Health Care-Associated Infection after Red Blood Cell Transfusion: A Systematic Review and Meta-Analysis
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.
