Blood cultures: key elements for best practices and future directions

Riedel, Stefan; Carroll, Karen C.

doi:10.1007/s10156-010-0069-1

Cited by 74 publications

(61 citation statements)

References 136 publications

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“…Blood cultures, the standard means of diagnosis of bloodstream infection, are one of most important tests performed in the clinical laboratory (13). Several variables influence ideal performance, including skin preparation prior to culture collection, the method and site of collection, the types of media utilized, the number of cultures collected, and the volume of blood sampled.…”

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Optimized Pathogen Detection with 30- Compared to 20-Milliliter Blood Culture Draws

Patel

Vetter²,

Harmsen

et al. 2011

J Clin Microbiol

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Using data from 23,313 patients, we assessed whether two blood culture sets of three bottles per set would detect more pathogens than two sets of two bottles per set and achieve similar sensitivity to collecting three sets of two bottles per set. We also compared the yield of aerobic and anaerobic bottles. Thirty milliliters of blood was distributed to one anaerobic and two aerobic bottles. Among 26,855 collections of >60 ml within 30 min, 1,379 (5.1%) were positive for a pathogen not requiring detection in more than one set to be considered a pathogen, with 72 additional distinct pathogens detected using two 30-ml compared to two 20-ml sets of one aerobic and one anaerobic bottle (increased yield, 7.9%; 95% confidence interval [CI], 6.2 to 9.8%). For conditional pathogens requiring detection in at least two positive blood cultures for classification as pathogens (i.e., otherwise classified as contaminants), there were 162 positive detections with two 30-ml sets, of which 16 would not have been detected by two 20-ml sets (increased yield, 11.0% [95% CI, 6.4 to 17.2%]). Among 134 subjects who had three sets of 30 ml each within a 30-min interval, there was complete concordance between 60 ml of blood drawn in the first two sets of 30 ml and three 20-ml sets (P ‫؍‬ 1.0). One aerobic bottle plus one anaerobic bottle yielded more pathogens than two aerobic bottles for organisms requiring a single (P < 0.001) and two (P ‫؍‬ 0.04) positive sets to be defined as pathogens. In conclusion, we showed that collection of two aerobic and one anaerobic blood culture bottles per set results in improved yield compared to two bottles per set. We also confirmed that an anaerobic bottle should be included in blood culture sets.An estimated quarter million patients develop bloodstream infections in the United States every year, with 14 to 38% associated mortality (1,11). Blood cultures, the standard means of diagnosis of bloodstream infection, are one of most important tests performed in the clinical laboratory (13). Several variables influence ideal performance, including skin preparation prior to culture collection, the method and site of collection, the types of media utilized, the number of cultures collected, and the volume of blood sampled. The last is generally considered paramount. Several studies indicate that assaying increasing volumes of blood increases the likelihood of detection of bacteremia (4, 7-10, 12, 14, 16, 18, 19). It has been recommended that 20 to 30 ml of blood be collected per set and that two to three sets be collected (13). This recommendation covers a wide range of blood volumes, sampling from 40 to 90 ml of blood. For the patient and the health care facility, the difference between collection of two and three blood culture sets may be significant in terms of cost and inconvenience. Collection of two blood culture sets using 20 ml per set (total, 40 ml of blood), which is performed in many health care facilities, may, however, compromise sensitivity.Using conventional manual blood culture and a maximum v...

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“…Several studies indicate that assaying increasing volumes of blood increases the likelihood of detection of bacteremia (4, 7-10, 12, 14, 16, 18, 19). It has been recommended that 20 to 30 ml of blood be collected per set and that two to three sets be collected (13). This recommendation covers a wide range of blood volumes, sampling from 40 to 90 ml of blood.…”

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Optimized Pathogen Detection with 30- Compared to 20-Milliliter Blood Culture Draws

Patel

Vetter²,

Harmsen

et al. 2011

J Clin Microbiol

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“…The Agency for Healthcare Research and Quality lists sepsis as the most expensive condition treated in U.S. hospitals, costing more than $20 billion in 2011 (1). Blood culture (BC) remains the standard means of detecting sepsis secondary to bloodstream infections (BSIs) (2). Prior studies have shown that several variables influence the detection of bacteremia, including skin preparation prior to venipuncture, the method and site of collection, the types of media utilized, the number of cultures collected, and, most importantly, the volume of blood cultured (3).…”

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Cost-Effectiveness of 30- Compared to 20-Milliliter Blood Cultures: a Retrospective Study

