BLOOD COMPONENTS
Screening of single-donor apheresis platelets for bacterial
contamination: the PASSPORT study results
Larry J. Dumont, Steven Kleinman, James R. Murphy, Rebecca Lippincott, Robert Schuyler,
Jaime Houghton, and Peyton Metzel
BACKGROUND: The PASSPORT study was an FDA-
mandated surveillance of outdated 7-day apheresis
platelets (APs) to assess the bacterial culture release
test (RT) performance and the chance of transfusing
APs containing viable bacteria compared to untested
5-day APs.
STUDY DESIGN AND METHODS: Aerobic and anaero-
bic culture bottles were inoculated with 4 to 5 mL from
APs 24 to 36 hours postcollection. APs were released
after 24 hours if no growth was observed. Released
APs were recalled for RT positives, and clinical services
were notified. Day 8 APs were recultured (surveillance
test [ST]). Initially positive RTs and STs were confirmed
by AP reculture.
RESULTS: A total of 388,903 RTs were accrued Sep-
tember 2005 through January 2008 from 52 regional
blood centers: RT-positive APs interdicted before trans-
fusion, 76 true positive (TP; 195/million; 95% confi-
dence interval [CI], 154-244/million) and 57
indeterminate (IN); and RT-positive APs transfused, 14
TP and 242 IN. There were 14 reported septic transfu-
sion reactions (STRs) from 13 AP collections (23 units)
transfused on Days 3 through 7; three STRs were from
Day 6 or 7 APs. There were two false-negative RTs
causing STRs in three patients. No deaths were
reported. STs had four TPs of 6039 tested (662/million;
95% CI, 180-1695/million).
CONCLUSIONS: RT culturing prevents issuance of
some bacterially contaminated APs. ST culture data
and clinical reports suggest that this screening fails to
detect all contaminated units. No fatalities were
reported related to AP transfusion. Additional actions or
testing may be required to further reduce the residual
STR risk of RT APs, even with a 5-day storage
limitation.
_2460 589..599
B
efore routine bacterial culture testing of plate-
lets (PLTs), transmission of bacteria in blood
components was the highest risk transfusion-
transmitted infectious disease. The incidence of
contamination has been reported between 0.3 and 1 per
1000 units (300-1000/million), while the risk of a clinical
septic transfusion reaction (STR) was between 75 and 402
per million for single-donor PLTs and PLTs from whole
blood, respectively.1,2 Bacterial contamination of PLTs for
transfusion has historically been one of the leading causes
of morbidity and mortality associated with transfusion,
reviewed by Yomtovian.3 This risk has been one of the
important determinants of the maximum storage time
permitted for room temperature–stored PLTs. Because
of concerns over bacterial proliferation in room
temperature–stored PLTs, the U.S. Food and Drug Ad-
ministration (FDA) reduced the permissible storage time of
PLTs from 7 to 5 days in the mid-1980s.4,5 In 2005, the FDA
cleared leukoreduced PLTs collected by apheresis (AP)
ABBREVIATIONS: AP(s) = apheresis platelet(s);
ARC = American Red Cross; BC = buffy coat; BPA(s) = aerobic
culture bottle(s); BPN(s) = anaerobic culture bottle(s);
BTA = BacT/ALERT Microbial Detection System;
CNS = coagulase-negative Staphylococcus; IN = indeterminate;
RT(s) = release test(s); SDP(s) = donor platelet(s);
ST(s) = surveillance test(s); STR(s) = septic transfusion
reaction(s); TP(s) = true positive(s).
From the Department of Pathology, Dartmouth Medical School,
Lebanon, New Hampshire; the University of British Columbia,
Vancouver, British Columbia, Canada; National Jewish Health,
Denver, Colorado; CaridianBCT, Inc., Lakewood, Colorado; and
Fenwal, Inc., Lake Zurich, Illinois.
Address reprint requests to: Larry J. Dumont, MBA, PhD,
Dartmouth-Hitchcock Medical Center, Department of Pathol-
ogy, One Medical Center Drive, Lebanon, NH 03756; e-mail:
larry.j.dumont@hitchcock.org.
Received for publication June 14, 2009; revision received
August 17, 2009, and accepted August 18, 2009.
doi: 10.1111/j.1537-2995.2009.02460.x
TRANSFUSION 2010;50:589-599.
Volume 50, March 2010 TRANSFUSION 589
DUMONT ET AL.

