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Bacterial Contamination of Platelet Concentrates: Perspectives for the

Future

Article  in  Laboratory Medicine · April 2010

DOI: 10.1309/LMQO2P2BSG1XXCSH

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 CE Update
Submitted 1.16.10 | Revision Received 2.8.10 | Accepted 2.22.10

Bacterial Contamination of Platelet Concentrates:

Perspectives for the Future
Giorgia Canellini, MD, Sophie Waldvogel, MD, Karin Anderegg, MD, Jean-Daniel Tissot, MD
(Service Régional Vaudois de Transfusion Sanguine, Epalinges, Switzerland)
DOI: 10.1309/LMQO2P2BSG1XXCSH

Abstract acute lung injury or bacterial sepsis. The latter nation as well as strategies to reduce this risk,

Downloaded from http://labmed.oxfordjournals.org/ by guest on December 27, 2015

Several risks are still associated with blood
transfusions. Reduction of transfusion-related
viral transmission has been a priority during
recent decades. Nevertheless, hemovigilance
systems implemented in different countries
clearly highlighted the impact of other severe
adverse events related to transfusions, such as
still remains associated with a high morbidity notably by employing either bacterial detection
and mortality and constitutes the most frequent or inactivation methods.
infectious hazard of transfusion. This complica- Keywords: platelets, transfusion, bacteria,
tion specifically concerns platelet concentrates pathogen detection, pathogen reduction
because of their favorable bacterial growth
conditions. This paper gives a brief overview on
platelet transfusion-related bacterial contami-

After reading this article, readers should be able to discuss the bacterial Blood Banking exam 61001 questions and corresponding answer form
risks of transfusion, their clinical impact, and the approaches used to are located after this CE Update on page 306.
reduce them.

Hemovigilance systems have been established in most
European countries as well as in North America. These systems
consist of reporting transfusion reactions and represent a net-
work of surveillance in order to monitor the risk of allogeneic
blood transfusions. Various systems have been established over
the years, with a somewhat different approach relative to the
country.1 In Switzerland, reporting transfusion events has
become a legal duty since 1998. The hemovigilance system was
implemented in our hospital during the last decade.2 The data,
summarized in Table 1, outline that the incidence as well as
the type of reactions differed upon the blood products trans-
fused. Platelets give rise to more transfusion reactions than red

Table 1_Categories of Transfusion Reactions*

RBCs Platelets Plasma Statistical Significance

Number of units distributed 38,815 4,773 13,033  

Transfusion reactions Number (%) Number (%) Number (%)
Febrile non-hemolytic transfusion reactions 98 (2.5) 22 (4.6) 0 P<0.001
Bacterial contaminations 7 (0.2) 3 (0.6) 0
Allergic reactions 23 (0.6) 17 (3.6) 11 (0.8) P<0.001
Isolated sign or symptom 7 (0.2) 1 (0.2) 0
Transfusion-related acute lung injury 0 1 (0.2) 0
Alloimmunization 1 (<0.1) 7 (1.5) –  
Total 136 (3.5) 51 (10.7) 11 (0.8) P<0.001
*adapted from Michlig et al 2 with publisher’s permission.

Corresponding Author Abbreviations

Giorgia Canellini, MD RBCs, red blood cells; NAT, nucleic acid amplification techniques;
giorgia.canellini@mavietonsang.ch CAD, compound adsorption device; PCR, polymerase chain
reaction; QALY, quality-adjusted life year

