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Original Investigation |

Health Care–Associated Infection After Red Blood Cell Transfusion:  A Systematic Review and Meta-analysis

Jeffrey M. Rohde, MD1; Derek E. Dimcheff, MD, PhD1; Neil Blumberg, MD2; Sanjay Saint, MD, MPH1,3,4,5; Kenneth M. Langa, MD, PhD1,3,4,5; Latoya Kuhn, MPH3,4; Andrew Hickner, MSI1,3; Mary A. M. Rogers, PhD1,3,5
[+] Author Affiliations
1University of Michigan, Division of General Medicine, Department of Internal Medicine, Ann Arbor
2Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
3VA Ann Arbor Medical Center/University of Michigan Patient Safety Enhancement Program, Ann Arbor
4VA Ann Arbor Health Services Research and Development Center of Excellence, Ann Arbor, Michigan
5Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
JAMA. 2014;311(13):1317-1326. doi:10.1001/jama.2014.2726.
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Published online

Importance  The association between red blood cell (RBC) transfusion strategies and health care–associated infection is not fully understood.

Objective  To evaluate whether RBC transfusion thresholds are associated with the risk of infection and whether risk is independent of leukocyte reduction.

Data Sources  MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cochrane Database of Sytematic Reviews, ClinicalTrials.gov, International Clinical Trials Registry, and the International Standard Randomized Controlled Trial Number register were searched through January 22, 2014.

Study Selection  Randomized clinical trials with restrictive vs liberal RBC transfusion strategies.

Data Extraction and Synthesis  Twenty-one randomized trials with 8735 patients met eligibility criteria, of which 18 trials (n = 7593 patients) contained sufficient information for meta-analyses. DerSimonian and Laird random-effects models were used to report pooled risk ratios. Absolute risks of infection were calculated using the profile likelihood random-effects method.

Main Outcomes and Measures  Incidence of health care–associated infection such as pneumonia, mediastinitis, wound infection, and sepsis.

Results  The pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I2 = 0%; τ2 <.0001). The number needed to treat (NNT) with restrictive strategies to prevent serious infection was 38 (95% CI, 24-122). The risk of infection remained reduced with a restrictive strategy, even with leukocyte reduction (RR, 0.80 [95% CI, 0.67-0.95]). For trials with a restrictive hemoglobin threshold of <7.0 g/dL, the RR was 0.82 (95% CI, 0.70-0.97) with NNT of 20 (95% CI, 12-133). With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery and 0.51 (95% CI, 0.28-0.95) in patients presenting with sepsis. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight.

Conclusions and Relevance  Among hospitalized patients, a restrictive RBC transfusion strategy was associated with a reduced risk of health care–associated infection compared with a liberal transfusion strategy. Implementing restrictive strategies may have the potential to lower the incidence of health care–associated infection.

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Figure 1.
Flow Diagram of Search Strategy

ISRCTN indicates International Standard Randomized Controlled Trial Number.

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Figure 2.
Forest Plot of Risk Ratios for Infection Comparing Restrictive vs Liberal Transfusion Strategies

The size of the data markers indicates the weight assigned to each study in the meta-analysis. The study by Gregersen et al did not provide raw counts in the abstract; risk ratios were pooled using point estimates and CIs.

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Figure 3.
Forest Plot of Risk Ratios for Infection Comparing Restrictive vs Liberal Transfusion Strategies by Patient Type

The size of the data markers indicates the weight assigned to each study in the meta-analysis. The study by Gregersen et al did not provide raw counts in the abstract; risk ratios were pooled using point estimates and CIs.

Graphic Jump Location

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