Snake in the grass: A case report of transfusion reactions due to contaminated donor arm disinfectant.

Bacterial contamination of blood components remains an on-going challenge. In the majority of cases, organisms contaminating the blood components are a part of normal skin flora. Here, we report a case of bacterial contamination of blood units through contaminated donor arm disinfectant. There was a series of reactions due to random donor platelet (RDP) transfusion. The patients had features of septic transfusion reactions. On root cause analysis, spirit swabs used for disinfection of donors' arm were identified as the culprit and presence of Clostridium difficile was established. All the blood components prepared on the dates of implicated RDP units were removed from the stock and we replaced the existing 70% alcohol disinfectant with chlorhexidine-alcohol-based antiseptic rub. Further, no such transfusion reactions were reported. Implementation of good donor arm disinfection technique in addition to the use of blood bags with diversion pouch is proposed to be best preventive strategy for resource-poor settings.

There has been a steep decline in the transmission of viral infection with the introduction of sensitive screening assays; however, bacterial contamination of blood components remains an ongoing challenge. Typically, bacterial contamination originates either from blood donor or the environment of blood collection, processing, and storage. We, however, encountered an unusual scenario of bacterial contamination of blood units through contaminated donor arm disinfectant.

Case Report

There was a sudden surge of reports of transfusion reactions in patients of hematology ward after random donor platelets (RDPs) transfusion in a tertiary care institute of North India. There were reports of eight patients who became symptomatic either during the transfusion or within 1 h of transfusion and presented with one or more of the following symptoms namely fever (>38°C), chills, rigors, hypotension, nausea, vomiting, and dyspnea but no hemoglobinuria. The transfusion was discontinued, and the bags along with patients’ samples were sent to blood bank for investigation. On testing in the blood bank, no hemolysis was evident in patients’ blood samples. We alerted the consulting physician to the possibility of septic transfusion reactions, and the patients were started on broad-spectrum antibiotics after obtaining the samples for culture.

Simultaneously, samples from patients and remnants of RDP bags were sent for culture to the Department of Microbiology. All the cultures in anaerobic media were positive after 48 h for both patients’ and RDP sample, and the reports of reactions to RDP were still rampant from various wards. To perform the root cause analysis [Figure 1], we collected samples of anticoagulants and additive solution aseptically from 10 unused blood bags of same lot and sent them for culture. We also took swabs from storage cabinets for culture. The cultures from all these samples came out to be negative, leading to greater perplexity. Since the reactions had occurred with multiple RDP units so we ruled out blood donors as a source of contamination. Finally, we sent the cotton swabs soaked in 70% alcohol which were used for donor arm disinfection at our center for culture. To our surprise, the culture showed positivity on anaerobic media once again. On performing the Gram-staining, the smear showed positive bacilli with oval subterminal spores raising suspicion toward Clostridium species. Following this, patients who had received the transfusions were started on metronidazole treatment. We further requested Department of Microbiology to identify the organism from positive cultures. For this, ELISA for toxin A and B (Premier Toxins A and B, Meridian Bioscience, Cincinnati, USA) was performed, and the presence of Clostridium difficile was established.

Figure 1

Ishikawa (Fishbone) diagram for identifying potential source of bacterial contamination of blood components.

After this, we inquired the staff of blood donation about handling of donor arm disinfectant at our center. It came out that cotton balls were made manually by a laboratory attendant and later 70% alcohol solution was poured on them. This was done by the same person every day in the morning, and swabs were used throughout the day for donation process. On interrogating, he revealed to have been attending his 12-year-old son suffering from diarrhea a few days back. It was evident that his poor hand hygiene may have introduced the bacteria into the disinfectant swabs. We immediately replaced the existing 70% alcohol disinfectant with chlorhexidine-alcohol-based antiseptic rub. The cotton swabs were replaced by sterilized cotton gauze pieces. The staff was educated on the importance of maintaining the hand hygiene for the safety of patients and their own selves. All the blood components prepared on the dates of implicated RDP units were removed from the stock.