labmedicine.com May 2010 ■ Volume 41 Number 5 ■ LABMEDICINE 301

CE Update
blood cells (RBCs) and fresh frozen plasma, especially regard-
ing febrile and allergic events. Most of the time, these febrile
reactions remain minor and are rarely associated with bacterial
contamination.3 However, this diagnosis depends directly on
the quality of bacteriological testing.
Decreasing the risk of transfusion-related viral transmis-
sions has been a priority for all blood transfusion services
worldwide. The introduction of blood donation screening with
antibody testing followed by nucleic acid amplification tech-
niques (NAT) have efficiently contributed to this risk reduc-
tion during the last decade. Nevertheless, transfusion remains
under the threat of a variety of blood-transmitted pathogens
(viruses, protozoa, helminths, prions, or bacteria), and bacterial
contamination of blood products emerges as the most frequent
infectious hazard of transfusion.4,5
The purpose of this review is to describe the clinical impact
of platelet transfusion-related bacterial infections, and to out-
line the different approaches used to decrease this risk.
Estimated Risks
Septic reactions are more commonly seen in platelet
transfusions as opposed to RBCs. This is mainly due to their
storage at room temperature, which promotes the growth of
even small bacterial inoculums. The risk of bacterial transfu-
sion reactions may vary according to the type and shelf life of
platelet products. As bacteria continue to proliferate over time,
the bacterial load increases, and the risk of sepsis is enhanced
consequently with older platelet units.6 Studies report a 5-fold
higher contamination rate between whole blood-derived and
single-donor apheresis platelets, due to the increased number
of phlebotomy involved in the collection of pooled platelets.7
Moreover, the increased rate of platelet transfusion-related
infections is directly associated with the age of transfused units,
leading the FDA to reduce the length of platelet storage from 7
to 5 days in 1986.8
Bacterial contamination occurs in about 1/3000 platelet
units and can lead to sepsis in 1 out of 6 contaminated prod-
ucts.5 In the United States, this residual risk has been halved
after the introduction of platelet bacterial testing in 2004
and is estimated at 1/6000 contaminated platelet products,
1/100000 septic reactions, and 1/500000 fatalities per distrib-
uted component.6,9 Nevertheless, platelet bacterial contamina-
tion continues to occur. In proportion, the bacterial risk of
platelet components is estimated to be 50–250 times higher
than the combined risk of HIV, HBV, HCV, and HTLV-1/2,
and transfusion-associated septic reactions represent the second
leading cause of blood transfusion-related death in the United
States after transfusion-related acute lung injury.10,11
Microbiology
Bacterial contamination of platelet components usually
results from the introduction of skin bacteria in the collection
bag at the time of venipuncture and less commonly from asymp-
tomatic donor bacteremia or during the processing. A wide range
of bacteria can proliferate in platelet products and reach clini-
cally dangerous levels during the storage period.12 These bacteria
are in the majority of Gram-positive pathogens of the skin flora,
such as staphylococci, corynebacteria, and bacillary species as
well as anaerobic diphteroid bacilli. Whereas contamination of
302 LABMEDICINE ■ Volume 41 Number 5 ■ May 2010 labmedicine.com
platelets with Gram-negative bacteria is less common, it most
likely results in septic fatality (60%).12 The occurrence of severe
infection in the recipient has been correlated to the extent of
bacterial proliferation in the platelet component, and a bacterial
load of >105 CFU/mL in the platelet bag is considered a serious
risk.13 Other features of the organisms, such as the virulence of
the strain, play an important role in transfusion-associated sep-
sis as illustrated by the occurrence of fever, rigors, and hypoten-
sion with transfusion of coagulase-negative staphylococci at
bacterial counts as low as 102 CFU/mL.14 The underlying con-
dition of the patient could also influence the clinical outcome
of a contaminated transfusion, which is more likely to become
serious when the immune system is compromised.
Whereas sometimes fever and chills are present during the
transfusion, the clinical signs and symptoms accompanying a
transmitted-transfusion sepsis are highly variable. The amount
of bacteria transfused is not always correlated with symptoms,
particularly in the case of neutropenic or febrile patients under
antibiotic therapy, among whom the signs of sepsis may be
missed. Thus, there is greater benefit to prevent the risk of
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bacterial infection by strictly watching the quality of the blood
product (active surveillance) rather than evaluating its clinical
consequences (passive surveillance).15
Bacterial Detection Methods
The following strategies are available to reduce the risk of
transfusion-related sepsis: improved donor selection, optimal
skin disinfection, removal of the first 10–30 mL of blood, bac-
terial detection, and pathogen inactivation methods. Diversion
of the initial blood donor flow to prevent contamination by
the skin flora has significantly improved the sterility of platelet
components with a reduction of the bacterial contamination
rate from 47% up to 77%, when used in conjunction with
donor-arm disinfection.16
When compared with bacterial detection techniques, sur-
rogate tests such as pH measurement, glucose level determina-
tion, or Gram’s stain coloration have been shown to be of low
sensitivity and therefore may be inadequate in routine use.14
Two automated culture methods are currently approved
for the detection of bacterial contamination in platelets. The
BacT/ALERT system (bioMerieux Clinical Diagnostics, Marcy
l’Etoile, France) is a colorimetric blood culture method based
on the detection of carbon dioxide produced by proliferating
microorganisms. It permits the detection of both aerobic and
anaerobic bacteria as well as yeasts and fungi.12 The platelet
sample should be inoculated for at least 24 hours after the col-
lection to allow for sufficient bacterial growth. A longer culture
time may be required for the detection of some slow growing
species such as Propionibacteria.9 In general, this method can
detect about 10 CFU/mL. The second bacterial detection
system is Pall eBDS (Pall, Basel, Switzerland): an enhanced
bacterial detection method based on the measurement of oxy-
gen consumption by organisms. It allows for the detection of
aerobic and facultative anaerobic bacteria. It is a closed system
that removes cellular components from the platelet sample and
provides compounds promoting bacterial growth.17 The in vitro
sensitivity was determined to be between 1–15 CFU/mL.18
A third method meeting the AABB standard is the Plate-
let PGD test (Verax Biomedical, Worcester, MA). This test is
a rapid, qualitative immunoassay for the detection of aerobic
and anaerobic bacteria. The limits of detection for common

