MMWR Morb Mortal Wkly Rep. 2018 Jun 29;67(25):718-722. doi: 10.15585/mmwr.mm6725a4.
During August 2017, two separate clusters of platelet transfusion-associated bacterial sepsis were reported in Utah and California. In Utah, two patients died after platelet transfusions from the same donation. Clostridium perfringens isolates from one patient's blood, the other patient's platelet bag, and donor skin swabs were highly related by whole genome sequencing (WGS). In California, one patient died after platelet transfusion; Klebsiella pneumoniae isolates from the patient's blood and platelet bag residuals and a nontransfused platelet unit were matched using WGS. Investigation revealed no deviations in blood supplier or hospital procedures. Findings in this report highlight that even when following current procedures, the risk for transfusion-related infection and fatality persists, making additional interventions necessary. Clinicians need to be vigilant in monitoring for platelet-transmitted bacterial infections and report adverse reactions to blood suppliers and hemovigilance systems. Blood suppliers and hospitals could consider additional evidence-based bacterial contamination risk mitigation strategies, including pathogen inactivation, rapid detection devices, and modified screening of bacterial culture protocols.
在 2017 年 8 月，犹他州和加利福尼亚州分别报告了两起血小板输血相关细菌性败血症的聚集性病例。在犹他州，两名接受同一供体血小板输注的患者在输注后死亡。对一名患者血液、另一名患者血小板袋和供体皮肤拭子的产气荚膜梭菌分离株进行全基因组测序（WGS）分析，结果高度相关。在加利福尼亚州，一名患者在血小板输注后死亡；对患者血液和血小板袋残留物以及未输注的血小板单位中的肺炎克雷伯菌分离株进行 WGS 分析，结果一致。调查未发现血液供应商或医院程序存在偏差。本报告中的发现强调，即使遵循当前的程序，输血相关感染和死亡的风险仍然存在，因此需要采取额外的干预措施。临床医生需要警惕监测血小板传播的细菌感染，并向血液供应商和血液警戒系统报告不良反应。血液供应商和医院可以考虑额外的基于证据的细菌污染风险缓解策略，包括病原体失活、快速检测设备以及改良的细菌培养方案筛选。
