Jeff Joel L.
Lumasag September 24, 2017
Section A2 Bacte Journal
Summary
Systematic screening of blood donations for the presence of blood-borne viruses has
resulted in a dramatic decrease of viral infections after blood transfusion, and bacterial sepsis
has become the most frequent infectious complication of transfusion in developed countries.
Red blood cell (RBC) preparations are the most frequently transfused blood component.
Although contamination of platelet concentrates are predominantly attributable to Gram-
positive bacteria from the skin flora, contaminations of RBC products involve primarily Gram-
negative organisms (mostly members of the Enterobacteriaceae) of endogenous origin. Yersinia
enterocolitica, associated with 46% of documented cases of clinical sepsis from contaminated
RBCs, is paradigmatic of such Gram-negative agents transmitted by blood infusion and
triggering severe sepsis and septic shock. In the study, we analyzed all available literature
descriptions of Y. enterocolitica PTS to (1) delineate the salient clinical features, (2) determine
the fatality rate and its evolution over time, (3) identify predictive factors of fatal outcome, and
(4) gain insights about appropriate therapeutic and preventive measures. Statistical analyses
were performed using the Prism, version 5, for Mac software (Graph Pad Software), using
Students t-test or MannWhitney U test, depending on the distribution of the data, to
compare continuous variables and the x^2 or Fishers exact test, depending on the population
size, to compare categorical variables.
The present work is a systematic review of 55 published cases of Y. enterocolitica PTS.
Cumulative data show that the signs of Y. enterocolitica PTS are generally of sudden onset
appearing during or shortly after (3 hrs) the transfusion, sometimes heralded by digestive
symptoms, chest and/or back pain, or even cutaneous rashes. This literature review also
provides evidence that antimicrobials effective against Y. enterocolitica should be promptly
administered to the patient as soon as a transmission-associated sepsis is suspected. Y.
enterocolitica contamination of donated blood samples is believed to be primarily intrinsically
occurring in the donor from an intestinal source before blood harvesting and processing. In
support of this view, a majority of the implicated donors had clinical, bacteriological, or
serological signs compatible with recent or ongoing Y. enterocolitica gastroenteritis at
donation. Several donors indicated no ongoing or recent illness in response to predonation
questioning but recalled the symptoms retrospectively during the post Y. enterocolitica PTS
investigation, which emphasizes the importance of careful predonation interviewing. At least 4
of 6 autologous donors in the present series had experienced gastroenteritis within a few days
before or after donation, and 2 had seen a physician for the problem. Nevertheless, this fact
was overlooked possibly because autologous blood is not perceived as dangerous, although it is
as prone as allogeneic blood to bacterial contamination by intrinsic or extrinsic (during blood
collection or processing) ways. Two of the autologous donors were below the age limit for
donating to the general blood supply and, thus, belonged to the age class with the highest
prevalence of Y. enterocolitica infection. Yersinia serologic testing in the donor at donation
would have avoided at least 9 PTS occurrences. In countries with high Y. enterocolitica
seroprevalence, this could restrict the blood supply to levels incompatible with the population
needs. The data suggest that Y. enterocolitica is more frequently transmitted by RBC units. 4
weeks old. However, one-third and more than onehalf ofY. Enterocolitica PTS cases were
associated with RBCs, 3 and, 4 weeks old, respectively, so that reducing the storage time to 4 or
even 3 weeks would leave a substantial proportion of Y. enterocolitica PTS occurrences.
However, subsequent prospective studies and hemovigilance system data yielded incidences
that were actually even lower. A nationwide American study identified a single case of Y.
Enterocolitica PTS from 1998 through 2000, when 24 million RBC units were transfused. The
New Zealander hemovigilance system detected only 1 Y. enterocolitica PTS among a total of
470000 RBC units transfused during 20052008. The French hemovigilance system recorded 11
Y. enterocolitica PTS cases per 723106 RBC units delivered during 19942003 and none in
15310 6 RBC units delivered during 20042009. These data suggest that the transfusion-
associated Yersinia risk has diminished in some countries since the mid-1990s. This evolution
probably results, at least in part, from improved prevention measures, such as universal
leukoreduction of blood products. The best compromise can vary from country to country
depending on the local epidemiology of Y. enterocolitica and constraints on the blood supply. It
is encouraging that the progressive implementation of an array of fairly simple measures aimed
at improving transfusion safety was accompanied by a possible reduction in Y. enterocolitica
PTS incidence in some countries. However, these measures have not eliminated the risk of Y.
enterocolitica PTS.