from three companies for storage through 7 days at room tion of the anaerobic bottle to the BTA, and assessed the
temperature based on acceptable PLT performance.6-8 To need for anaerobic culturing in this application.
implement storage of AP for up to 7 days, the FDA required
a postmarketing surveillance study to assess the field per-
formance of the bacterial screening method used as a MATERIALS AND METHODS
release test (RT) for APs. CaridianBCT, Inc. (formerly
Blood center participants
Gambro BCT, Inc.), initiated the study and was later joined
Participating blood collection centers were FDA registered
by Fenwal, Inc. (formerly Baxter, Inc.). This report will
and/or licensed facilities for AP collection and had
present the outcomes of the Post Approval Surveillance
received FDA approval to label single-donor platelets
Study of Platelet Outcomes, Release Tested—PASSPORT.
(SDPs) for 7 days of storage through either an exception
In 2003 the AABB issued Standard 5.1.5.1 requiring
under 21 CFR 640.120, Alternative Procedures; to
100% testing of all PLT products for bacteria by March
9 610.53(c), Dating Periods; or a prior approval supplement
2004. In response, many blood collection organizations
to their biological license application (Table 1). Participa-
implemented 100% bacterial screening of AP as a quality
tion in PASSPORT was an FDA requirement for any blood
control (QC) test using the bioMérieux BacT/ALERT Micro-
center requesting approval to label PLTs for 7-day storage.
bial Detection System (BTA; bioMérieux, Durham, NC), a
All participants were initially enrolled as Tier 1 centers that
widely used system in North America and Europe both for
required collection and reporting of all RT results, micro-
diagnostic clinical microbiology and for the testing of PLT
10-12 biology follow-up, and reporting of applicable clinical
products. This system had been cleared by FDA for the
data. Larger centers were then transitioned to a Tier 2 par-
QC testing of leukoreduced PLTs. We surveyed the first 20
ticipant that required, in addition to the Tier 1 informa-
months of experience from several US blood suppliers that
tion, reculturing of all available Day 8 APs. One Tier 2
tested 4-mL APs in the aerobic bottle and found a con-
center maintained a 5-day AP expiration, sequestered in
firmed positive rate of 178/million (95% confidence inter-
quarantine-expired APs under standard blood bank
val [CI], 139-224/million; n = 405,088) and possibly as high
storage conditions, and recultured these APs on Day 8. All
as 291/million (95% CI, 241-349/million) if indeterminate
RTs, surveillance tests (STs), and other aspects of the study
(IN) results were included (7-day PLT storage using PLTs
were adhered to by the center.
collected with the COBE Spectra apheresis systems and the
Trima automated blood component collection systems
and tested with the BTA, PN 777018-718, Gambro BCT [see
supporting information available in the online version of APs
this paper]). At that time, previous incidence estimates for APs were collected on the COBE Spectra, Trima (Caridian-
positive cultures using both aerobic and anaerobic bottles BCT, Inc., Lakewood, CO), or the Amicus separator
at 4 mL of inoculum per bottle were determined from small (Fenwal, Inc., Lake Zurich, IL) according to the manufac-
sample sizes and in a limited number of institutions in the turer’s directions; tested; and labeled according to FDA
United States. Data from a single institu-
tion in our survey estimated true con-
firmed positive for a release criteria of TABLE 1. Participating blood centers
positive in either or both bottles at 606/ Avera McKennan Hospital Hoag Memorial Hospital
million (95% CI, 165-1551/million, Bergen Community Regional Blood Center Indiana Blood Center*
Blood Banks of Mid-Florida Inland Northwest Blood Center
n = 6600 APs), which was at that time the
Blood Center of New Jersey Lackland Blood Donor Center
largest reported screening results using Blood Center of Northcentral Wisconsin Madigan Army (Armed Services
an anaerobic and aerobic testing Blood Bank Center)
Blood Centers of the Pacific Maimonides Medical Center
scheme for AP.
Blood Systems, Inc.*† Mayo Clinic
Our primary objective in this post- Bonfils Blood Center*‡ Mississippi Blood Services
marketing surveillance study was to Central Jersey Blood Center Mississippi Valley Regional Blood
Center
demonstrate that 7-day APs when tested
Coffee Memorial Blood Center New Brunswick Affiliated Hospital
using the BTA would not present a Community Blood Center (Appleton, WI) New York Blood Center*
greater risk of a detectable bacterially Community Blood Center, Dayton (CBC/CTS) Sheppard Community Blood Center
Community Blood Center, Greater Kansas City South Texas Blood & Tissue
contaminated PLT unit than 5-day APs
Community Blood Center, South Florida Southeastern Community Blood Center
untested for bacterial contamination. CVPH The Blood Connection*
We also estimated the sensitivity of the Florida Blood Services University of Iowa/DeGowin
Florida’s Blood Centers, Inc. University of North Carolina*
two-bottle RT, estimated the prevalence
* Tier 2 participants.
of bacterial contamination for untested
† Includes multiple regional centers.
and for two-bottle BTA–tested APs, ‡ APs labeled for 5-day storage.
determined the performance contribu-

