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Restrictive red blood cell transfusion regimen lowered risk for HAI
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In hospitalized patients, a restrictive strategy of red blood cell transfusion appears to reduce the risk for health care-associated infection vs. a liberal transfusion strategy, according to recent findings.
“Transfusion of red blood cells (RBCs) is a common inpatient therapy, with approximately 14 million units transfused in 2011 in the United States, 84.8% of which were leukocyte reduced,” researchers wrote.
In the systematic review and meta-analysis, Jeffrey M. Rohde, MD, of the University of Michigan, and colleagues conducted a literature search of the MEDLINE, Embase and several other clinical trial databases. Studies were considered eligible for the analysis if they met the following requirements: randomized study population; consisted of two comparison groups in which one received a restrictive RBC transfusion regimen and the other group underwent a liberal RBC transfusion regimen; and documentation of infectious outcomes after these strategies. There was sufficient information on 18 randomized trials with a combined 8,735 patients to conduct a pooled meta-analysis, according to the data published in JAMA.
The researchers calculated RRs for each study and analyzed the cumulative risk for infection in the restrictive RBC transfusion group vs. the cumulative infection risk in the liberal RBC transfusion group. A random-effects model was used to pool these RRs across the multiple studies.
The combined risk for all serious infections was 11.8% (95% CI, 7%-16.7) in the restrictive RBC transfusion group vs. the pooled risk of 16.9% (95% CI, 8.9-25.4) in the liberal RBC regimen. The RR for the correlation between transfusion regimen and serious infection was 0.82 (95% CI, 0.72-0.95), with minimal heterogeneity between studies. The number needed to treat with the restrictive regimen to prevent serious infection was 38 (95% CI, 24-122). The decreased infection risk with a restrictive strategy remained consistent even with leukocyte reduction (RR=0.8; 95% CI, 0.67-0.95).
In studies with a restrictive hemoglobin threshold of less than 7 g/dL, the RR was 0.82 (95% CI, 0.7-0.97), with a number needed to treat of 20 (95% CI, 12-133). When the data were stratified by patient type, the RR was 0.7 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery and 0.51 (95% CI, 0.28-0.95) in patients hospitalized with sepsis. Patients with cardiac disease, critical illnesses, acute upper gastrointestinal bleeding and infants with low birth weight did not exhibit significant differences in infection prevalence by RBC threshold.
“We found that, even among patients receiving RBC units with leukocyte reduction, a restrictive RBC transfusion strategy was associated with a lower risk of health care–associated infection,” the researchers wrote. “This meta-analysis of randomized trials suggests that, for every 1,000 patients in which RBC transfusion is under consideration, 26 could potentially be spared an infection if restrictive strategies were used.”
In an accompanying editorial, Jeffrey L. Carson, MD, of Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J., wrote that this study questions the use of increasing hemoglobin levels in patients with anemia.
“[This study] confirms yet another potential adverse outcome associated with transfusion: serious infectious disease,” Caron wrote. “Clinical trials are needed to establish the optimal transfusion thresholds, to provide additional information about the risks and benefits of RBC transfusion, and to determine how best to use RBC transfusion.”
For more information:
Carson JL. JAMA. 2014;311:1293-1294.
Rohde JM. JAMA. 2014;311:1317-1326.
Disclosure: See the full study for a list of researchers’ financial disclosures.
Perspective
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Harry S. Jacob, MD, FRCPath(Hon)
The pathophysiology underlying these results is not obvious. I suggest that increased iron released from transfused red cells may be involved. Bacteria require iron, and it is well known (by surgeons) that peritoneal blood is particularly dangerous in fomenting lethal infectious peritonitis.
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