Reduce Patient Risk of Transfusion-Associated Sepsis

Cerus Final Intercept United States 3

Quality Improvement After Multiple Fatal Transfusion-Transmitted Bacterial Infections1

    • A neutropenic leukemia patient received routine outpatient platelet and RBC transfusions.
    • Platelets and first RBC unit were transfused without incident, within minutes of starting the second RBC transfusion patient developed rigors, transfusion was stopped.
    • Symptoms resolved temporarily, but two hours later was admitted for neutropenic fever.
    • Given timeline and neutropenia, contamination of the platelet unit was not suspected, and the co-component platelet unit was not quarantined.
    • The following morning, visual inspection of the co-component revealed “cotton ball”-like flocculation of Staphylococcus aureus, testing revealed a match to the infection in the patient.
case study transfusion reaction figure small
(Click image to enlarge)


contaminated platelet bag

Contaminated platelet bag showing Staphlyococcus aureus.


Additional Resources:

Download an educational poster on diagnosis of a septic transfusion reaction

sepsis hai poster

8.5"x11"     11"x17"


1. Nelson R, Ivey J, Eder A. Transfusion 2017;57:2309-10.


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