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Original Investigation
April 2, 2014

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

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

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 randomized trials with 8598 patients met eligibility criteria, of which 17 trials (n = 7456 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 10.6% (95% CI, 5.6%-15.9%) in the restrictive group and 12.7% (95% CI, 7.0%-18.7%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and infection (serious infections and selected infections, combined) was 0.92 (95% CI, 0.82-1.04) with little heterogeneity (I2 = 6.3%; τ2 = .0041). The RR for the association between transfusion strategies and serious infection was 0.84 (95% CI, 0.73-0.96; I2 = 0%, τ2 <.0001). The number needed to treat (NNT) with restrictive strategies to prevent serious infection was 48 (95% CI, 36-71). The risk of infection remained reduced with a restrictive strategy, even with leukocyte reduction (RR, 0.83 [95% CI, 0.69-0.99]). For trials with a restrictive hemoglobin threshold of <7.0 g/dL, the RR was 0.86 (95% CI, 0.72-1.02). With stratification by patient type, the RR for serious infection was 0.72 (95% CI, 0.53-0.97) 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 compared with a liberal transfusion strategy was not associated with a reduced risk of health care–associated infection overall, although it was associated with a reduced risk of serious infection. Implementing restrictive strategies may have the potential to lower the incidence of serious health care–associated infection.