590 TRANSFUSION Volume 50, March 2010


AP Storage Days
D0 D1 D2 D3 D4 D5 D6 D7 D8
RT – Two bottle ST – Two bottle
Incubate ≥ 24 hr Incubate 7 days
Release Data Analysis
Fig. 1. PASSPORT flow: APs were collected on Day 0, sampled
for two-bottle RTs 24 to 36 hours after collection, and released
to inventory as 7-day PLTs if BTA negative after 24 hours on
test (one center labeled only for 5-day shelf life, see text). All
centers participated in the RT phase. APs not transfused at the
end of Day 7 were resampled for surveillance cultures. Cul-
tures were held up to 7 days. See text for details.
and AABB requirements and stored in bags approved for
7-day storage under standard blood bank conditions. The
use of access line diversion pouches was not specified and
not prospectively tracked. After review of participants’ use
and ordering of disposable sets absent access line diver-
sion pouches (i.e., Spectra dual-needle and Amicus kits
with sample pouches on the return line), we estimate less
than 1% of the reported RT and none (0%) of the reported
ST units were without access line diversion pouches.
RT
The RT was an enhancement to the BTA QC instructions
for use and was FDA cleared (7-day PLT storage using PLTs
collected with the COBE Spectra apheresis systems and
the Trima automated blood component collection
systems and tested with the BTA, PN 777018-718, Gambro
BCT [see supporting information available in the online
version of this paper]). Briefly, APs were aseptically
sampled between 24 and 36 hours post–apheresis collec-
tion (Fig. 1). APs in multiple bags (e.g., to be split) were
pooled into one bag for sampling. APs that had already
been divided into multiple products were sampled indi-
vidually. (The study sponsors are aware of only one par-
ticipating center that routinely tested individual AP bags.
This represented 2609 of 388,903 RTs [0.67%] and 62 of
6039 STs [1.0%].) A positive culture from one or more mul-
tiple products from the same donation was considered as
a positive for the donation. Aliquots (4-5 mL) of APs were
inoculated within 6 hours into both one aerobic (BPA) and
one anaerobic (BPN) culture bottle according to the direc-
tions for use for the BTA and sampler used, and bottles
were placed into the BTA within 3 hours of inoculation for
incubation and automated monitoring. APs remained in
quarantine for a minimum of 24 hours after introduction
of the culture bottles to the incubator and were released if
PASSPORT: BACTERIAL SCREENING OF PLTs
no growth was indicated during the first 24 hours. Culture
bottles remained on test until either the bottle was indi-
cated positive for growth or the expiration date of the AP,
whichever was earlier.
APs with an initial-positive RT were quarantined
along with any cocomponents. Confirmatory testing using
a culture-based test was initiated by resampling the AP or
AP cocomponent from the sample collection (i.e., a split) if
unavailable. Confirmatory testing may have been with the
BTA or other method used by the clinical microbiology
laboratory. Organisms from confirmed positives (true
positive [TP]) were isolated and identified using standard
methods. APs or cocomponents that had been released
before the initial-positive RT were recalled. In cases where
AP had been transfused, the clinical service was notified of
the RT result and the organism identification when avail-
able from subcultures of the positive BTA bottle. The clini-
cal condition of the transfusion recipient was noted and
the recipient was followed according to the particular
hospital’s protocol and appropriate data, when available,
were reported to the study.
Transfusion reactions possibly related to a bacterial
source reported to the blood center were noted along with
pertinent case information such as clinical signs and
symptoms, patient blood culture results, AP culture
results (confirmatory testing), and organism identifica-
tion. Confirmatory testing using a culture-based test was
initiated by resampling the AP or AP cocomponent from
the sample collection (i.e., a split) if unavailable.
Classification of events was according to AABB Asso-
ciation Bulletin 04-07 (Table 2).13 RTs were reported to the
study sponsors quarterly using an electronic spreadsheet
(Excel for Windows, Microsoft Corp., Redmond, WA),
which included the number of RTs, number of initial
positives, results by bottle type, time to detection, con-
firmation testing results, microbiologic identifications,
follow-up investigations, age of AP at transfusion, and
relevant clinical experience. Data summaries were sub-
mitted semiannually to the FDA by the study sponsors.
ST
APs beyond 7 days from collection were resampled before
the end of Day 8, and BTA BPAs and BPNs were inoculated
in the same manner as the RT. The products included
deliberately outdated products, such as those used for QC
monitoring or those that did not meet release criteria, or
those that naturally outdated due to lack of demand or
other reasons. APs were then held in the refrigerator in
case of the need to resample for a confirmatory test. BTA
were held for 7 days. Positive cultures were followed up by
subculturing BTA bottles and reculturing the retained AP.
Surveillance testing was reported via a Web-based
case report form to the database managed at the data
coordinating center, National Jewish Health, Division of
Volume 50, March 2010 TRANSFUSION 591
DUMONT ET AL.

TABLE 2. Classification of results: from AABB Bulletin 04-07

Classification Not transfused Transfused
TP Positive confirmatory test Positive confirmatory test or posttransfusion sepsis confirmed by blood culture
False positive Negative confirmatory test Negative confirmatory test and no clinical or microbiologic evidence of posttransfusion sepsis
IN No confirmatory test or Posttransfusion sepsis with no confirmatory test or other combinations of component and
could not be interpreted recipient results in situations where the component has been transfused
True negative Not applicable Posttransfusion sepsis with negative confirmatory test
False negative Not applicable Posttransfusion sepsis with blood culture confirmation and organism match between product
and patient and positive confirmatory test on product