pathogenic bacteria have been determined to be of substantial
equivalence to cultures, but post-marketing studies are under-
way Many other detection technologies are under development:
microcalorimetry, real-time polymerase chain reaction (PCR),
microbial spores biosensors, flow cytometry, detection of pepti-
doglycan, or monitoring bacterial response.
Since 2004 the introduction of bacterial detection in the
United States has decreased by more than 50% of the rate of
bacterial reactions after the transfusion of apheresis platelets.6
Extending the time before sampling and using a large sample
volume should increase the probability of identifying platelet
products with a low level of bacteria.9,19 Unlike viral detection,
bacterial detection represents a real challenge as bacteria can
be present below the detection limit (<1 CFU/mL) at the time
of collection and can proliferate to significant levels within
the 5-day platelet storage period. Bacterial detection requires a
method to detect species with different growth patterns and to
provide rapid and highly-sensitive results at the time of issue.
The bacterial detection methods have demonstrated their own
limits, highlighted by the occurrence of septic transfusion reac-
tions to platelet concentrates with false-negative test results.
On the other hand, patients who had been transfused with a
positive product, already released at the time of the positive
detection, had no evidence of reaction.20,21 This late positivity
of screening tests could be explained by the presence of slow
growing skin bacteria bearing low pathogenicity.9 As men-
tioned previously, success has been seen with bacterial detection
methods applied to the blood processing, allowing to markedly
reduce the risk of transfusion-associated bacterial infections.
Nevertheless, they have not been shown to completely prevent
the release of contaminated platelet concentrates or avoid the
rejection of safe blood products.
Pathogen Reduction Technologies
Pathogen reduction technologies allow inactivation of
viruses and bacteria in contaminated platelet concentrates by
inhibiting proliferation. Several different approaches have been
developed to further improve the security of blood products.
The following 2 methods are currently employed for platelet
inactivation: psoralen and riboflavin-based.22
The INTERCEPT blood system (Cerus, Concord, CA)
uses amotosalen, a synthetic psoralen. This compound belongs
to furocoumarins, which are well known photo-sensitizers
isolated from plants and already employed in the treatment
of different skin diseases. Amotosalen has the potential to
enter the cell and reversibly intercalate into helical regions of
nucleic acids. Exposure to long wavelength ultraviolet light
(UV-A) leads to covalent crosslinks to pyrimidine bases,
blocking DNA and RNA replication.23 After light treatment,
the residual amotosalen and its metabolites are removed by
a compound adsorption device (CAD). Numerous studies
have shown the ability of amotosalen to significantly reduce
pathogens contained in platelet units. Bacteria, protozoa, and
enveloped viruses are uniformly sensitive to psoralen inactiva-
tion, as opposed to non-lipid-enveloped viruses demonstrating
a variable sensitivity.24-26 By interacting with nucleic acids,
amotosalen modify genomic DNA in leukocytes, leading to the
inactivation of T lymphocytes with more efficacy than gamma
irradiation. The great sensitivity of T lymphocytes to psoralen
suggests this method may prevent leukocyte-mediated adverse
immune reactions associated with platelets transfusion such as
labmedicine.com May 2010 ■ Volume 41 Number 5 ■ LABMEDICINE 303
CE Update
transfusion-associated graft-versus-host disease, and platelets-
related febrile non-hemolytic transfusion reaction.27 Several
centers have confirmed the good tolerance profile of routine
psoralen-treated platelets and have discontinued them.28-30
Although no relevant toxic or immune (neoantigens) effects
have been reported with the INTERCEPT blood system, some
authors mentioned in vitro platelets metabolic changes and a
reduced aggregation response after addition of amotosalen.31 In
a large study, the transfusion of treated platelets was associated
with a lower platelet count increment and shorter transfusion-
free intervals, partially explained by a loss of platelets during
processing.32 This clinical observation suggests that possible
storage lesions might be implicated in a need for a greater num-
ber of platelet transfusions after pathogen reduction by amo-
tosalen.33 Nevertheless, pathogen-inactivated platelets perform
equally well as standard preparations in terms of stopping the
clinical bleeding.
A second approach, similar to psoralen-based method,
uses riboflavin and is commercially available under the trade
name Mirasol PRT (CaridianBCT, Lakewood, CO).34 Ribo-
Downloaded from http://labmed.oxfordjournals.org/ by guest on December 27, 2015
flavin, also known as vitamin B2, is a natural compound found
in many foodstuffs and is classified as “generally regarded as
