Contamination of Bone Marrow Products with an Actinomycete ResemblingMicrobacteriumSpecies and Reinfusion into Autologous Stem Cell and Bone Marrow Transplant Recipients

Bacterial contamination of bone marrow or peripheral blood stem cell transplant products typically occurs with skin flora or, rarely, gram-negative organisms. We describe a clonal outbreak of contamination in transplant products caused by contamination with an aerobic actinomycete that occurred at our institution during the summer of 2001. From 1 July through 12 September 2001, 73 peripheral blood or bone marrow stem cell products were obtained from 39 patients, and 34 products were found to be contaminated with the outbreak strain. Fourteen patients were reinfused with contaminated cells, and the outbreak strain was isolated from the blood cultures for one patient. Investigation revealed multiple potential sources for contamination during the product cryopreservation process. The outbreak of contamination was aborted upon modification of the cryopreservation process.