^http://www.eucast.org/rapid_ast_in_blood_cultures/, 6. Use of laboratory test results in patient management by clinicians in Malawi. In addition, hospital protocols and guidelines advice that BCs should be collected in the event of a temperature spike in order to optimize BC yield. Dailey P, Osborn J, Ashley E, Baron E, Dance D, Fusco D, et al. (2008) 61:50913. (2003) 289:7269. doi: 10.1128/JCM.02205-13. doi: 10.1007/s12262-008-0018-8. However, a review from 2011 suggests that only 3.8% of total blood volume can be safely sampled (for all laboratory analyses combined over a 24 h period) in children beyond the neonatal period, and this safety value is further challenged by higher rates of severe anemia in children in LMICs, particularly caused by severe Plasmodium falciparum malaria, which predisposes to Gram-negative BSI (43, 151, 168, 169). (2018) 24:836844. Arch Pathol Lab Med. S. Wang, Malmvall BE, Alestig K, Brorson JE, Elgefors B. Discover a faster, simpler path to publishing in a high-quality journal. Although this effect might be due to the high yield in the ED within the first 24 hours of admission, we advise physicians to be critical when ordering BCs, especially after 24 hours of admission. Elliott TS, Stevens CM, Macrae F, Hart IT, Healing DE, Palmer M, et al. As far as we know, this is the first study to evaluate the epidemiology and clinical significance of BCs in the general hospital population. Diagnostic stewardship for blood cultures in the emergency department Disclaimer. If a correlation between timing of BC and BC yield exists, then this might improve the pathogen recovery rate and consequently optimize the diagnostic efficiency of BCs. J Clin Microbiol. The addition of resins may even increase the time-to-detection for some bacteria, such as Pseudomonas species (113). Paediatr Infect Dis J. Weinstein MP, Reller LB, Murphy JR, Lichtenstein KA. Reducing the blood culture contamination rate in a pediatric emergency department and subsequent cost savings abstract. doi: 10.1016/j.cmi.2017.05.007, PubMed Abstract | CrossRef Full Text | Google Scholar. Diagn Microbiol Infect Dis. Suboptimal compliance with blood culture standards at a district hospital in Cape Town. Evaluation of the BinaxNOW PBP2a assay for the direct detection of methicillin resistance in Staphylococcus aureus from positive blood culture bottles. doi: 10.1016/S0022-3476(74)80308-2, 166. Detection of bacteremia: Blood cultures and other diagnostic tests JAMA. A Cochrane review of 2015, however, found no experimental or quasi-experimental publications which had studied the effect of one-step vs. two-step procedures on actual blood culture contamination (204). (1984) 19:979. Ortiz E, Sande M. Routine use of anaerobic blood cultures: are they still indicated? Performance characteristics of a commercially prepared biphasic blood culture bottle. (1978) 92:79. (2019) 4:4654. Improvement of positive blood culture detection by agitation. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Because of the challenges related to visual detection of growth, other strategies were employed before the widespread use of automated monitoring of blood culture bottles. The spectrum of contaminants in LMICs differs slightly to HICs; for example, more Bacillus species are seen in LMICs (178). Patients were eligible if they met the following inclusion criteria: (i) were 18 years or older; (ii) at least one BC was collected from them either at the ED or one of the general wards (all wards were included)during the seven month study period (1 September 2016 till 31 March 2017). (2007) 7:18. (2013) 19:51320. (2013) 1:20712. ^https://www.bd.com/resource.aspx?IDX=11265, 4. If financially sustainable, butterfly needles are therefore recommended. (1994) 14:5968. Elantamilan D, Lyngdoh VW, Khyriem A, Rajbongshi J, Bora I, Devi ST, et al. J Clin Microbiol. This review will therefore focus on blood culture methods and techniques appropriate for settings with limited resources. Yagupsky P, Nolte FS. doi: 10.1111/j.1537-2995.2009.02434.x, 204. PLoS Negl Trop Dis. 279. Limited focus has been given to the association between timing of specimen collection at different time points during admission and their yield. Dargre S, Parienti JJ, Roupie E, Gancel PE, Wiel E, Smaiti N, et al. This review aims to provide an overview of the state-of-the-art of sampling and processing of blood cultures, with emphasis on its use in LMICs. Performing direct identification and/or antibiotic susceptibility testing on grown blood culture broth can also lead to faster diagnosis and decision-making. Sex Transm Infect. Clin Infect Dis. Number of blood cultures, BC yield, contamination rate, and NND per department. Given the effectiveness of diverting the first portion of blood, contamination could actually be reduced by sampling first other blood collection tubes if a butterfly needle with vacutainer system is used. J Infect Chemother. (2005) 129:12225. Bull World Health Organ. Detailed Analysis of the Characteristics of Sample Volume in Blood Culture Bottles. 