Storage duration of red blood cell transfusion and Clostridium difficile infection: a within person comparison.

Mary A M Rogers,Dejan Micic,Neil Blumberg,Vincent B Young,David M Aronoff,Gayatri Vedantam

doi:10.1371/journal.pone.0089332

Abstract

ObjectiveRandomized controlled trials demonstrated that red blood cell (RBC) transfusion elevates the risk of infection, and trials are underway to evaluate whether RBC storage affects outcomes. We previously reported that transfusion predicts Clostridium difficile infection (CDI) and, therefore, planned an investigation to examine this further using a more robust design.DesignWithin-person case-crossover study. Hospitalizations in which CDI developed (n = 406) were compared to hospitalizations for the same individuals in which CDI did not occur (n = 949). Transfusion volume and storage duration were assessed prior to the onset of CDI.SettingUniversity of Michigan Health System.PatientsParticipants were individuals with a diagnosis of CDI from July 2009 through June 2012.Measurements and Main ResultsDuring the hospitalizations when CDI occurred, 34.7% of the patients received allogeneic RBC transfusions (mean volume, 688 ml) compared to 19.0% of patients in hospitalizations without CDI (mean volume, 180 ml). The odds of healthcare-associated CDI increased by 76% (95% CI 1.39–2.23) for every liter of RBCs transfused and was elevated in both nonsurgical (OR = 1.90) and surgical (OR = 1.86) hospitalizations. In patients who received RBC transfusions, the odds of developing CDI increased by 6% for every additional day of RBC stored and by 53% for every week of additional storage (P = 0.002).ConclusionsHospitalizations in which a patient received a greater volume of RBC transfusions were more likely to be associated with the development of CDI. RBC units stored for a longer duration were associated with the development of healthcare-associated CDI after adjustment for RBC volume.

Highlights

The Choosing WiselyH initiative from the American Board of Internal Medicine lists the avoidance of red blood cell transfusions for arbitrary thresholds among its list of Five Things Physicians and Patients Should Question [1]
Hospitalizations in which a patient received a greater volume of red blood cell (RBC) transfusions were more likely to be associated with the development of Clostridium difficile infection (CDI)
RBC units stored for a longer duration were associated with the development of healthcare-associated CDI after adjustment for RBC volume

Summary

Introduction

The Choosing WiselyH initiative from the American Board of Internal Medicine lists the avoidance of red blood cell transfusions for arbitrary thresholds among its list of Five Things Physicians and Patients Should Question [1]. This advice coincides with the strong recommendation from AABB (formerly American Association of Blood Banks) to adhere to a restrictive transfusion strategy (7 to 8 g/dL) for hospitalized stable patients, based on a systematic review of randomized clinical trials performed between 1950 and 2011 [2]. Preliminary pilot randomized trials have not shown significant differences in clinical outcomes for length of storage in critically ill or surgical patients [9,10,11] or for major neonatal morbidities or infectious complications in infants [12]

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