key: cord-0982525-0wfoz26x
authors: Hartnett, Kathleen P.; Powell, Krista M.; Rankin, Danielle; Gable, Paige; Kim, Janice J.; Spoto, Samantha; Breaker, Erin; Hunter, Robert; Dotson, Nychie; McAllister, Gillian; Stevens, Valerie; Halpin, Alison Laufer; Houston, Hollis; Epson, Erin; Malarkey, Mary; Mendoza, Melissa; McNeill, Lorrie; Perkins, Kiran M.
title: Investigation of Bacterial Infections Among Patients Treated With Umbilical Cord Blood–Derived Products Marketed as Stem Cell Therapies
date: 2021-10-07
journal: JAMA Netw Open
DOI: 10.1001/jamanetworkopen.2021.28615
sha: a173aa874cc7dbc91153e44a830cda2ad071405f
doc_id: 982525
cord_uid: 0wfoz26x

IMPORTANCE: The number of clinics marketing stem cell products for joint diseases, chronic pain, and most recently, COVID-19, has increased despite warnings from the US Food and Drug Administration that stem cell products for these and other indications have not been proven safe or effective. OBJECTIVE: To examine bacterial infections in 20 patients who received umbilical cord blood–derived products marketed as stem cell treatment. DESIGN, SETTING, AND PARTICIPANTS: This case series is a national public health investigation including case-finding, medical record review and abstraction, and laboratory investigation, including sterility testing of products and whole-genome sequencing of patient and product isolates. Participants included patients who developed bacterial infections following administration of umbilical cord blood–derived products marketed as stem cell treatment during August 2017 to September 2018. Data analysis was performed from March 2019 to September 2021. EXPOSURES: Umbilical cord blood–derived products marketed as stem cell treatment. MAIN OUTCOMES AND MEASURES: Data were collected on patient infections and exposures. The Centers for Disease Control and Prevention performed sterility testing on undistributed and distributed vials of product marketed as stem cell treatment and performed whole-genome sequencing to compare patient and product bacterial isolates. RESULTS: Culture-confirmed bacterial infections were identified in 20 patients (median [range] age, 63 [2-89] years; 13 male patients [65%]) from 8 US states who sought stem cell treatment for conditions including pain, osteoarthritis, rheumatoid arthritis, and injury; all but 1 required hospitalization. The most frequently isolated bacteria from patients with infections were common enteric species, including Escherichia coli (14 patients) and Enterobacter cloacae (7 patients). Of unopened, undistributed products sampled for testing, 65% (22 of 34 vials) were contaminated with at least 1 of 16 bacterial species, mostly enteric. A patient isolate from Arizona matched isolates obtained from products administered to patients in Florida, and patient isolates from Texas matched undistributed product sent from the company in California. CONCLUSIONS AND RELEVANCE: Unapproved stem cell products can expose patients to serious risks without proven benefit. Sequencing results suggest a common source of extensive contamination, likely occurring during the processing of cord blood into product. Patients and health care practitioners who are considering the use of unapproved products marketed as stem cell treatment should be aware of their unproven benefits and potential risks, including serious infections.

CDC's initial call was for any culture-confirmed infection in a patient who had received a ReGen Series product since February 1, 2018 (i.e., the earliest product administration date among patients recognized as of October 4, 2018) . However, because CDC later received reports of infections in patients who had received ReGen Series products before this date, cases were ultimately defined as any culture-confirmed infection in patients who had received ReGen Series products since mid-2017, when Liveyon was believed to have begun distribution of the Genetech-processed products. Health department staff either relied on practitioners involved in a patient's care to complete the case abstraction forms or completed abstraction forms themselves. Study data were collected and managed using REDCap electronic data capture tools hosted at CDC. 1,2 REDCap is a secure, web-based software platform designed to support data capture for research studies. Health departments submitted de-identified data to CDC via e-mail or directly uploaded information into REDCap.

The outer surface of each vial was sanitized with 70% isopropanol before aliquots (0.25-0.5 mL) were injected into tryptic soy broth at a 1:10 dilution. The broth was incubated at 35°C for up to 14 days and screened for bacterial growth. Species identification was performed on all bacterial isolates using the matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS). Undiluted product and serial microdilutions were placed on tryptic soy agar plates containing 5% sheep blood in duplicate and incubated at 35ºC for 48 hours before enumeration. When quantifying microbial burden, the lower limit of detection was 100 colonyforming units (CFU) per mL and the upper limit of detection was 300,000 CFU/mL.

Genomic DNA was extracted from bacterial isolates using the automated nucleic acid purification Maxwell 16 MDx system (Promega, Madison, WI), and DNA was sheared using the Covaris ME220 (Woburn, Massachusetts) to approximately 600 bp. Samples were then library prepped using the NuGEN Ovation Ultralow V2 System 1-96 kit and single indices (San Carlos, CA), and sequenced using the Illumina MiSeq reagent kit v2 (San Diego, CA) yielding 250 bp paired-end reads. Raw reads were processed using QuAISAR-H, a custom quality control and analyses bioinformatics pipeline. 3 Species identification was performed using Average Nucleotide Identity (ANIm) and samples were checked for contamination using Kraken and Gottcha. 4, 5 Assemblies were generated using SPAdes, classified using multilocus sequence typing (MLST), and annotated by Prokka. [6] [7] [8] High quality single nucleotide variants (hqSNV) were enumerated and cluster core genome calculated using the Single Nucleotide Variant Phylogenomics (SNVPhyl) pipeline. 9 eFigures 1 and 2 show whole genome sequencing results. Phylogenetic hqSNV trees from clusters linked to ReGen Series products, across multiple donors and multiple states for 1) Enterobacter cloacae (0-4 hqSNVs across a core genome of 96.6%) and, 2) Escherichia coli (0-34,604 hqSNVs across a 66.6% core genome). Phylogenetic hqSNV trees for each Genus display overall clustering as well as relatedness by branch length. Isolates on the same branch of the tree are more closely related to each other than to isolates on different branches.

Research electronic data capture (REDCap) -A metadatadriven methodology and workflow process for providing translational research informatics support

The REDCap consortium: Building an international community of software partners

Development and application of QuAISAR-H: A bioinformatics pipeline for short read sequences of healthcare-associated pathogens. ASM Conference on Rapid Applied Microbial Next Generation Sequencing and Bioinformatic Pipelines

Kraken: Ultrafast Metagenomic Sequence Classification Using Exact Alignments

Accurate Read-Based Metagenome Characterization Using a Hierarchical Suite of Unique Signatures

Spades: A New Genome Assembly Algorithm and Its Applications to Single-Cell Sequencing

Prokka: Rapid Prokaryotic Genome Annotation

SNVPhyl: a single nucleotide variant phylogenomics pipeline for microbial genomic epidemiology