Efficacy of diversion pouch in prevention of transfusion-transmissible bacterial infections

Muhammad Ali Rathore; Mohammad Abdul Naeem; Anum Javed; Mansoor Ishaq Raja

doi:10.4103/GJTM.GJTM_81_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 5 | Issue : 2 | Page : 159-162

Efficacy of diversion pouch in prevention of transfusion-transmissible bacterial infections

Muhammad Ali Rathore, Mohammad Abdul Naeem, Anum Javed, Mansoor Ishaq Raja
Screening Department, Armed Forces Institute of Transfusion, Rawalpindi, Pakistan

Date of Submission	16-Aug-2020
Date of Decision	10-Oct-2020
Date of Acceptance	14-Oct-2020
Date of Web Publication	13-Nov-2020

Correspondence Address:
Muhammad Ali Rathore
Screening Department, Armed Forces Institute of Transfusion, Rawalpindi
Pakistan

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/GJTM.GJTM_81_20

Abstract

Background and Objectives: Blood transfusion is a lifesaving therapeutic intervention; however, transfusion-transmissible bacterial infections pose a great risk to recipients. Adhering to stringent blood donor disinfection technique in conjunction with first aliquot diversion has mitigated the risks of bacterial sepsis. The aim of this study was to evaluate the prevalence of bacterial contamination and assessing the preventive effect of diversion pouches implemented during whole blood collections in a regional blood center in Rawalpindi, Pakistan. Methods: A cross-sectional study was performed from December 2019 to February 2020. A total of 300 diversion pouches filled with 20 mL of whole blood samples were included in the study. Aerobic and anaerobic blood culture vials were inoculated and incubated in the BD BACTEC™ FX40 instrument at 35°C until positive and for 7 days if negative. The culture vials flagged positive were subcultured onto a set of solid media to isolate and identify the implicated microbial species, followed by testing the whole blood-derived platelet component of the blood sample that tested positive. Results: The prevalence of bacterial contamination of whole blood using the diversion pouch was detected as 0.3% (n = 1/300). The bacterial species identified were coagulase-negative Staphylococcus. The platelet component of the positive whole blood sample showed an absence of the contaminant. Conclusion: The results of this study suggest the significance of diversion as an effective way of preventing bacterial contamination of whole blood components. This necessitates its usage in all other blood banks of Pakistan to enhance the safety of transfused blood.

Keywords: Blood culture, disinfection, prevalence

How to cite this article:
Rathore MA, Naeem MA, Javed A, Raja MI. Efficacy of diversion pouch in prevention of transfusion-transmissible bacterial infections. Glob J Transfus Med 2020;5:159-62

How to cite this URL:
Rathore MA, Naeem MA, Javed A, Raja MI. Efficacy of diversion pouch in prevention of transfusion-transmissible bacterial infections. Glob J Transfus Med [serial online] 2020 [cited 2020 Nov 27];5:159-62. Available from: https://www.gjtmonline.com/text.asp?2020/5/2/159/300639

Introduction

Transfusion is a lifesaving medical intervention, but associated sepsis is a major risk which could lead to morbidity and mortality.^[1] Septic transfusion reactions could be severe depending on the initial inoculum and type of bacterial species present in the blood products. These present with fever, abdominal cramps, myalgia, disseminated intravascular coagulation, and finally death of the recipients.^[2] Among cellular blood components, platelets are more prone to contamination due to storage at growth favorable temperature (20°C–24°C) with continuous agitation compared with red blood cells which are stored under refrigeration (2°C–6°C).^[3] The most likely source of bacterial contamination includes donor arm-derived skin commensals, dimpled or scarred antecubital fossa, and contaminated collection equipment.^[4] The concern about transient donor's bacteremia induced by dental procedures such as tooth repair or extraction is improbable among healthy donors.^[5] Therefore, current strategies including improved skin disinfection and use of diversion pouch followed by automated blood culture have been adopted to combat bacterial sepsis following transfusion of contaminated whole blood products along with the unnecessary deferral of healthy donors.^[6] The diversion technique, first used by Olthuis et al. in 1995, is based on redirecting initial flow of blood from donor into a diversion pouch to restrict the entry of bacteria into the units of whole blood components.^[7] In this study, triple blood bags with diversion pouches (Terumo, Vietnam) were used to assess the prevalence of bacterial contamination of whole blood along with its preventive effect.

Materials and Methods

A cross-sectional study was conducted at a regional blood center in Rawalpindi for a period of 3 months from December 2019 to February 2020

Ethics: This study was done after approval of the ethical review board of the institute.

The sample size was calculated using formula n = Z² P (1-P)/d² with 95% confidence interval, margin of error d = 0.02, and prevalence of blood culture contamination, P = 3% which has been set by the American Society for Microbiology and the Clinical Laboratory Standards Institute.^[8] This calculation gave a minimum of 291 diversion pouches, but in this study, a total of 300 diversion pouches were collected.

Inclusion criteria consisted of all blood donors with age ranges from 18 to 60 years. Health assessment was done using a standardized questionnaire and deferred if they documented any viral, parasitic, or bacterial infection or any other serious illness in accordance to the WHO guidelines. Before collection procedure, the venipuncture site was first swabbed with povidone-iodine (7% w/v) for 30 s, followed by isopropyl alcohol (70% v/v) for another 30 s in an inward to outward manner. Subsequently, phlebotomy was performed, and 20 mL of initial aliquot of whole blood was collected in a diversion pouch attached to the triple blood bag collection system. This sample was then tested for bacterial contamination by inoculating 10 mL in each aerobic (BD BACTEC^™ plus Aerobic/F) and anaerobic (BD BACTEC^™ plus Anaerobic/F) culture vials and incubated in the BD BACTEC^™ FX40 (Becton, Dickinson and Company, USA) automated detection system at 35°C until positive and for 7 days if negative. Positively flagged culture vials were then subcultured onto blood, MacConkey, and chocolate agar for isolation and identification of implicated microbial species. These culture plates were incubated aerobically at 37°C for 24–48 h, while chocolate agar was placed under anaerobic environment at 37°C for 48 h. Upon detection of positive culture vial, 10mL sample taken from the whole blood-derived platelet component was inoculated into BD BACTEC^™ aerobic and anaerobic culture vials and incubated under the same conditions.