Issued bacterially contaminated 7-day APs is no

AP (N) RT (NRT)
Outdate (>7 days)
Confirmed Positive (nRT)
Confirmed Positive (nST) 50,000 will have an estimated sample
Fig. 2. Surveillance study flow diagram. A large number of APs (NRT) are tested rou-
tinely using the RT on Day 1 (RT) of which nRT are found as TPs. Outdated products
(NST) are tested in the ST of which nST are confirmed positives. See text for estimates
of rates.
Biostatistics. Data included ST results, RT results, clinical
information for recipients transfused with a split AP
whose associated split AP was positive in the ST, confir-
matory test results, and organism identifications. Data
summaries were submitted semiannually to FDA by the
study sponsors.
Sample size and analysis plan
We performed the primary analysis by testing the hypoth-
esis that the residual risk of detectable bacteria in APs
stored 7 days is less than the risk of untested APs using a
95% confidence limit. The following rates were estimated
from observed confirmed positives (Fig. 2) using a soft-
ware program (NCSS, Kaysville, UT).
R RT (RT-positive incidence rate) = n RT N RT
R ST (ST-positive incidence rate) = n ST N ST
R U (Untested SDP positive incidence rate) = R RT + R ST .
The null hypothesis will be rejected if the upper one-
sided confidence limit of RST is less than the point estimate
of RU. A priori sample size calculation was based on the
assumptions that RRT = 200/million (1/5000) from early
testing using aerobic bottles and that RT sensitivity will be
50% or more; thus, a sample size of 50,000 STs will demon-
strate with 95% confidence that the residual risk of a
more than 200/million provided that
fewer than five confirmed-positive STs
are detected. The CI approach requires a
reduction in the proportion of collec-
ST (NST) tions positive at the RT from the a priori
estimate of 200/million to 80/
million or less, where four positive col-
lections of 50,000 will have an 95% upper
confidence limit of 183/million. Five of
proportion 100/million and a 95% upper
confidence limit of 210/million and
would not pass this criterion.
The sensitivity of RT was calculated
by dividing the RT rate by the combined
rates from RT and ST for confirmed
positives; the latter is assumed as the reference or gold
standard. The agreement between the aerobic and
anaerobic bottle results for RT TPs was estimated using
the McNemar test of correlated proportions.
RESULTS
New York Blood Center was the first participant to imple-
ment 7-day APs under the current scheme.14 A total of 52
centers eventually enrolled from September 2005 through
April 2008 when the study was stopped by the sponsors
(Table 1, Fig. 3). Accrual of RTs and STs reached 388,903
and 6039 by study termination (Fig. 4). A total of 790 AP
collections were interdicted before transfusion with 76
TPs and 57 INs (Table 3). Three-hundred seven initial
positives were transfused, of which 14 could be confirmed
as TP and 51 as false-positive. The vast majority of initial
positives that were transfused, 242, could not be verified
because a confirmatory culture could not be performed
and/or there was no adverse event in the patient; these
were classified as IN. Two APs with a negative RT were
associated with STRs (i.e., false-negative RT). Each of
these false RT-negative donations was subsequently
divided into two transfusable products. The first-
collection split products were transfused on Day 6 after
collection and resulted in one recipient with a fever in
whom confirmed coagulase-negative Staphylococcus
(CNS) grew in both the remainder of the AP and the blood

592 TRANSFUSION Volume 50, March 2010

 PASSPORT: BACTERIAL SCREENING OF PLTs

culture of the patient. There was no reaction in the second transfusion reactions without further sequelae related to
patient. The second-collection split products were trans- the transfusion event.
fused on Day 4 and resulted in two STRs with Staphylococ- There were 14 TP RTs transfused before interdiction
cus aureus cultured from the remaining volume of both that resulted in two transfusion reactions. A total of 242 RT
split products. The patients all recovered from the indeterminants were transfused resulting in 11 reported
reactions. As mentioned above, two false-negative RTs
with three associated reactions were reported, for a total of
TABLE 3. RT outcomes 16 transfusion reactions possibly related to bacterial con-
Cumulative September Events per million tamination. This is an event rate of 41 STRs per million
Description 2005-April 2008 (95% CI) collections (95% CI, 24-67/million), or 28/million (95% CI,
SDP collections 388,903 16-48/million) transfused products assuming a collection
Interdicted
TP 76 195 (154-245) split rate of 50%. No deaths were reported. These 16 cases
False positive 657 1689 (1563-1824) were evaluated and further categorized into definite, pos-
IN 57 147 (111-190) sible or probable, or unlikely associated with a bacterially
Transfused
TP 14 36 (20-60) contaminated AP using a modification of the Canadian
False positive 51 131 (98-172) guideline for investigation of bacterial contamination,
IN 242 622 (547-706) summarized in Table 4.15 Figure 5 shows the 16 reported
False negative 2 5 (1-19)
transfusion reactions as a function of the age of the PLT
when transfused. One PASSPORT participant did not label
60 APs for 7-day shelf life, resulting in 12,833 or 388,903
51 52 (3.3%) APs that were not at risk to be transfused on Day 6
50
47 or Day 7. The per-unit risk by storage day cannot be cal-
43 culated since PASSPORT did not collect information on
40
38 the overall storage age distribution of APs at the time of
33
30 transfusion.
RT TPs reactive in both aerobic and anaerobic bottles
20
18
are summarized in Table 5. TPs reactive in only one bottle
12 are shown in Table 6. As expected, obligate anaerobes
10
9 (Fusobacterium spp., Peptostreptococcus, Prevotella oralis,
1 1 and Bacteroides eggerthii) as well as the aerotolerant
0
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 anaerobe Propionibacterium sp. were the predominant
2005 2006 2007 2008 anaerobic-only reactives. There was a significant discor-
dance between the aerobic and anaerobic bottles for
Fig. 3. PASSPORT enrollment: participating regional sites. detection of TPs, with the anaerobic bottle detecting 80 of
92 TPs 87.0% (95% CI, 78.6%-92.4%)
450,000 7,000 compared to 44 of 92 for the aerobic
388,903 bottle 47.8% (95% CI, 37.9-57.9%;
400,000
6,039 6,000 p < 0.0001). (Note that the two false
350,000 negatives in Table 3 were included for
320,983 these calculations.) Only 34 (45%) of
5,000
Cumulative RT

