Quality Improvement After Multiple Fatal Transfusion-Transmitted Bacterial Infections

Area of Science:

• Hematology
• Infectious Disease
• Transfusion Medicine

Background:

• Transfusion-transmitted bacterial infection (TTBI) from platelet components poses a significant, often underrecognized, risk.
• Previous safety measures, including 24-hour prospective culture, were insufficient to prevent fatal TTBI events.

Observation:

• Multiple fatal and severe TTBI cases were linked to Klebsiella pneumoniae contamination in split-apheresis platelet donations.
• A critical review identified opportunities for improvement in bacterial detection and prevention strategies.

Findings:

• Implementing a secondary, 48-hour prospective culture post-collection identified two true positive cases (0.01%) missed by the initial 24-hour culture.
• Subsequent implementation of bacterial testing at issue and pathogen reduction further enhanced transfusion safety.

Implications:

• While rare, TTBI remains a prominent cause of morbidity and mortality associated with platelet transfusions.
• The presented corrective and preventive action (CAPA) strategy, including extended culture periods, shows promise in reducing TTBI risk.
• The balance between enhanced safety and potential increased costs of these measures requires careful consideration.