title: Bacterial contamination of platelets at a university hospital: increased identification due to intensified surveillance.
abstract: BACKGROUND
  A cluster of bacterial contamination of platelets occurred at a university hospital in a one-month period. This unusual clustering allowed us to examine the likely mechanism of contamination and clinical sequelae.
  
  
  METHODS
  We reviewed medical records of patients receiving random donor platelet transfusions to determine numbers of platelets transfused, reactions reported, and episodes of bacterial contamination. We also reviewed procedures at the collecting blood agencies and the hospital blood bank.
  
  
  RESULTS
  Four patients received bacterially contaminated platelets during June and July 1991. The rates of reported platelet transfusion reactions increased significantly (P < 0.001) from September 1989 through July 1991 (study period); in addition, the rate of contamination of platelets during June and July 1991 was 23-fold higher than during the previous 21 months (P < 0.001). Surveillance methodology changed dramatically during the study period, contributing to the recognition of the current cluster. Pathogens isolated from the contaminated platelet pools were Bacillus cereus, Staphylococcus epidermidis, or Pseudomonas aeruginosa in titers ranging from 10(6) to 10(8) colony forming units/mL. Four constituent individual platelet units identified as the probable cause of the outbreak (including one postepidemic episode) were significantly older (mean age, 4.8 days) than 106 randomly selected individual platelet units (mean age, 3.7 days; P = 0.04). Platelet pools were transfused an average of 2.5 hours after pooling. Review of blood collection and platelet preparation practices did not identify breaks in procedure or technique that could have caused contamination.
  
  
  CONCLUSIONS
  Increased awareness of platelet transfusion reactions by clinical staff and routine culturing of all platelets associated with transfusion reactions will identify contaminated platelets. Identification of contaminated platelets is necessary to treat affected patients appropriately and to determine the prevalence of and risk factors for contaminated platelets (Infect Control Hosp Epidemiol 1994;15:82-87).
authors.affiliation: Hospital Infections Program, Centers for Disease Control and Prevention, Atlanta, GA 30333.
authors.forename: S
authors.initials: S
authors.lastname: Zaza
authors.forename: J I
authors.initials: JI
authors.lastname: Tokars
authors.forename: R
authors.initials: R
authors.lastname: Yomtovian
authors.forename: N V
authors.initials: NV
authors.lastname: Hirschler
authors.forename: M R
authors.initials: MR
authors.lastname: Jacobs
authors.forename: H M
authors.initials: HM
authors.lastname: Lazarus
authors.forename: L T
authors.initials: LT
authors.lastname: Goodnough
authors.forename: L A
authors.initials: LA
authors.lastname: Bland
authors.forename: M J
authors.initials: MJ
authors.lastname: Arduino
authors.forename: W R
authors.initials: WR
authors.lastname: Jarvis
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016470:Bacteremia / Q000453:epidemiology* / Q000209:etiology*; D000094902:Blood Banking / Q000379:methods; D001792:Blood Platelets / Q000382:microbiology*; D001800:Blood Specimen Collection / Q000379:methods; D016000:Cluster Analysis; D003428:Cross Infection / Q000453:epidemiology* / Q000209:etiology*; D004196:Disease Outbreaks; D005260:Female; D006785:Hospitals, University; D006801:Humans; D017053:Infection Control; D008297:Male; D008875:Middle Aged; D017713:Platelet Transfusion / Q000009:adverse effects*; D015995:Prevalence; D012307:Risk Factors