2016

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). Hospitals receive higher reimbursement for patients with documented septicemia. We determined the cost-effectiveness of 30-ml versus 20-ml BCs using results from our institution and previously published data. Positive BC results from 292 bacteremic episodes were reviewed. The costs of the reagents, equipment, phlebotomist, and technologist time were determined. The medical records department provided Medicare reimbursement (MR) data for patients with selected ICD-9 codes. These data provided an estimate of the annualized increase in MR versus costs associated with conversion to 30-ml BCs. MR for 464 annual primary BSIs was $24,808/episode. An expected 7.2% increase in BSIs detected using 30-ml BCs would add 34 additional cases annually and increase MR by $843,472. Comparative MR data for cases where septicemia complicated another diagnosis were available for 4 International Classification of Diseases, Ninth Revision (ICD-9) codes: laparoscopic cholecystectomy, biliary tract disorders, pneumonia, and cellulitis. The mean incremental MR was $9,667 per episode, which projected to a $483,350 revenue increase annually. The annual cost associated with conversion to 30-ml BCs was estimated to be $157,798. Thus, the potential net increase in hospital revenue would be $1,169,031 for 30-ml versus 20-ml BCs. Our results suggest that conversion to 30-ml BCs may not only improve patient care by detecting more BSIs but also increase hospital revenue substantially. According to the CDC, sepsis affects Ͼ800,000 Americans annually and is the ninth leading cause of disease-related deaths (1). The Agency for Healthcare Research and Quality lists sepsis as the most expensive condition treated in U.S. hospitals, costing more than $20 billion in 2011 (1). Blood culture (BC) remains the standard means of detecting sepsis secondary to bloodstream infections (BSIs) (2). Prior studies have shown that several variables influence the detection of bacteremia, including skin preparation prior to venipuncture, the method and site of collection, the types of media utilized, the number of cultures collected, and, most importantly, the volume of blood cultured (3).All studies have indicated that as the volume of blood cultured increases, the likelihood of detecting bacteremia also increases (4-13). Patel et al. recently demonstrated that two 30-ml BC sets with 3 bottles per set (2 aerobic and 1 anaerobic) had improved pathogen detection for both nonconditional (not requiring detection in more than one set to be considered positive) and conditional (requiring detection in at least two positive blood cultures for classification as a pathogen and otherwise categorized as a contaminant) pathogens with an improved yield of 7.9% and 11.0%, respectively (3).However, inoculation of only two 20-ml sets of BCs is standard practice in our institution and we suspect at many other similar institutions also (3). This practice is most likely secondary to the notion that increasing the number of blood culture bottles per episode of bacteremia will result in ...

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“…Recovery of pathogens in blood culture can be affected by multiple parameters in addition to bacterial concentration, including blood volume, culture medium composition and volume, and incubation time (10). Successful recovery of these attenuated RASV-Sp strains from blood culture without added supplements may be due in part to the enrichment factors present in F medium, which include yeast extract, animal tissue digest, sucrose, hemin, menadione, and vitamin B 6 , as well as nutritional components available in human blood.…”

Section: Discussionmentioning

confidence: 99%

Rapid, Sensitive Recovery of Recombinant Attenuated Salmonella enterica Serovar Typhi Vaccine Strains from Human Blood

Lottenbach

Kelly-Aehle²,

Brenneman

et al. 2013

Clin Vaccine Immunol

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Prior to initiating a phase 1 dose escalation trial of the safety and immunogenicity of live, oral, recombinant, attenuated Salmonella enterica serovar Typhi vaccine strains in human subjects, the suitability of conventional blood culture procedures to rapidly and reliably detect the organisms in human blood was investigated. Blood culture specimens, with and without added growth supplements, were inoculated with study organism concentrations ranging from approximately 300 to as few as 1 to 2 CFU/10 ml culture and processed in a Bactec 9240 fluorescent series aerobic blood culture system. All cultures seeded with >6 CFU and 93% of cultures seeded with ϳ1 to 2 CFU were identified as positive for microbial growth within 44 h of incubation. The results were within the performance standard of <5 days to detection that is expected for Gram-negative cultures seeded at 10 to 50 CFU/vial. Recovery of test organisms from blood culture was not improved by the addition of supplements, but cultures with added supplements were identified positive an average of 5 h sooner than those without added supplements. Reliable detection of the investigational vaccine strains at <1 CFU/ml of blood within 2 days in conventional blood culture without added supplements allowed for shortened confinement time of study volunteers without compromising subject safety.T he ability to sensitively and rapidly monitor for bacteremia caused by live oral vaccine organisms is crucial for the evaluation of the safety of investigational vaccines in human subjects during clinical trials. Prior to initiating a phase 1 dose escalation trial of the safety and immunogenicity of live, oral, recombinant, attenuated Salmonella enterica serovar Typhi (S. Typhi) vector strains in human subjects, the suitability of conventional blood culture procedures to identify bacteremia caused by these investigational organisms was investigated.Blood culture is generally considered the standard method for diagnosis of typhoid bacteremia but has been shown to detect only 40 to 70% of typhoid patients (1). In a quantitative study of bacteremia in typhoid fever patients, 50% of patients identified by positive blood culture had less than 1 CFU/ml of blood (2), illustrating the need for highly sensitive methods of detection. Rubin et al. (1) described methods to improve detection of S. Typhi in blood by use of a radiolabeled DNA probe specific for the genes encoding the Vi antigen present in concentrated blood samples. These methods were shown to detect Ͻ1 CFU/ml of S. Typhi in bacteremic typhoid patients; however, these methods are not currently applied in most clinical laboratories.Advances in blood culture technology in the clinical lab have greatly enhanced the speed and sensitivity of detection of a broad range of clinically significant pathogens in blood (3). The current standard, Bactec Standard/10 Aerobic/F culture vials, together with Bactec 9240 brand fluorescent series instruments (Becton, Dickinson Diagnostic Instrument Systems, Sparks, MD), provide a sensitive, conti...

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Blood cultures: key elements for best practices and future directions

Cited by 74 publications

References 136 publications

Optimized Pathogen Detection with 30- Compared to 20-Milliliter Blood Culture Draws

Optimized Pathogen Detection with 30- Compared to 20-Milliliter Blood Culture Draws

Cost-Effectiveness of 30- Compared to 20-Milliliter Blood Cultures: a Retrospective Study

Rapid, Sensitive Recovery of Recombinant Attenuated Salmonella enterica Serovar Typhi Vaccine Strains from Human Blood

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