300,000 these organisms were detected in both

Cumulative ST

4,369 bottles; this latter observation may be

250,000 4,000
partially due to sampling volume
200,000 effect16 and may also be influenced by
3,000
193,078 the enriched media in the anaerobic
2,571
150,000 bottle allowing some organisms to grow
2,000
better in that device.
100,000
84,380 Diphtheroids are usually speciated
1,234
1,000 as either Corynebacteriae spp. (aerobes
50,000 27,221
5,883 367 and facultative anaerobes) or P. acnes
0 0 (obligate anaerobes and aerotolerant
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 anaerobes). These, along with strict
2005 2006 2007 2008 anaerobic organisms, are considered by
some as being of little clinical signifi-
Fig. 4. Accrual of release-tested AP collections and surveillance-tested Day 8 APs. cance in the setting of anaerobically

Volume 50, March 2010 TRANSFUSION 593

 DUMONT ET AL.

594 TRANSFUSION
TABLE 4. Clinical transfusion reactions reported as associated with bacterial infusion
PLT Patient blood
Classification Case age (days) RT† Clinical culture Confirmation test Comments
Definite 1* 4 Staph. aureus Severe septic reaction Staph. aureus Staph. aureus Cocomponent to Case 2
2* 4 Staph. aureus Fever, hypotension Negative Staph. aureus Cocomponent to Case 1
3* 6 CNS Fever CNS CNS Cocomponent transfusion on Day 6 with
no reaction
Possible/probable 4‡ 3 Corynebacterium sp. Short of breath, hypotension ND Diphtheroid Cocomponent transfusion on Day 3 with

Volume 50, March 2010

no reaction
5§ 4 Negative Fever hypotension Staph. epidermidis ND Negative RT
6§ 4 Negative Fever CNS Bacillus sp. Cocomponent transfusion on Day 4 with
no reaction
7§ 4 Negative Nondescript reaction ND ND Cocomponent transfusion on Day 7 with
no reaction
8‡ 5 P. acnes Fever CNS P. acnes
9§ 5 Bacillus sp. Hypotension CNS ND Cocomponent transfusion on Day 3 with
no reaction
10§ 5 Negative Nausea, back pain ND ND Cocomponent transfusion on Day 5 with
no reaction
11§ 6 Negative Chills, hives Enterococcus sp. ND Cocomponent transfusion on Day 5 with
no reaction
12§ 6 Negative Fever Staph. epidermidis ND
Unlikely 13§ 3 Diphtheroids Hives ND ND
14§ 4 Negative Fever Negative ND Cocomponent transfusion on Day 4 with
no reaction
15§ 5 P. acnes Fever Negative ND
16§ 7 Negative Periorbital edema, hives Negative Nonhemolytic
Streptococcus
* False-negative RT.
† Positive RT BTA cultures became positive after the release of AP and transfusion of the AP.
‡ TP RT.
§ IN.
CNS = coagulase-negative Staphylococcus.
 PASSPORT: BACTERIAL SCREENING OF PLTs

stored PLTs. Exclusion of obligate anaerobes, diphthe-
roids, Corynebacteriae spp., and Propionibacterium
spp. from the comparison of the two bottles then fails
to demonstrate a significant difference between the
bottles (anaerobic 46 of 57, 80.7%; 95% CI 68.7%-88.9%
vs. aerobic 43 of 57, 75.4%, 95% CI 62.9%-84.8%;
p = 0.5127).
Time to detection of those organisms detected in
both bottles was on average shorter in the aerobic bottle
for staphylococcal species (by 2.3 hr for Staph. aureus and
9 hr for CNS), longer for streptococcal species (by 2.9 hr
for Strep. viridans and 1.3 hr for Strep. gallolyticus/bovis),
and approximately the same for other organisms.
However, there is little practical difference in these times
since all but two of the 33 detected in both bottles were
identified during the 24-hour quarantine period between
culturing and release. The RT sensitivity of the two-bottle
system was approximately 25.9% based on TP rates of
both aerobic and obligate anaerobic organisms in the RT
and the ST (231/893 per million). Yet, because of the small
number of ST and ST positives, if the two ST results with
discordant identifications (see below) are considered false
7 RU. However, the upper 95% confidence for the residual
6 with 95% confidence that 7-day-stored APs have a residual
5
4 targeted 50,000 resulting in a severely underpowered
3
positives, then the sensitivity increases to 41% (231/562
per million).
Accrual of APs into surveillance testing beyond 7
days of storage was well below expectations, likely due to
the dramatic reduction in outdates and AP wastage
after the implementation of 7-day PLTs.17 Of the 6039 ST
APs, there were 19 initial positives with four confirmed
positives (Table 7). It was because of these four ST cases
that the PASSPORT study was terminated. Two of the
four had concordant organism identifications from the
confirmatory tests, and two had discordant identifica-
tions. The ST with Staph. epidermidis was one-half of a
split AP collection. The sister PLTs were transfused on
Day 4 with no transfusion reaction. One of the
confirmation-discordant PLTs (Strep. viridans and
coagulase-negative Streptococcus on ST with P. acnes on
confirmation) was also a split-AP collection. Aliquots
from the sister PLT were transfused three times, once on
Day 3 and twice on Day 6, to the same infant with no
adverse reactions.
The point estimate of the residual risk for contami-
nated product was 662/million, RST, less than the esti-
mated total contamination at collection of 893/million,
risk was 1515/million; thus, we are unable to conclude
risk less than 893/million, RU. Because of the early termi-
nation of PASSPORT, the ST accrual fell well below the
study (post hoc estimate, 20%).