Thereafter, there were no reports of septic transfusion reactions. As a part of our quality control program, four units of RDP are sent for bacterial culture every week.

Discussion

In the majority of cases of bacterial contamination of blood components, the source is donor skin commensal microflora or bacteremia in asymptomatic donors. However, in this case, the contaminant was found to be C. difficile which is not a part of normal skin flora and colonization was probably a result of fecal contamination from a patient of C. difficile associated diarrhea. Although the vegetative form of C. difficile is fragile, it is capable of sporulating when environmental conditions do not support growth.[1] The spores persist as skin contaminant on the patients even after diarrhea resolves and gets transmitted from one person to other.[2] It has been found that C. difficile spores are resistant to the bactericidal effects of alcohol and could be transmitted even after application of alcohol-based rubs.[3] In this case, the bacterial spores survived in alcohol-based disinfectant solution and were transmitted to blood transfusion recipients through contaminated blood components. A similar case has been reported by García-Erce et al. where blood components were contaminated due to Burkholderia cepacie growing in chlorhexidine bottles.[4]

Efficacy of a skin disinfection method is dependent on several factors such as type and concentration of antiseptic used the mode of application, whether there is a single- or two-step method, the time that the antiseptic is in contact with the skin and the training of the personnel applying the disinfectant. A study which has compared chlorhexidine and alcohol two-step method to one-step chlorhexidine and alcohol methods found no difference between the efficacy of two methods with reduced skin disinfection time with latter.[5] This holds greater importance in an overcrowded setting like ours where there are large numbers of donors waiting, and staff members have to work very quickly. Hence, we have implemented a one-step method to reduce the time per procedure and complexity of using more than one reagent.

The patients who received contaminated RDP units suffered only mild to moderate reactions instead of life-threatening sepsis because we were using blood bags with diversion pouch at our center, which has resulted in fewer number of bacteria passing into blood unit and hence into recipient. A National Health Service Blood and Transplant study has indicated reduction in contamination by 47% using diversion alone, and by 57% using improved donor arm disinfection. Implementing improved donor arm disinfection in conjunction with diversion has been found to result in 77% reduction in bacterial contamination.[6] As per Drugs Controller General of India, a strictly standardized procedure should be in use to achieve surgical cleanliness for preparing venepuncture site to provide maximum possible assurance of sterile product.[7] A two-step method involving a scrub with a 0.75% povidone-iodine compound followed by an application of a 10% povidone-iodine preparation solution is recommended in the AABB Technical Manual for donor arm disinfection.[8]

Two technologies are available for testing the sample for bacterial contamination immediately before transfusion. First is Pan Genera Detection Immunoassay (Verax Biomedical Inc.,) which can detect Gram-positive as well as Gram-negative bacterial strains.[9] Another approach is real-time monitoring of O2 concentrations within platelet concentrates using special testing probes.[10] The disadvantage of this approach is that only aerobic bacteria which consume O2 will be detected.

Three most common methods to inactivate pathogens in platelet concentrates photo-chemically are amotosalen/ultraviolet A (UVA), riboflavin/UVA–UVB, and UVC. Studies have demonstrated that these methods are particularly efficient in preventing transfusion-related bacterial infections, obviate the need for γ-inactivation for GvHD prophylaxis and extend the maximum shelf life of platelets from 5 to 7 days.[11]

Several other approaches tried by researchers worldwide such as detailed health history of blood donors, reduction in storage time of blood components, leukofiltration and addition of antibiotics to blood components have not been found to be greatly favorable and effective. The approach which has been considered most promising in reducing the transfusion-associated bacterial sepsis is routine testing of blood to detect bacteria shortly before transfusion to the recipient and pathogen inactivation of blood components to reduce bacterial load.[12] However, these seem to be remote amenities for resource poor settings in a country like India. Thus, the most feasible strategy would be systematic and comprehensive donor selection and screening, scrubbing the phlebotomy site with improved disinfectants containing alcohol and chlorhexidine, use of diversion pouch along with the implementation of proper hand cleaning by blood bank staff as these measures are easy, economical, and require limited staff.

Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.