A 47-year-old woman was admitted to the hospital
for complex spinal surgery. The surgery went well without
complications, and postoperatively she was transferred to a general
surgical ward. Shortly thereafter, she spiked a fever, became
tachycardic, hypotensive, and hypoxic, and developed a red rash
across her chest. She was reintubated (placed back on the
mechanical ventilator), given an infusion of dopamine to maintain
adequate blood pressure, and transferred to the intensive care unit
(ICU). She was found to have severe septic shock and developed
multiorgan system failure. On initial evaluation, the clinicians
were puzzled and confused because there was no clear cause for her
On the same day, a 76-year-old man with coronary
artery disease and a prosthetic aortic valve was admitted for
spinal surgery. The procedure went well, and he was stable and
transferred to a general surgical ward postoperatively. Later that
evening, he developed tachycardia, hypotension, and hypoxia,
requiring reintubation and transfer to the ICU. He was found to
have sepsis and, despite extensive diagnostic testing, the clinical
team could not identify a clear cause for his decompensation.
Given the similarity in clinical course, the
hospital investigated the two cases. Upon detailed review, the
blood bank discovered that both patients had received
intraoperative platelet transfusions from the same batch of
platelets. With further testing, it was determined that the entire
batch of platelets was contaminated with Staphylococcus
aureus, a virulent and aggressive bacteria often found in
The 47-year-old woman remained critically ill for
many days and had Staphylococcus aureus in her bloodstream
for more than a week despite antibiotic therapy. She had a long and
complicated hospitalization, but she was ultimately discharged in
stable condition. The bacterium was never cultured from the blood
of the 76-year-old man, but he remained febrile in the ICU for many
days. Given his prosthetic valve, an echocardiogram was obtained
that showed possible bacterial endocarditis (infection of his heart
valve with the bacteria). In addition to a prolonged
hospitalization, he required 6 weeks of intravenous antibiotics as
a result of the contaminated platelet transfusion.
1. Zuck TF. Greetings—A final look back
with comments about a policy of a zero-risk blood supply.
Transfusion. 1987;27:447-448. [go to PubMed]
2. Stramer SL. Current risks of
transfusion-transmitted agents: a review. Arch Pathol Lab Med.
2007;131:702-707. [go to
3. Eder AF, Chambers LA. Noninfectious
complications of blood transfusion. Arch Pathol Lab Med.
4. Dodd RY. Current risk for transfusion
transmitted infections. Curr Opin Hematol. 2007;14:671-676.
5. Dodd RY, Notari EP IV, Stramer SL. Current
prevalence and incidence of infectious disease markers and
estimated window-period risk in the American Red Cross blood donor
population. Transfusion. 2002;42:975-979. [go to
6. Busch MP, Kleinman SH, Nemo GJ. Current and
emerging infectious risks of blood transfusions. JAMA.
2003;289:959-962. [go to
7. Stramer SL, Glynn SA, Kleinman SH, et al;
National Heart, Lung, and Blood Institute Nucleic Acid Test Study
Group. Detection of HIV-1 and HCV infections among
antibody-negative blood donors by nucleic acid-amplification
testing. N Engl J Med. 2004;351:760-768. [go to
8. Busch MP, Young MJ, Samson SM, et al; for
Transfusion Safety Study Group. Risk of human immunodeficiency
virus (HIV) transmission by blood transfusions before the
implementation of HIV-1 antibody screening. Transfusion.
1991;31:4-11. [go to PubMed]
9. Gresens CJ, Holland PV. The disappearance of
transfusion-transmitted hepatitis C virus infections in the United
States. Clin Liver Dis. 2001;5:1105-1113. [go to
10. Petersen LR, Epstein JS. Problem solved? West
Nile virus and transfusion safety. N Engl J Med. 2005;353:516-517.
11. Linden JV, Wagner K, Voytovich AE, Sheehan J.
Transfusion errors in New York state: an analysis of 10 years'
experience. Transfusion. 2000;40:1207-1213. [go to
12. Yomtovian R. Bacterial contamination of
blood: lessons from the past and road map for the future.
Transfusion. 2004;44:450-460. [go to
13. Yomtovian R, Palavecino E. Bacterial
Contamination of Blood Products—History and Epidemiology. In:
Brecher ME, ed. Bacterial Contamination of Blood Products.
Bethesda, MD: American Association of Blood Banks; 2003.
14. Jacobs MR, Good CE, Lazarus HM, Yomtovian RA.
Relationship between bacterial load, species virulence, and
transfusion reaction with transfusion of bacterially contaminated
platelets. Clin Infect Dis. 2008;46:1214-1220. [go to
15. Kuehnert MJ, Roth VR, Haley NR, et al.
Transfusion-transmitted bacterial infection in the United States,
1998 through 2000. Transfusion. 2001;41:1493-1499. [go to
16. Niu MT, Knippen M, Simmons L, Holness LG.
Transfusion-transmitted Klebsiella pneumoniae fatalities, 1995 to
2004. Transfus Med Rev. 2006;20:149-157. [go to
17. U.S. Food and Drug Administration, Center for
Biologics Evaluation and Research. Fatalities Reported to FDA
Following Blood Collection and Transfusion: Annual Summary for
Fiscal Years 2005 and 2006. Bethesda, MD: U.S. Food and Drug
Administration. Available at: http://www.fda.gov/cber/blood/fatal0506.pdf.
18. Chiu EK, Yuen KY, Lie AK, et al. A
prospective study of symptomatic bacteremia following platelet
transfusion and of its management. Transfusion. 1994;34:950-954.
[go to PubMed]
19. U.S. Food and Drug Administration, Center for
Biologics Evaluation and Research. Guidance for Industry: Notifying
FDA of Fatalities Related to Blood Collection or Transfusion.
Bethesda, MD: U.S. Food and Drug Administration; 2003. Available
Association of Blood Banks. Association Bulletin #03-12 Further
Guidance on Methods to Detect Bacterial Contamination of Platelet
Components. Bethesda, MD: American Association of Blood Banks;