2 DISCUSSION
1 The PASSPORT study, and consequently the use of 7-day-
stored PLTs in the United States, was called to an early
0
termination based on concerns by the study sponsors that
Day 3 Day 4 Day 5 Day 6 Day 7
the residual risk of a bacterially contaminated AP labeled
Fig. 5. Storage of APs with transfusion reactions reported as for 7-day storage was unacceptably high. With a total sur-
associated with bacterial infusion. Solid bar = definite, prob- veillance population of only 6039, we were unable to dem-
able, or possible association. onstrate with 95% confidence that the residual risk of
a BTA-screened AP, as defined in this
protocol, was less than that of an
TABLE 5. RT TP reactive in aerobic and anaerobic bottles unscreened AP, the latter risk being esti-
Organism Number TTD BPA* TTD BPN* mated from the study data. It is note-
Citrobacter 2 4.2, 8.8 4.4, 8.4 worthy that small changes in the
Escherichia coli 5 9.0 (5.3-13) 8.4 (5.3-10.8)
microbiologic outcome have a dramatic
Klebsiella pneumoniae 1 10 10
Serratia marcescens 1 6.1 7 effect on these estimates. For example, if
Group C strep 2 15, 16 17.3, 13.7 two of the four ST positives in Table 7
Group G beta hemolytic strep 2 8.7, 8.9 8.4, 8.6
were judged false positives because of
Enterococcus spp. 2 8.1, 12 8.5, 12
Staph. aureus 6 12.8 (8.2-23) 15.1 (8.5-27.2) the discordance between the ST and the
Coagulase-negative Staphylococcus 6 17.7 (11.4-23.3) 25.4 (12.2-69.3) confirmatory test, then the residual risk
Strep. viridans 1 20.9 18
estimate would be 331/million with a
Strep. gallolyticus/bovis 6 11.9 (9.3-14.5) 10.6 (8.6-11.7)
95% upper confidence limit of 1042/
* Data are individual times or mean with range.
TTD = time to detection (hr). million. Although not part of the original
study evaluation criteria, there was also

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DUMONT ET AL.

concern that the 662/million residual risk of screened AP per year per 400,000 AP collections. However, they further
was greater than the RT yield of 231/million, indicating concluded that any replacement of the 6- and 7-day-old
poor test sensitivity. The reported transfusion reactions in APs using PLTs manufactured from whole blood, either RT
PASSPORT that are likely to have been associated with a screened or tested by surrogate methods, would negate
bacterially contaminated AP span a range of AP storage this small decrease and would be likely to increase the
age from 3 to 7 days, with only 3 of 12 reactions assessed as number of STRs.
definitely or possibly caused by transfusion-transmitted Two key a priori assumptions used in designing PASS-
bacteria occurring with PLTs stored greater than 5 days in PORT have proved to be grossly incorrect. First, we
age. A weakness in these data is the lack of information on observed that the sensitivity of the RT scheme was 25.9%
the overall age distribution of APs at transfusion, thereby (assuming that all four STs were TPs), substantially below
preventing estimates of transfusion reaction risk by day. the a priori guess of 50% or more. Second, we estimated
The PASSPORT data neither refute nor support an the incidence of bacterially contaminated APs at collec-
increased risk of bacterial sepsis for APs stored for 6 or 7 tion would be approximately 200/million based on early
days compared to those stored for 4 or 5 days. In a recent testing data obtained at 24 hours postcollection using a
analysis of the risk of discontinuing 7-day PLT availability, 4-mL sample incubated in only one aerobic culture bottle.
Kleinman and colleagues18 estimated that replacement of The data presented here suggest the contamination level
all 6- and 7-day-old APs with 5-day-labeled AP RTs is more likely much higher at 893/million (RU) or approxi-
screened may reduce the number of STRs by one or two mately 1/1000. This estimate is supported by other
national surveillance studies. The right
side of Fig. 6 shows results from three
TABLE 6. RT TP reactive in only one bottle studies of bacterial culturing of PLTs
Organism Number TTD§ using a two-bottle BTA RT and a ST of
Aerobic bottle only (BPA) older PLTs. The first is PASSPORT as
Bacillus sp. 1 23.28
Corynebacterium sp. 1 29.1 reported here. The second is from the
Staph. aureus 2 10.2, 13.3 Irish Blood Transfusion Service where
Coagulase-negative Staphylococcus 3 23 (17.2-29) they performed a two-bottle RT using
Strep.: alpha hemolytic 1 17.5
Strep.: beta Group C 1 16.2 8 mL per bottle on APs and on PLTs from
Strep. salivaris 1 12.4 whole blood prepared using the buffy
Anaerobic bottle only (BPN) coat (BC) method (Dr W. Murphy, per-
Coagulase-negative Staphylococcus 5 30.3 (17.4-57.6)
Strep. spp. 3 11.4 (10.6-12.2) sonal communication, 2007).19 The sur-
Corynebacterium sp. 2 74.4, 77.8 veillance numbers are a mix of APs and
Diphtheroid* 6 103 (84-137) BCs selected at times of 4 days or older
Propionibacterium sp.† 22 103 (53-127)
Aspergillus 1 72.8 in storage age. The Welsh Blood Service
E. coli 1 11.5 conducted a similar study (Dr G. Rowe,
Fusobacterium spp.‡ 1 47.7 personal communication, 2007). Since
Peptostreptococcus‡ 1 55.2
Lactobacillus 1 105.6 these studies differ in various details on
Bacillus sp.–not anthracis 1 14.9 the type of PLTs, the timing and volumes
No organism identified 1 35.5 cultured in the RT, and the timing of the
P. oralis and B. eggerthii‡ 1 34.9
ST, care must be taken in comparing
* Diphtheroids were not further speciated and may include Propionibacterium sp. and
Corynebacterium sp. them with PASSPORT. However, the
† Aerotolerant anaerobe. general picture supports the low sensi-
‡ Obligate anaerobe. tivity of the BTA RT observed in PASS-
§ Data are individual times or mean with range.
TTD = time to detection (hours). PORT and verifies an overall initial
contamination rate of approximately

