Status:
Ready to upload
Record number:
1796
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
1:10 000; septic reactions 1:125 000; fatality 1:500 000
Time to detection:
2 hours and 30 minutes from the beginning of platelet transfusion to the onset of syptoms
Alerting signals, symptoms, evidence of occurrence:
Chills, rigors, hypotension, nausea, and vomiting, later fever.
Demonstration of imputability or root cause:
The platelet concentrate and the patient samples were found to be contaminated with a S. aureus strain that exhibited the same phenotypic and genome sequencing profiles.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
References:
Reference attachment:
Suggest references:
Maria Loza-Correa, Yuntong Kou, Mariam Taha, et al. Septic transfusion case caused by a platelet pool with visible clotting due to contamination with Staphylococcus aureus. TRANSFUSION 2017;57;1299–1303
Note:
ADD THE FOLLOWING REFERENCES:
1. Bertrand X, Leconte des Floris MF, Bardonnet K, Morel P, Talon D. Staphylococcus aureus-contaminated apheresis platelets traced to donors' nasal carriage. Transfusion. 2006 Feb;46(2):310-1.
2. Coutinho H, Galloway A, Ajdukiewicz K, Cleeve V. A case of Staphylococcus aureus septicaemia following platelet transfusion. Journal of clinical pathology. 2010 Mar;63(3):262-3
Expert comments for publication:
Publication confirms that visual inspection of blood components before transfusion is an essential safety practice to interdict the transfusion of bacterially contaminated units.