PLATELET TRANSFUSION-INDUCED SERRATIA-MARCESCENS SEPSIS DUE TO VACUUM TUBE CONTAMINATION

Three instances of Serratia marcescens septicemia in two patients following infusion of platelet concentrates stored at 22 C, and the isolation of the organism from one unit of a platelet concentrate, led to a study to determine the possible sources of such contamination. Cultures of the available blood products, derived from the same blood donations used to prepare the suspect platelet concentrates, yielded Serratia marcescens from two units of cryoprecipitate and from one unit of red blood cells. All other available blood products were sterile. Serratia marcescens was isolated in considerable numbers from 82 per cent of the vacuum tubes from one manufacturer's lot in use in the transfusion center at the time of the septic episodes. Six other lots of vacuum tubes prepared by the same manufacturer in use at the same time were sterile. The organism was not found in samples from other equipment, materials or personnel involved in the preparation of the blood products. Simulation of the blood collection technique using vacuum tubes from the contaminated lot, when filled from an in‐line needle as used following the blood collection procedure, gave contamination of the primary pack with Serratia marcescens in five of the six experiments attempted. The contaminated vacuum tubes were thus considered the most likely source of contamination of the platelet concentrates. 1979 AABB