TABLE 7. ST confirmed positive

Day 8 culture
Organism TTD BPA TTD BPN Confirmatory test
Staph. aureus 3.7 7.2 Staph. aureus
Staph. epidermidis 7.4 4.3 Staph. epidermidis*
Strep. viridans 30.8 9.6 Diphtheroid
Strep. viridans, coagulase-negative Staphylococcus Negative 24.6 P. acnes†
* Split sister product transfused on Day 4 with no reaction.
† Split sister product aliquots transfused on Days 4 and 6 (¥2) with no reactions.

596 TRANSFUSION Volume 50, March 2010

 PASSPORT: BACTERIAL SCREENING OF PLTs

which would not have been detected in

the aerobic bottle. However, the clinical
risk of the most commonly detected
anaerobic organisms (e.g., Propionibac-
terium sp.) has not been established. In
PASSPORT, although we have demon-
strated a significant discordance
between results for confirmed TPs
between the two bottle types, removing
the anaerobic organisms that some
argue may not be clinically meaningful
reduced this effect.
The most frequently detected TP
anaerobic organisms in this study were
the Corynebacterium, diphtheroid, and
Propionibacterium species. The time to
detection for these TPs is generally
Fig. 6. Interstudy bacterial positive rates: confirmed-positive RT and surveillance beyond the window where AP can be
(Surv.) test rates (positive per million, 95% CI) are shown for four national studies, interdicted (Table 6), thus compromis-
left to right: The ARC for the first reported rates in the aerobic bottle before imple- ing the utility of the RT, as described
mentation of other risk reduction strategies (4-mL aerobic cultures in which 61.5% here, for preventing transfusion of these
of the collections utilized sample diversion);20 ARC with diversion and a 4-mL contaminants. In addition, the available
aerobic culture (a subset of the 1,004,206);20 ARC after diversion with an 8-mL evidence of the clinical risk associated
aerobic culture;21 PASSPORT (PsPrt) 4- to 5-mL aerobic culture; PASSPORT (PsPrt) 4 with transfusion of these contaminants
to 5 mL per bottle two-bottle RT; PASSPORT ST; Irish Blood Transfusion Service AP, is inadequate to support or refute the
BC PLTs, surveillance; Welsh Blood Service AP, BC PLTs, surveillance. Surveillance need for their detection and interdic-
results for the Irish and Welsh are a mix of APs and BCs tested at 4 days or older. tion. This study did interdict before
transfusion three other cases of obligate
1000/million (1/1000) when both aerobic and anaerobic anaerobic organisms (Fusobacterium spp., Peptostrepto-
organisms are included. coccus, P. oralis, and B. eggerthii), adding some support for
The data presented here are also consistent with the addition of anaerobic screening to all RT.
those reported by the American Red Cross (ARC) using a A weakness in the present analysis is that we could
similar RT scheme where they incubated one 4-mL AP not quantitate the actual clinical risks. We were unable to
sample taken 24 to 36 hours postcollection in only one weight our laboratory results either by the organism type
aerobic bottle.20 The aerobic bottle confirmed-positive and virulence or by the titer (which was not determined);
rates for PASSPORT (121/million) and ARC (119/million) both are known to be important factors in assessing the
are nearly identical. Based on the analysis of Benjamin potential for STRs in recipients of bacterially contami-
and Wagner,16 ARC has doubled their sample volume to nated PLTs. In PASSPORT, fast-growing Gram negatives
8 mL still in only one aerobic bottle, which would be known to include some of the most clinically significant
expected to increase their detection rate, and in the same organisms were identified in the RT and interdicted before
time frame implemented sample diversion pouches for all transfusion, and none of the reported transfusion reac-
plateletpheresis collections, which should decrease the tions were associated with Gram-negative bacteria. This
contamination rate from skin flora. With these changes, study also demonstrated the difficulties of using a surro-
their detection rate for confirmed positives has increased gate microbiologic in vitro test as the primary outcome.
to 166/million.21 The PASSPORT 8-mL culture results, Culture tests are often associated with false positives, con-
divided between one aerobic and one anaerobic bottle, tamination of the test system, and great difficulty in
remain slightly above this rate at 231/million (p = 0.54). follow-up. One small mistake in the setting of a rare event
There has been an ongoing debate regarding the can severely swing outcomes and subsequent decisions. It
necessity of anaerobic culture of aerobically stored APs. is possible that one or both of the two discordant ST cul-
The PASSPORT data set represents the largest collection of tures fall into this category. The use of a clinical endpoint,
two-bottle culture results for APs screened under a well- such as STR, while having an even lower incidence rate,
defined RT scheme. The incremental yield from anaerobic would be more meaningful in rendering judgments
culturing is 110/million and includes both aerobic organ- related to patient risk.
isms that might also have been detected with 8 mL of We estimated before PASSPORT initiation that the full
volume in the aerobic medium and obligate anaerobes, rollout and implementation by blood centers would take