105. Clinical impact of preincubation of blood cultures at 37C. (2009) 47:81922. detected 85% of pathogens with blind subculture within 24 h, whereas in only 48% of positive cultures visual signs of growth could be detected within 24 h of incubation (238). J Trop Pediatr. Clin Microbiol Infect. How to Properly Collect a Blood Culture - The RN Educator (2017) 29:5662. Because of simplicity, concerns regarding iatrogenic anemia, widespread use in hospitals and comparability across published literature, we recommend the use of the age-based simple algorithm depicted in Table 5 (e.g., sampling 0.5 ml for neonates <1 month of age, 1 ml for children age 236 months and to sample 4 ml in children 36 months of age), despite our awareness of the limitations of this strategy. Weckbach LS, Staneck JL. 249. Affiliation 1 Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Mich. PMID: 8154947 No abstract available . doi: 10.1093/ajcp/78.3.348, 304. It must be noted that all of these studies performed a blind subculture within 24 h of incubation; not performing blind subculture may even lead to lower detection rates after 48 h of incubation. This study showed that blood cultures are inefficient in detecting bacteremia. To counteract the effect of antibiotics on growth of bacteria in the broth, antibiotic removal devices have been in use since 1982 (105). McDonald J, Knowles K, Sorger S. Assessment of gelatin supplementation of PEDS Plus BACTEC blood culture medium. 83. (1998) 17:5669. (2003) 41:2137. (2014) 52:1898900. J Clin Microbiol. LMICs are defined depending on gross national income per capita by the World Bank1. (2016) 387:88293. The median time until the collection of the first BC was 19.7 hours (IQR 13.645.7). Altindis M, Koroglu M, Demiray T, Dal T, Ozdemir M, Sengil AZ, et al. BMC Infect Dis. 73. Laboratory Turnaround Time. (1985) 17:4016. J Perinatol. BMC Med. It requires applying a tourniquet on the arm, palpating the vein that will be used for the sampling, and applying appropriate antiseptics at the place of sampling. To the best of our knowledge, this is the first attempt to evaluate the efficiency of BCs using NND. <> 64. Saito T, Ilinuma Y, Takakura S, Nagao M, Matsushima A, Shirano M, et al. doi: 10.1016/0732-8893(86)90001-5, 51. <>/Metadata 151 0 R/ViewerPreferences 152 0 R>> *Correspondence: Sien Ombelet, sombelet@itg.be, Clinical Microbiology in Low Resource Settings, View all doi: 10.1099/jmm.0.45533-0, 269. Am J Clin Pathol. Analysis of trends per hospital ward can alert outbreaks (63, 64). Quality indicators for monitoring of blood culturesthey can be used for validation as well as for monitoring purposes. Schematic representation of biphasic bottle. A blood culture is recommended for all septic patients. Learn Test Match Created by ana82371 Terms in this set (20) A 2-hour postprandial specimen should be drawn a. Barenfanger J, Graham DR, Kolluri L, Sangwan G, Lawhorn J, Drake CA, et al. Despite this theoretical possibility, there is no documented evidence for increased contamination with vented bottles. Clin Microbiol Rev. Evaluation of a fourth-generation latex agglutination test for the identification of Staphylococcus aureus. EMA. Several publications list which variables should be measured to ensure quality. 82. Lamy B, Dargire S, Arendrup MC, Parienti JJ, Tattevin P. How to optimize the use of blood cultures for the diagnosis of bloodstream infections? Laboratory work-up of these contaminants demands time and money, both of which are not in large supply in resource-limited settings. Spivack ML, Shannon R, Natsios GA, Wood J. 42. doi: 10.1111/j.1469-0691.1999.tb00713.x, 299. Authors P H Chandrasekar 1 , W J Brown. Clin Infect Dis. doi: 10.1586/eri.10.76, 8. International guidelines have not reached consensus on the time frame for BC transportation [2123]: current recommendations vary from within two to four hours after collection [2123]. Schematic representations of special biphasic bottle designs. We evaluated the effect of pre-analytical