0·05); however, fewer RBCs were transfused following PR platelet administration (P < 0·05). The mean time-to-next platelet component transfusion was slightly shorter following PR platelet transfusion (P = 0·002). The rate of non-septic transfusion reactions did not differ (all P > 0·05). Septic transfusion reactions (N = 5) were seen only after CONV platelet transfusions (P = 0·011). These results provide evidence for comparable clinical efficacy of PR and CONV platelets. PR platelets eliminated septic transfusion reactions without increased risk of other types of transfusions with only slight increase in platelet utilisation.

Adverse transfusion reactions in transfused children

Transfusion in paediatrics requires specific guidelines, because child physiology and pathology differ significantly as compared to adults. Adverse transfusion reactions in transfused children also vary in type and frequency, but there is a better understanding of these reactions in adults than in children. However, for the most frequent adverse transfusion reactions, the overall prevalence is higher in children than in adults, with the exception of post-transfusion red blood cell alloimmunisation, which is lower, excluding patients with haemoglobinopathies. In several studies, allergic reactions were the most frequently reported adverse transfusion reaction in paediatrics, and the platelet concentrate the most frequently implicated blood product. Early diagnosis of certain adverse transfusion reactions such as haemosiderosis, is essential in order to initiate the best therapy and obtain a good clinical outcome. The prevention of adverse transfusion reactions in children is required, but needs further clinical studies in paediatrics. Lastly, changes in technology, policy and clinical practices will improve transfusion safety in children.

The long and winding road to pathogen reduction of platelets, red blood cells and whole blood

Pathogen reduction technologies (PRTs) have been developed to further reduce the current very low risks of acquiring transfusion-transmitted infections and promptly respond to emerging infectious threats. An entire portfolio of PRTs suitable for all blood components is not available, but the field is steadily progressing. While PRTs for plasma have been used for many years, PRTs for platelets, red blood cells (RBC) and whole blood (WB) were developed more slowly, due to difficulties in preserving cell functions during storage. Two commercial platelet PRTs use ultra violet (UV) A and UVB light in the presence of amotosalen or riboflavin to inactivate pathogens' nucleic acids, while a third experimental PRT uses UVC light only. Two PRTs for WB and RBC have been tested in experimental clinical trials with storage limited to 21 or 35 days, due to unacceptably high RBC storage lesion beyond these time limits. This review summarizes pre-clinical investigations and selected outcomes from clinical trials using the above PRTs. Further studies are warranted to decrease cell storage lesions after PRT treatment and to test PRTs in different medical and surgical conditions. Affordability remains a major administrative obstacle to PRT use, particularly so in geographical regions with higher risks of transfusion-transmissible infections.