MAUDE MDR 5975518

MDR report key
5975518
Report number
3003925919-2016-00006
Event key
0
Event type
3
Date of event
2016-08-13
Date received
2016-09-23
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
CAROL MOORE
Address
2550 STANWELL DRIVE CONCORD CA 94520 US
Phone
925-925-9258
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1INTERCEPT BLOOD SYSTEM FOR PLATELETSINTERCEPT PLATELETSCERUS CORPORATIONPJFR N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12016-09-2301. H

Event Narratives#

N

Patient 1

CERUS MEDICAL ASSESSMENT: CERUS MEDICAL REVIEWER CONCURS WITH THE REPORTER'S ASSESSMENT THAT THE EVENT WAS NON-SEVERE AND SERIOUS DUE TO HOSPITALIZATION/PROLONGATION OF HOSPITALIZATION. A DEVICE MALFUNCTION WAS NOT REPORTED. HOWEVER, THE CERUS MEDICAL REVIEWER DOES NOT CONCUR WITH THE REPORTER'S ASSESSMENT THAT THE EVENT CONSTITUTED A "SUSPECTED SEPTIC TRANSFUSION REACTION", OR THAT IS WAS PROBABLY RELATED TO THE TRANSFUSION OF INTERCEPT PLATELETS. NO EVIDENCE WAS PROVIDED THAT THE PLATELET CONCENTRATE WAS CONTAMINATED AND THE FEVER APPARENTLY DID NOT COINCIDE WITH THE TRANSFUSION. PATIENT SYMPTOMATOLOGY AND CLINICAL EVOLUTION DOES NOT SUPPORT THE PRESUMPTIVE DIAGNOSIS OF A SEPTIC TRANSFUSION REACTION. PLATELET COUNT INCREMENT POST TRANSFUSION DOES NOT SUPPORT IT EITHER, AND THE PLATELET BAGS WERE NOT CULTURED OR EXAMINED. INTERCEPT BLOOD TREATMENT RESULTS IN GREATER THAN OR EQUAL TO 6.3 LOG REDUCTION (CFU/ML) OF E. COLI PER THE APPROVED PACKAGE INSERT. NUSSBAUMER ET AL. TESTED THE PATHOGEN INACTIVATION EFFICACY OF THE IBS WITH VARYING CONCENTRATIONS OF SEVEN BACTERIAL SPECIES (INCLUDING E.COLI 1-100 CFUS/UNIT) AND FOUND THAT NO BACTERIA WERE DETECTED THROUGHOUT 5 DAYS OF STORAGE REGARDLESS OF THE SPECIES, LEVEL OF CONTAMINATION, AND SAMPLING TIME. CONVERSELY, OTHER SOURCES OF INFECTION, SUCH AS A URINARY TRACT INFECTION WERE NOT RULED OUT. LACKING EVIDENCE OF PLATELET CONTAMINATION, BACTERIAL ISOLATES OR FURTHER CLINICAL EVIDENCE TO SUPPORT A DIAGNOSIS OR A SUSPECTED SEPTIC TRANSFUSION REACTION, IT IS CONCLUDED THAT THE EVENT WAS UNLIKELY RELATED TO THE INTERCEPT BLOOD SYSTEM OR THE PLATELET TRANSFUSION. NUSSBAUMER W, ALLERSTORFER D, ET AL. PREVENTION OF TRANSFUSION OF PLATELET COMPONENTS CONTAMINATED WITH LOW LEVELS OF BACTERIA: A COMPARISON OF BACTERIA CULTURE AND PATHOGEN INACTIVATION METHODS. TRANSFUSION 2007 JUL;47(7):1125-33. NOT RETURNED TO MANUFACTURER.

D

Patient 1

CASE (B)(4) IS A SPONTANEOUS REPORT RECEIVED FROM THE MEDICAL DIRECTOR AT THE (B)(6) IN (B)(6) ON 24-AUG-2016, AND FURTHER COMMUNICATIONS ON THE INITIAL REPORT ON 28-AUG-2016, 31-AUG-2016, 05-SEP-2016, 08-SEP-2016, 14-SEP-16, AND 15-SEP16. THE REPORT INVOLVES A (B)(6) MALE CAUCASIAN PATIENT, WHO RECEIVED INTERCEPT PLATELET COMPONENTS (PC) ON (B)(6) 2016 AND EXPERIENCED A SERIOUS ADVERSE EVENT DESCRIBED AS A SUSPECTED SEPTIC TRANSFUSION REACTION WITH ESCHERICHIA COLI. CONCURRENT MEDICAL CONDITIONS INCLUDED CHRONIC MYELOID LEUKEMIA (CML). CONCOMITANT MEDICATIONS INCLUDED GLIVEC (IMATINIB). MEDICAL HISTORY WAS NOT REPORTED. ON (B)(6) 2016, SIX WHOLE BLOOD UNITS WERE COLLECTED AND USED IN PREPARATION FOR A BUFFY COAT POOL AND TREATED WITH THE INTERCEPT BLOOD SYSTEM ON THE FOLLOWING DAY, (B)(6) 2016. THE EXPIRATION DATE OF THE PC UNIT WAS 13-AUG-2016. ON (B)(6) 2016, THE PATIENT RECEIVED TWO UNITS OF RBC TRANSFUSION. ON (B)(6) 2016 AT 12:27H, THE PATIENT RECEIVED ONE UNIT OF INTERCEPT PC TRANSFUSION, 1.168 X 10883/ 377 ML (PC COUNT/VOLUME) VIA PERIPHERAL LINE, FOR BLEEDING AND THROMBOCYTOPENIA (