time on the BC yield by analyzing the first cultures collected during their ED stay. Rapid detection of ESBL-producing gram-negative bacteria isolated from blood: a reasonable and reliable tool for middle and low resource countries. Performing antibiotic susceptibility testing directly from blood culture broth decreases the turnaround time with 1 day but requires rapid identification as the procedure often depends on the pathogen. Print 2019 Aug. Zhu Y, Qiao L, Prudent M, Bondarenko A, Gasilova N, Mller SB, Lion N, Pick H, Gong T, Chen Z, Yang P, Lovey LT, Girault HH. No significant difference was found using three predefined cut-off points ( 6 hours versus > 6 hours, 12 hours versus > 12 hours, 24 hours versus > 24 hours), with p-values of 0.816, 0.474, and 0.676 respectively (Table 3). Copyright: 2019 Nannan Panday et al. (2017) 318:12419. This approach has also had good results in a low-income country; after the introduction of a team of nurses dedicated to phlebotomy in Malawi, contamination rates decreased from 19.6 to 5% (179). (2016) 315:80110. Clin Microbiol Infect. Evaluation of the necessity for routine terminal subcultures of previously negative blood cultures. p. 107109. Int J Nurs Stud. More confusingly, some organisms representing true pathogens in HICs, such as Pseudomonas aeruginosa or other non-fermenting Gram-negative organisms, are sometimes considered as contaminants in LMICs (181, 184). doi: 10.1016/j.cmi.2018.02.008, 294. Decreased mortality associated with prompt gram staining of blood cultures. Ericson E, Klingspor L, Ullberg M, Ozenci V. Clinical comparison of the Bactec Mycosis IC/F, BacT/Alert FA, and BacT/Alert FN blood culturevials for the detection of candidemia. This concept was repeated by Binkhamis et al. PLOS is a nonprofit 501(c)(3) corporation, #C2354500, based in San Francisco, California, US. J Lab Physicians. (2011) 49:27580. doi: 10.1128/CMR.00062-05, 174. Therefore, the necessity of sampling blood using separate venipunctures, referred to as multi-sampling, has been contested. Blood Cultures in the Critical Care Unit - CHEST Although research on the factors influencing BC yield has already led to improvements in specimen collection and reduction in contamination rates, the current practice of BC collection is still inefficient with a pathogen recovery rate of just 7% [1, 2, 512]. (2013) 51:40836. The long study period of seven months enabled us to include a large number of patients of all medical specialties with a wide-range of clinical conditions. Blood culture contamination: a College of American Pathologists Q-Probes study involving 640 institutions and 497134 specimens from adult patients. The negative impact of antibiotic use prior to sampling on the yield of blood cultures is substantial, as the presence of antibiotics in the serum can inhibit the growth of bacteria (97100). doi: 10.1001/jama.1991.03460030071031. First and foremost, clinical bacteriology facilities in LMICs have to be strengthened and supported. (1974) 27:5379. Blood Culture Contamination: A Clinical and Financial Burden - ResearchGate Weinstein MP, Reller LB, Mirrett S, Wang WL, Alcid DV. Soc Sci Med. (2014) 14:17. J Hosp Infect. Moreover, the lack of critical testing volume will deny the laboratory technicians the opportunity to gain sufficient experience in processing blood cultures, thus impacting the quality of the test results and decreasing clinicians' confidence in the testing. According to a recent WHO report, out-of-pocket payments, although in decline, still account for 37% of the total healthcare cost in Africa and 44% in South-East Asia (282). described contamination rates as low as 1.6% when sampling via newly inserted catheters by following a sterile technique protocol in a pediatric emergency department (228). Isaacman DJ, Karasic RB, Reynolds EA, Kost SI. The associated cost of contamination per blood culture is estimated to range between $2844 . Ann Emerg Med. (2018) 64:38994. 