Results

A total of 300 whole blood samples collected using the diversion pouch were included in this study. Of these, only one aerobic culture vial was flagged positive with a graph showing phases of bacterial growth [Figure 1]. The prevalence of bacterial contamination using diversion pouch was detected as 0.3% (n = 1/300). Upon subculture, microbial contaminant isolated was coagulase-negative Staphylococcus (CoNS). However, whole blood-derived platelet component of the positive blood sample was flagged negative after 7 days of automated incubation. The graph of negative culture vial containing whole blood-derived platelet sample showed a characteristic horizontal pattern [Figure 2].

Figure 1: The graph of positive culture vial (whole blood)

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Figure 2: The graph of negative culture vial (whole blood-derived platelet sample)

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Discussion

Posttransfusion septic reactions, mostly attributed to the unsafe supply of platelets than any other blood component, need to be mitigated by adopting preventive strategies such as improved donor arm disinfection and redirecting the initial flow of blood into a predonation pouch. These techniques have the potential to dramatically reduce bacterial contamination.^[9] The employment of diversion pouches is not in routine practice in the blood banks of Pakistan due to high cost. Therefore, this study was aimed at assessing the prevalence and efficacy in terms of preventing bacterial contamination of the whole blood, which subsequently leads to the supply of safe blood products. Venipuncture site disinfection before phlebotomy is a crucial intervention to reduce the transmission of bacteria by transfusion. Different studies demonstrated the impact of multiple variables such as one or two-step disinfection method, type of disinfectant, and mode of application on the antiseptic efficacy. In the present study, a two-step procedure using povidone-iodine and alcohol swabs was used. These combinations of disinfectants were found to be effective cleansing agents in a study from India, despite Staphylococcus species were isolated, which is consistent with the presence of potential contaminant of the current study.^[10] Application of these two agents was also found to be effective in a study from Brazil.^[11] In discordant with the current study protocol, povidone-iodine skin disinfection method was not as much as effective as single step 2% chlorhexidine swabs in a study from the USA.^[12] Another study from China also reported that predonation skin disinfection using single-step chlorhexidine-isopropyl alcohol was more efficacious than dual disinfection process.^[13] In contrast, a study from Iran found equivalent efficacy of chlorhexidine alcohol to that of povidone-iodine in a comparative study because no positive culture was reported after disinfection.^[14]

In the present study, out of 300 whole blood samples collected in the diversion pouch, 0.3% (n = 1/300) of diversion pouches were contaminated. The bacterial species identified were Gram-positive cocci such as CoNSwhich is a resident skin flora on the donor's arm. This indicates the exogenous cause as a source of contamination mainly attributed to inappropriate skin disinfection such as insufficient contact time or amount of antiseptic used. In addition, disinfection process can only reduce but not eliminate bacterial contamination. Therefore, skin fragment containing live microbes might be dislodged by phlebotomy needle into the diversion pouch, which is a possible explanation of the presence of bacterial contaminant.^[15] Bacterial growth kinetics is greatly influenced by the component environment and storage conditions. The rationale for choosing the platelet component was that bacteria can grow exponentially at room temperature (20°C–24°C) than any other blood component.^[16] This is also possible that contaminating bacteria might get inactivated by autosterilization process due to the presence of bactericidal agents in the whole blood, which is augmented by extended postdonation holding period (6–24 h). On the other hand, pathogens employ effective evasion strategies to overcome immune response which leads to their survival and propagation in whole blood components.^[17] In our settings, whole blood units were kept at room temperature and processed into components within 3 h; thus, it is suggested that this storage period conferred minimum bactericidal effect. Therefore, detection of negative culture vial inoculated with whole blood-derived platelet sample demonstrated the effectiveness of using diversion pouch.

Limitations of study

Given the differences in the study design and small sample size, comparison of data is acceptable to a very limited extent.

The current prevalence rate of 0.3% is higher than 0.21% prevalence rate reported by Korte et al. in 2006 in a study conducted in Netherland.^[18] The most recent study from Malaysia reported 1.7% rate of prevalence which is much higher than the current study.^[19] Efficacy of diversion technique in reducing whole blood bacterial contamination was also demonstrated in studies from Japan and China.^[20],[21] In 2011, Bolarinwa et al. showed 8.8% prevalence of bacterial contamination of whole blood and blood products collected without diversion pouch among Nigerians.^[22] Therefore, this high rate, which is discordant with the present study, truly indicates the significance of diverting initial aliquot of donor's blood.

The current bacterial contamination rate of diversion pouches needs to be further mitigated by educating phlebotomy staff about strict adherence to the standard operating procedures such as optimum dose and contact time of antiseptic used, change of gloves if contaminated, or between donors to avoid cross contamination which may enhance the efficiency of diversion pouch in reducing the risk of bacterial transmission in the blood supply chain.^[23]

To conclude, this study confirms the significance of diversion as an effective way of reducing the potential of bacterial contamination to enter into the blood supply chain. Although the microorganism detected belongs to skin commensal which have less pathogenicity, one should not consider this as apathogenic, particularly in view of the immunosuppressive condition of the recipient. This necessitates its usage in all other blood banks of Pakistan in conjunction with optimization of disinfection process to achieve zero risk transfusion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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