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P14 JURNAL Bacterial Contamination of Platelet Concentrates P
P14 JURNAL Bacterial Contamination of Platelet Concentrates P
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Jean-Daniel Tissot
Lausanne University Hospital
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Abstract acute lung injury or bacterial sepsis. The latter nation as well as strategies to reduce this risk,
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 country.1 In Switzerland, reporting transfusion events has
European countries as well as in North America. These systems become a legal duty since 1998. The hemovigilance system was
consist of reporting transfusion reactions and represent a net- implemented in our hospital during the last decade.2 The data,
work of surveillance in order to monitor the risk of allogeneic summarized in Table 1, outline that the incidence as well as
blood transfusions. Various systems have been established over the type of reactions differed upon the blood products trans-
the years, with a somewhat different approach relative to the fused. Platelets give rise to more transfusion reactions than red
blood cells (RBCs) and fresh frozen plasma, especially regard- platelets with Gram-negative bacteria is less common, it most
ing febrile and allergic events. Most of the time, these febrile likely results in septic fatality (60%).12 The occurrence of severe
reactions remain minor and are rarely associated with bacterial infection in the recipient has been correlated to the extent of
contamination.3 However, this diagnosis depends directly on bacterial proliferation in the platelet component, and a bacterial
the quality of bacteriological testing. load of >105 CFU/mL in the platelet bag is considered a serious
Decreasing the risk of transfusion-related viral transmis- risk.13 Other features of the organisms, such as the virulence of
sions has been a priority for all blood transfusion services the strain, play an important role in transfusion-associated sep-
worldwide. The introduction of blood donation screening with sis as illustrated by the occurrence of fever, rigors, and hypoten-
antibody testing followed by nucleic acid amplification tech- sion with transfusion of coagulase-negative staphylococci at
niques (NAT) have efficiently contributed to this risk reduc- bacterial counts as low as 102 CFU/mL.14 The underlying con-
tion during the last decade. Nevertheless, transfusion remains dition of the patient could also influence the clinical outcome
under the threat of a variety of blood-transmitted pathogens of a contaminated transfusion, which is more likely to become
(viruses, protozoa, helminths, prions, or bacteria), and bacterial serious when the immune system is compromised.
contamination of blood products emerges as the most frequent Whereas sometimes fever and chills are present during the
infectious hazard of transfusion.4,5 transfusion, the clinical signs and symptoms accompanying a
The purpose of this review is to describe the clinical impact transmitted-transfusion sepsis are highly variable. The amount
of platelet transfusion-related bacterial infections, and to out- of bacteria transfused is not always correlated with symptoms,
line the different approaches used to decrease this risk. 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
pathogenic bacteria have been determined to be of substantial transfusion-associated graft-versus-host disease, and platelets-
equivalence to cultures, but post-marketing studies are under- related febrile non-hemolytic transfusion reaction.27 Several
way Many other detection technologies are under development: centers have confirmed the good tolerance profile of routine
microcalorimetry, real-time polymerase chain reaction (PCR), psoralen-treated platelets and have discontinued them.28-30
microbial spores biosensors, flow cytometry, detection of pepti- Although no relevant toxic or immune (neoantigens) effects
doglycan, or monitoring bacterial response. have been reported with the INTERCEPT blood system, some
Since 2004 the introduction of bacterial detection in the authors mentioned in vitro platelets metabolic changes and a
United States has decreased by more than 50% of the rate of reduced aggregation response after addition of amotosalen.31 In
bacterial reactions after the transfusion of apheresis platelets.6 a large study, the transfusion of treated platelets was associated
Extending the time before sampling and using a large sample with a lower platelet count increment and shorter transfusion-
volume should increase the probability of identifying platelet free intervals, partially explained by a loss of platelets during
products with a low level of bacteria.9,19 Unlike viral detection, processing.32 This clinical observation suggests that possible
bacterial detection represents a real challenge as bacteria can storage lesions might be implicated in a need for a greater num-
be present below the detection limit (<1 CFU/mL) at the time ber of platelet transfusions after pathogen reduction by amo-
of collection and can proliferate to significant levels within tosalen.33 Nevertheless, pathogen-inactivated platelets perform
the 5-day platelet storage period. Bacterial detection requires a equally well as standard preparations in terms of stopping the
method to detect species with different growth patterns and to clinical bleeding.
provide rapid and highly-sensitive results at the time of issue. A second approach, similar to psoralen-based method,
The bacterial detection methods have demonstrated their own uses riboflavin and is commercially available under the trade
limits, highlighted by the occurrence of septic transfusion reac- name Mirasol PRT (CaridianBCT, Lakewood, CO).34 Ribo-
most commonly contaminating platelet concentrates, thus pro- 9. Walther-Wenke G. Incidence of bacterial transmission and transfusion reactions
viding a potential new strategy for bacterial inactivation in the by blood components. Clin Chem Lab Med. 2008;46:919–925.
near future.45 10. Blajchman MA, Beckers EA, Dickmeiss E, et al. Bacterial detection of
platelets: Current problems and possible resolutions. Transfus Med Rev.