308. In case of steam autoclavation of blood culture bottles, it must be kept in mind that the fluid inside the blood culture bottle must reach 121C during at least 15 min to ensure effective decontamination. It allows identification of the responsible organism (s) for sepsis, appropriate choice of empirical and specific antibiotic (s) and points toward further investigations required to identify the focus of infection. Therefore, manual blood culture bottles are still most frequently used in LMICs and contribute worldwide to approximately the double of market share compared to automated systems (27). Biosafety in the Laboratory: Prudent Practices for Handling and Disposal of Infectious Materials, Vol. doi: 10.1097/00006454-199607000-00011, 168. Am J Med. A state-of-the art. The choice of which bottles to use is therefore highly dependent on the specific setting, and every center is encouraged to perform its own evaluation on the need for anaerobic blood culture (69). Hawkins BL, Peterson EM, de la Maza LM. Washington, DC: National Academy Press (1989). (2017) 55:161220. Aseptic technique refers to the practices and procedures used to minimize the risk . (1997) 35:26348. Klaerner HG, Eschenbach U, Kamereck K, Lehn N, Wagner H, Miethke T. Failure of an automated blood culture system to detect nonfermentative gram-negative bacteria. LH additionally contributed to figure design. Not all hospitals, however, have seen this decrease in anaerobic bacteremia (290, 291). Doern GV. doi: 10.1016/j.ajem.2014.04.010, 11. However, some studies have shown proportions of low-level bacteremia (< 10 CFU/ml) in 23 to 69% of infants and children (163165). Subculturing can then be done by inverting the bottle and flooding the agar plates with the broth-blood mixture. For anaerobic blood culture bottles, headspace contains CO2 and nitrogen dioxide (NO2). Kellogg J. Clin Infect Dis. Prediction of bacteremia using TREAT, a computerized decision-support system. An official website of the United States government. It is impossible to retrieve the exact time of BC collection on the wards due to the discrepancy between BC order time and BC collection time. 254. Am J Clin Pathol. Clin Infect Dis. In accordance with the VUmc medical research regulations, this study was approved by the Medical Ethical Committee of the VU University Medical Center (METC VUmc). (1998) 36:37313. 84 p. Available online at: https://www.who.int/maternal_child_adolescent/documents/management_childhood_conditions/en/, 21. Because of gas production and possible aerosol formation, opening the blood culture bottle to perform subculture substitutes a risk to the laboratory technician. doi: 10.1128/JCM.00552-10, 268. In this study, three blood cultures of 20 ml detected 98.2% of BSI and only with four blood cultures, >99% of BSI episodes were detected. doi: 10.1128/JCM.01831-09. Many articles however recommend an age-based sampling strategy illustrated in Table 5 (166, 170, 171). New Microbiol. Kirn TJ, Weinstein MP. 85. Prevalence of microbial pathogens in blood cultures: an etiological and histopathological study. (1974) 27:2739. Pathogens like Salmonella enterica or Burkholderia pseudomallei are uncommon in HICs but account for a large proportion of pathogens in Africa and South-East Asia (5, 19, 4447). In these systems, the carbon dioxide production by micro-organisms in the bottles is continuously monitored, either by colorimetric or fluorescent detection. Hall MM, Mueske CA, Ilstrup DM, Washington JA. However, many bacteria do colonize the . Kaditis AG, O'Marcaigh AS, Rhodes KH, Weaver AL, Henry NK. (2015) 21:14. Bekeris LG, Tworek JA, Walsh MK, Valenstein PN. Effects of volume and periodicity. Laboratory Biosafety Manual. Blood cultures and immunocompromised patients. doi: 10.1111/acem.12337, 234. Clinical comparison of an agar slide blood culture bottle with tryptic soy broth and a conventional blood culture bottle with supplemented peptone broth. Blood Culture Utilization in the Hospital Setting: a Call for Our study populations, however, were significantly different. Given the importance of the total volume of liquids in the autoclave on the time needed to sterilize, it is important not to overfill the autoclave with liquid waste and to validate the maximum liquid load the autoclave can still safely sterilize. J Clin Microbiol. Binkhamis K, Forward K. Effect of the initial specimen diversion technique on blood culture. Moreover, it is more time-consuming than conventional blood culture. J Clin Pathol. Clin Pediatr (Phila). For detection of mycobacterial, fungal or yeast infections in the blood, other broth types and incubation times may be needed. Pediatr Infect Dis J. Caldeira D, David C, Sampaio C. Skin antiseptics in venous puncture-site disinfection for prevention of blood culture contamination: systematic review with meta-analysis. J Clin Microbiol. Semret M, Ndao M, Jacobs J, Yansouni C. Point-of-care and point-of-can: leveraging reference-laboratory capacity for integrated diagnosis of fever syndromes in the tropics. Clin Infect Dis. Secondly, this was a single center