Adverse Occurrence type:
Possible transmission in 3 of 324 culture-negative frozen bone allograft uses (<1%) while the overall postop infection rate was 4-5%..
Time to detection:
10 - 18 days
Alerting signals, symptoms, evidence of occurrence:
In a retrospective study of use of 324 culture-negative frozen bone allografts (180 large, 144 small), their infection rate (5% for bone tumor surgery, 4% for hip arthroplasty) was not different from surgery using a sterilized metal prosthesis. Three cases were from Serratia marcescens (same antibiotic susceptibility and major biotyping, same cadaveric donor, negative procurement cultures). Of the three Serratia infections from possible cotaminated bone allograft, one developed wound infection after 10 days, was treated by debridement and antibiotics but developed a chronic infection. The other two developed wound infections on day 18 that were cleared by debridement and antibiotics.
Demonstration of imputability or root cause:
Level 3. Possible bacterial infection transmitted from contaminated bone allograft. Same organism in 3 patients, same bone donor but no other link: procurement cultures negative. Unused bones from same donor culture negative. The authors call these cases " a definite possibility" and "possible transmission"