Volume 50, March 2010 TRANSFUSION 597

DUMONT ET AL.
between 6 and 12 months from the time of introduction;
however, this took over 2 years. We also anticipated that
we would have approximately 30 centers participating in
surveillance testing with cumulative annualized collec-
tions of 250,000 7-day APs; at a 5% rate of capturable out-
dated products we estimated an accrual of 12,500 expired
PLT products per year. The goal of surveillance of a base of
250,000 AP collections per year fell short, and the accrual
of STs was further hampered by the unexpectedly large
reduction in PLT discards due to outdating.12
Incremental reductions in the residual risk of bacte-
rial infection have occurred through rigorous skin prepa-
ration before venipuncture, diversion of up to the first
40 mL of blood, and bacterial culture testing as described
here.22 For APs these steps have had an important effect as
demonstrated in the recent FDA report of transfusion-
associated mortality, where the number of reported
deaths has dropped from a 2001 to 2005 average of six per
year to two per year for fiscal years 2006 through 2008.23
Additional decreases in the clinical risk from bacterially
contaminated APs are likely to come from two technologi-
cal advances. The first is the implementation of rapid tests
that may be effectively applied close in time to the trans-
fusion event.24 The other, effective pathogen reduction
technology, may hold the best hope of driving down the
residual risk to extremely low levels.25,26
In conclusion, while RT culturing prevents issuance
of some bacterially contaminated APs, ST culture data and
clinical reports of STRs suggest that this screening fails to
detect a number of bacterially infected units. Neverthe-
less, no fatalities were reported related to transfusion AP
PLTs labeled for 7-day storage. The data fall short of per-
mitting strong conclusions related to the overall clinical
risk of transfusion-transmitted bacteria. Additional
actions or testing may be required to further reduce the
residual STR risk of RT SDPs, even with 5-day storage.
ACKNOWLEDGMENTS
In addition to the principal investigators listed below, we thank
the blood center personnel, too numerous to name here, for their
tremendous efforts in developing SOPs, license amendments,
equipment installations, validations, submission of data,
responses to queries, and so on: Henry Travers, Avera McKennan
Hospital; David Sharp, MD, Bergen Community Blood Services;
Jim Whited, Blood Banks of Mid-Florida; Eric Senaldi, MD, Blood
Center of New Jersey; Diane Carlson, Blood Center of North
Central Wisconsin; Kim-Anh Nguyen, MD, Blood Centers of the
Pacific; Melanie Porter, The Blood Connection; Helen Pleasant,
Blood Systems, Inc.; Daniel Ambruso, MD, Bonfils; Joseph Hulina,
CBC/CTS Dayton; Eric Senaldi, MD, Central Jersey Blood Center;
Mary Townsend, MD, Coffee Memorial Blood Center; Jay Meni-
tove, MD, Community Blood Center Kansas; Lynn Crow, Commu-
nity Blood Center, Appleton; Bruce Lenes, MD, Community Blood
Centers of South Florida; Michael Ludwig, CVPH Medical Center;
598 TRANSFUSION Volume 50, March 2010
Richard Gammon, MD, Florida’s Blood Centers; Deborah
Williams, Florida’s Blood Services, Inc.; Arell Shapiro, MD, Hoag
Memorial Hospital; Dan Waxman, MD, Indiana Blood Center;
Robert Ranlett, MD, Inland Northwest Blood Center; Robert
Purkhiser, Lackland AFB; Angel Cologne, M Maj MAMC, Madigan
Army Medical Center; Alicia Gomensoro, MD, Maimonides
Medical Center; Jeffrey L.Winters, MD, Mayo Clinic; Pamenla Jett,
MD, Mississippi Blood Services; Louis Katz, Mississippi Valley
Regional Blood Center; Mercy Kuriyan, MD, NBAH Blood Center;
Donna Strauss, New York Blood Center; Volker Dube, MD,
Shepeard Community Blood Center; Norman Kalmin, MD, South
Texas Blood & Tissue; Debbie Nennstiel, Southeastern Commu-
nity Blood Center; Mark Brecher, MD, UNC Hospital; and Thomas
Raife, MD, University of Iowa Hospitals/ DeGowin Blood Center.
CONFLICT OF INTEREST
This study was supported by CaridianBCT, Inc., and Fenwal, Inc.
LJD and SK are independent consultants to CaridianBCT, Inc.
RL and RS are employees of CaridianBCT, Inc. JH and PM are
employees of Fenwal, Inc.
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SUPPORTING INFORMATION
Additional Supporting Information may be found in the
online version of this article:
Supporting text: Seven Day Platelet Storage Using Plate-
lets Collected with the COBE® Spectra™ Apheresis
Systems and the Trima® Automated Blood Component
Collection Systems and Tested with the BacT/ALERT®
Microbial Detection Systems.
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting materials sup-
plied by the authors. Any queries (other than missing
material) should be directed to the corresponding author
for the article.
Volume 50, March 2010 TRANSFUSION 599