2005;19:259–272.
11. Vamvakas EC, Blajchman MA. Transfusion-related mortality: The ongoing risks
of allogeneic blood transfusion and the available strategies for their prevention.
Conclusion Blood. 2009;113:3406–3417.
The ability of pathogen reduction technologies to inacti- 12. Wagner SJ. Transfusion-transmitted bacterial infection: Risks, sources and
vate a broad spectrum of organisms (viruses, fungi, bacteria, and interventions. Vox Sang. 2004;86:157–163.
parasites) is 1 of the most convenient answers facing the rapidly 13. Morel P, Deschaseaux M, Bertrand X, et al. Transfusion-transmitted bacterial
evolving epidemiological environment as well as the continu- infection: Residual risk and perspectives of prevention. Transfus Clin Biol.
2003;10:192–200.
ous appearance of new pathogens. The occurrence of pathogens
with a strong epidemic potential and/or with a high prevalence, 14. Yomtovian RA, Palavecino EL, Dysktra AH, et al. Evolution of surveillance
methods for detection of bacterial contamination of platelets in a university
as well as the diversity of existing pathogens not systematically hospital, 1991 through 2004. Transfusion. 2006;46:719–730.
detected using standard screening approaches, strongly argue for 15. Kuehnert MJ, Roth VR, Haley NR, et al. Transfusion-transmitted
the introduction of inactivation procedures rather than continu- bacterial infection in the United States, 1998 through 2000. Transfusion.
ously introducing new biological tests. �����������������������
The bacterial
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transmis- 2001;41:1493–1499.
sion still represents a threat in transfusion medicine. Because of 16. McDonald CP, Roy A, Mahajan P, et al. Relative values of the interventions of
their favorable bacterial growth conditions (eg, storage at room diversion and improved donor-arm disinfection to reduce the bacterial risk from
blood transfusion. Vox Sang. 2004;86:178–182.
temperature, biological composition), platelets are of special
33. Solheim BG, Seghatchian J. The six questions of pathogen reduction technology: 41. Reddy HL, Dayan AD, Cavagnaro J, et al. Toxicity testing of a novel riboflavin-
An overview of current opinions. Transfus Apher Sci. 2008;39:51–57. based technology for pathogen reduction and white blood cell inactivation.
34. Goodrich RP, Edrich RA, Li J, et al. The Mirasol PRT system for pathogen Transfus Med Rev. 2008;22:133–153.
reduction of platelets and plasma: An overview of current status and future 42. Asano H, Lee CY, Fox-Talbot K, et al. Treatment with riboflavin and ultraviolet
trends. Transfus Apher Sci. 2006;35:5–17. light prevents alloimmunization to platelet transfusions and cardiac transplants.
35. Joshi PC. Comparison of the DNA-damaging property of photosensitised Transplantation. 2007;84:1174–1182.
riboflavin via singlet oxygen (1O2) and superoxide radical O2- mechanisms. 43. Jackman RP, Heitman JW, Marschner S, et al. Understanding loss of donor
Toxicol Lett. 1985;26:211–217. white blood cell immunogenicity after pathogen reduction: Mechanisms
36. Perez-Pujol S, Tonda R, Lozano M, et al. Effects of a new pathogen-reduction of action in ultraviolet illumination and riboflavin treatment. Transfusion.
technology (Mirasol PRT) on functional aspects of platelet concentrates. 2009;49:2686–2699.
Transfusion. 2005;45:911–919. 44. Mohr H, Steil L, Gravemann U, et al. A novel approach to pathogen reduction
37. Picker SM, Oustianskaia L, Schneider V, et al. Functional characteristics of in platelet concentrates using short-wave ultraviolet light. Transfusion.
apheresis-derived platelets treated with ultraviolet light combined with either 2009;49:2612–2629.
amotosalen-HCl (S-59) or riboflavin (vitamin B2) for pathogen-reduction. 45. Mohan KV, Rao SS, Atreya CD. Evaluation of antimicrobial peptides as
Vox Sang. 2009;97:26–33. novel bactericidal agents for room temperature-stored platelets. Transfusion.
38. Ruane PH, Edrich R, Gampp D, et al. Photochemical inactivation of selected 2009;50:166–172.
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