study representing a relatively large university teaching hospital. J Clin Microbiol. However, baseline contamination rates were also low in these studies; in settings where contamination is much more prevalent, such as most LMICs, the same relative decrease in contamination rates will lead to a higher number of averted contaminants. did not find evidence for the effectiveness of this measure in decreasing contamination, however they noted that their study was not powered to detect such an effect as they had quite low rates of contamination overall (206). For anaerobic bacteria, Columbia broth, pre-reduced peptone broths, thioglycolate broths, and thiol broths are advantageous, supposedly based on their low redox potential (76, 77, 8991). Lemming L, Holt HM, Petersen IS, stergaard C, Bruun B. Bactec 9240 blood culture system: to preincubate at 35C or not? In: Adelberg E, editor. (2008) 27:4005. In contrast to this, a recent meta-analysis found no significant difference between any of the antiseptics under study (povidone iodine, iodine tincture, chlorhexidine compounds, or chlorhexidine alcohol) (200), although its methods have been criticized (201). Clin Lab Med. Diagn Microbiol Infect Dis. Petti CA, Woods CW, Reller LB. (2012). doi: 10.3389/fmicb.2016.00697, 24. Thereafter, all false-positive cultures were coded as negative cultures. Furthermore the number of BCs required to retrieve one positive culture in the different wards and the ED was also calculated and reported as number needed to draw (NND). This led to growth of pathogens on solid media the day after incubation for 10 out of 14 grown blood cultures, making an appreciable impact for patient management, as none of these bottles had shown visual signs of growth the day before (261). (2005) 43:25102. Their usefulness in daily practice is therefore rather limited. Most frequently, contamination happens during venipuncture, when skin fragments containing normal skin flora are dislodged and aspirated together with the sampled blood. doi: 10.1128/JCM.39.10.3578-3582.2001, 301. However, high room temperatures are common in LMICs, warranting short transport times when using automated blood culture systems to avoid false-negative results. PLoS ONE. Diagn. Isaacman D, Karasic R. Utility of collecting blood cultures through newly inserted intravenous catheters. Auckenthaler R, Ilstrup DM, Washington JA. Blood cultures must be obtained whenever there is a clinical suspicion of BSI. A convenient consequence of this is that the work-up of blood cultures for identification and antibiotic susceptibility testing is relatively straightforward, as no further isolation of different possible pathogens has to be done. For these values, only the first BCs collected in the ED were included. For antibiotic susceptibility testing, lateral flow assays have been developed to rapidly detect methicillin-resistant Staphylococcus aureus (277), extended-spectrum beta-lactamase (ESBL) (278) and carbapenemases (279), directly from blood culture broth. A comparison between the ED and general wards showed that BCs collected in the ED had a significantly higher BC true-positive yield, even after adjustment for age and gender (11.2% and 5.8%, p<0.001). Nasir AA, Babalola OM. We compared the blood culture yield between the early group (24 hours after admission) and the late group (> 24 hours of admission). More in line with these concerns, CLSI recommends sampling of maximum 1% of the total blood volume (for infants and younger children) (88). (2008) 70:6872. Unique blood culture for diagnosis of bloodstream infections in emergency departments: a prospective multicentre study. Quantitative blood cultures in childhood bacteremia. The true consequences of false-positive results. 1994 Apr 25;154(8):841-9. . (1986) 23:7003. p. 1216. Appl Biosaf. Pre-incubation of blood culture bottles at 35C, for example in a small incubator in the emergency department, can speed up detection of growth in manual blood culture systems (267), but is not advised for automated systems as it may result in false-negative results (23, 268270). doi: 10.1016/S0022-3476(96)70388-8, 167. Kelly MT, Buck GE, Fojtasek MF. J Clin Diagnostic Res. A relatively simple way of improving the speed of detection is by ensuring that the bottles arrive in the laboratory in a timely manner. Brucella species grow slowly with a need for extended incubation times. Significant changes in the methods and techniques of obtaining BCs have occurred since the first inception of BCs into clinical practice.