safe” by the FDA. Riboflavin interacts with nucleic acids after
exposure to UV light, causing irreversible damage to DNA and
RNA.35 In contrast to amotosalen, the removal of residual ribo-
flavin metabolites is not necessary at the end of the procedure.
Whereas metabolic activity and parameters of activation are
increased in riboflavin-treated platelets, their adhesive proper-
ties are maintained, most likely through an up-regulation of
their mitochondria-based respiration.36,37 The Mirasol PRT
system is able to efficiently inactivate viruses and bacteria in
platelet concentrates.34,38 As with amotosalen treatment, the
non-lipid-enveloped viruses are variably sensitive.33 Riboflavin
and UV light may protect up to 98% of bacterially-contami-
nated platelet units, while the culture method is significantly
less effective (66%). This is particularly true at a low bacterial
load (ie, <20 CFUs per unit), which corresponds to the most
clinically relevant contamination level.39 The Mirasol PRT
system is also an alternative to gamma irradiation in prevent-
ing transfusion-associated graft-versus-host disease.40 So far, no
treatment-related toxicity was observed.41 Data from experi-
mental animal studies indicate riboflavin photo-activation may
decrease the risk of alloimmunization and induce tolerance in
organ transplantation.42,43 These results are of potential clinical
importance for transfusion medicine.
A third inactivation method, which is based on the micro-
biocidal and virucidal properties of the short-wave ultraviolet
light alone (UVC; wavelength range, 200–280 nm), is under
development.44 It inactivates pathogens mainly by its direct
interaction with nucleic acids. Thus, this approach could elimi-
nate the use of photochemicals or their photoproducts. Poten-
tial interest of this procedure has been demonstrated but needs
further investigation.44
A new bactericidal approach using peptides has recently
emerged in the field of bacterial inactivation. These antimicro-
bial peptides, either natural or synthetic, interact with the lipid
membrane of the bacteria, creating clusters on the cell surface,
which increase membrane permeability and lead to bacterial
death. These peptides can be used in different environments,
such as blood or plasma, and do not show host-cell toxicity.45
Their efficacy depends on the structure of the peptide and on
the lipid composition of the bacteria cell membrane. This ap-
proach is able to decrease by several logs the number of bacteria
CE Update
most commonly contaminating platelet concentrates, thus pro-
viding a potential new strategy for bacterial inactivation in the
near future.45
Conclusion
The ability of pathogen reduction technologies to inacti-
vate a broad spectrum of organisms (viruses, fungi, bacteria, and
parasites) is 1 of the most convenient answers facing the rapidly
evolving epidemiological environment as well as the continu-
ous appearance of new pathogens. The occurrence of pathogens
with a strong epidemic potential and/or with a high prevalence,
as well as the diversity of existing pathogens not systematically
detected using standard screening approaches, strongly argue for
the introduction of inactivation procedures rather than continu-
ously introducing new biological tests. �����������������������
The bacterial
�������������������
transmis-
sion still represents a threat in transfusion medicine. Because of
their favorable bacterial growth conditions (eg, storage at room
temperature, biological composition), platelets are of special
concern. Pathogen inactivation technologies for plasma are on
the market, and pathogen inactivation of whole blood will con-
stitute the next revolution in the field of transfusion medicine.
Comparison studies between pathogen reduction technology
and culture of platelet products have shown, at least for ribofla-
vin and UV light, an efficacy in favor of inactivation.39 Pathogen
inactivation represents a proactive paradigm having evolved to
become a potential pre-emptive approach for ridding the blood
supply of most transfusion-transmitted infections.46 However,
to become widely accepted, pathogen inactivation technologies
must prove to be both cost-effective and not associated with new
risks to recipients.47 Quality-adjusted life year (QALY) cost anal-
yses are also mandatory to evaluate the suitability of new transfu-
sion medicine technologies and their ability to eliminate fatal
outcomes related to platelet transfusion, taking into account
the limited financial resources of most health systems.48 Finally,
long-term studies are necessary to demonstrate the definitive
safety of this revolutionary approach. Nevertheless, at the begin-
ning of the 21st century, no one will accept that a patient will
die after transfusion of contaminated platelets by bacteria when
efficient measures are available. The balance between life saving
by transfusion and risk of dying by administrating unsafe prod-
ucts is definitively toward pathogen inactivation. LM
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