Fatal septic shock associated with transfusion‐transmitted Serratia marcescens

Abstract

A 3-year-old girl with relapsed acute myelogenous leukemia received a transfusion of a 5-day-old single-donor volume-reduced HLA-matched platelet (PLT) unit before a CAT scan-guided drainage of pleural fluid. Within minutes of completing the transfusion, the patient, who was receiving a broad-spectrum antibiotic (meropenem), became febrile, confused, and hypotensive. Despite aggressive treatment, she died of multisystem organ failure 21 hours after transfusion. Blood and urine samples obtained from the recipient 18 hours after the transfusion, while on antibiotics, were negative for the presence of bacteria. Serratia marcescens, however, was isolated from cultures of the recipient's blood, urine, liver, and lung obtained at autopsy.Investigations were conducted at Canadian Blood Services, the PLT provider, and at the hospital. The PLT product was positive for the presence of Gram-negative bacilli, had 3.0 × 10 9 colony-forming units (CFUs) per mL of S. marcescens, and contained 194,400 EU per mL of endotoxin . Samples obtained from the plasma removed during volume reduction (performed 30 min before transfusion), the PLT filter, and saline solution attached to the PLT pack were positive for the presence of the same bacterium . Pulse-field gel electrophoresis genotyping of S. marcescens isolates from different samples showed that they had identical band patterns (Fig. 1).Several items having the same lot numbers as the items used during collection of the transfused unit, namely, plateletpheresis collection sets, vacutainer tubes, recalled and in-date apheresis PLT units, and secondary sample bags, were cultured and found to be negative for the presence of S. marcescens. Blood and urine samples provided by the donor were also negative for the presence of this bacterium, and the donor confirmed that he was not ill before or after the transfusion.Twenty-nine hours after collection, approximately 15 mL of PLTs from the implicated unit were transferred to a sample bag. This secondary bag was separated from the remaining PLTs, which were stored in a shaking incubator until they were volume-reduced and transfused. A sample of 4 mL of PLTs was taken from the sample bag and inoculated into an aerobic culture medium bottle (BPA) for testing of bacterial contamination with an automated blood culture system (BacT/ALERT, bioMérieux Canada Inc., St. Laurent, Québec, Canada). The culture was nega-Fig. 1. Genotyping of S. marcescens isolates. Genomic DNA was extracted from all of the bacterial isolates, followed by digestion with Spe I and pulse-field gel electrophoresis analysis at the Hospital for Sick Children, Toronto. Lanes M = = = = lambda ladder. Lanes 1 through 7 = = = = samples obtained during the investigation of this case: Lane 1 = = = = saline solution attached to the PLT pack; Lane 2 = = = = removed supernatant plasma; Lane 3 = = = = transfused PLT product; Lane 4 = = = = blood from the patient's central line; Lane 5 = = = = autopsy blood; Lane 6 = = = = autopsy liver; and Lane 7 = = = = autopsy left lung; Lanes 8 and...

Serratia Infections: from Military Experiments to Current Practice

“…Opportunistic infections attributed to S. marcescens have been traced to many different sources over the years. Contaminated ultrasonic nebulizers (320), ventilator nebulizers (374), inhalation therapy medications (335), inhalation therapy stock solutions (391), air conditioning units (223,304), shaving brushes used prior to surgery (237,408,409), pressure transducers (30,112,397), tap water from pressure-monitoring equipment (327), urine-measuring containers, urinometers, urine-collecting basins, and urinals (147,329,349,356,418), a cystoscopy area (222), sinks (202,356), bronchoscopes (304,353,389), reusable rectal balloons (61), electrocardiogram leads (360), vitrectomy apparatuses (211), theater linen (124), glass syringes used for preparing intravenous injection fluids (382), saline solutions (66), heparinized saline (375), cream used for obstetric pelvic examinations (365), liquid nonmedicated soap (337), a liquid soap dispenser (374), a finger ring (201), tap water used to take oral medications (186), betamethasone injections (77), an anesthetic (propofol) (33,181,278), a narcotic (fentanyl) (289), and transfusion products (315,342,403) have all been found to be reservoirs for S. marcescens.…”

Biofilm Formation and Quorum-Sensing-Molecule Production by Clinical Isolates of Serratia liquefaciens

“…are opportunistic Gram-negative bacteria that belong to the family Enterobacteriaceae. Serratia marcescens and Serratia liquefaciens are frequently encountered in nosocomial infections (1)(2)(3)(4). S. liquefaciens is an increasingly recognized cause of transfusion-related sepsis and has been reported as a cause of meningitis, thrombophlebitis, corneal ulcers, and other infections (5)(6)(7)(8)(9)(10).…”

Implementation of a proficiency testing programme for bacterial screening in platelet preparations in Canada

“…Of these, five units were confirmed as true positives, 18 cultures were considered false or discordant positives due to contamination, and 31 cultures were false‐positives due to instrument errors. One false‐negative fatal case was also reported during this period at CBS [15]. Other centres have also documented false‐ negative results, some of them resulting in severe or fatal reactions [3,14,16–20].…”