Fatal Sepsis Associated With Bacterial Contamination of Platelets — Utah and California, August 2017

Roberta Z. Horth, PhD; Jefferson M. Jones, MD; Janice J. Kim, MD; Bert K. Lopansri, MD; Sarah J. Ilstrup, MD; Joy Fridey, MD; Walter E. Kelley, DO; Susan L. Stramer, PhD; Ashok Nambiar, MD; Lynn Ramirez-Avila, MD; Amy Nichols, MBA; Wendy Garcia; Kelly F. Oakeson, PhD; Nicholas Vlachos, MS; Gillian McAllister; Robert Hunter, MS; Allyn K. Nakashima, MD; Sridhar V. Basavaraju, MD


Morbidity and Mortality Weekly Report. 2018;67(25):718-722. 

In This Article

Abstract and Introduction


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