Getting to zero: Impact of a device to reduce blood culture contamination and false-positive central-line–associated bloodstream infections

Abstract

Objective: To assess the impact of initial specimen diversion device (ISDD) on inpatient and emergency department blood culture contamination (BCC), central-line–associated bloodstream infection (CLABSI) standardized infection ratios (SIRs), and antibiotic administration. Design: Single-center quasi-experimental prospective cohort study wherein phlebotomists used traditional venipuncture with or without the ISDD while registered nurses (RNs) used traditional venipuncture. Method: BCC events among phlebotomists and RNs were observed and compared from March 17, 2019, through January 21, 2020, defined by contaminant detection in 1 of 4 bottles for matched sets or 1 of 2 bottles in both subsets for coagulase negative staphylococci. CLABSIs throughout this period were recorded and SIRs were calculated. Enhanced oversight took place through July 21, 2019, with chart review assessing antibiotic use for patients with possible BCC. Results: Overall, 24% of blood cultures obtained were from patients in intensive care. Phlebotomists using traditional venipuncture (n = 4,759) had a 2.3% BCC rate; phlebotomists using the ISDD (n = 11,202) had a 0% BCC rate. RNs drew 7,411 BCs with a 0.8% BCC rate. The CLABSI SIR was decreased from 1.103 in 2017 and 0.658 in 2018 to 0.439 in 2019. The CLABSI incidence was 33%–64% of predicted value for each 2019 quarter. This range fell to 18%–37% after the exclusion of likely false-positive results. Among 42 patients with possible BCC under enhanced oversight, 2 patients were treated with prolonged antibiotic courses. Conclusions: ISDD use by phlebotomists was associated with BCC reduction and reduced false-positive CLABSI results. This patient-care quality improvement could constitute sustainable antibiotic stewardship expansion.

Diagnostic Stewardship: A Systematic Review and Meta-analysis of Blood Collection Diversion Devices Used to Reduce Blood Culture Contamination and Improve the Accuracy of Diagnosis in Clinical Settings

“…Of 30 articles reviewed in further detail, 12 studies met the inclusion criteria for this systematic literature review [ 20–31 ] ( Figure 1 ). Of them, 5 were nonrandomized prospective controlled studies [ 20 , 21 , 27 , 28 , 30 ], 4 were quasi-experimental (pre-/postintervention comparison) studies [ 22 , 23 , 26 , 29 ], 2 were randomized clinical trials [ 25 , 31 ], and 1 was a case-control study [ 24 ] ( Table 1 ). Ten were conducted in the United States [ 20–29 ] and 2 were conducted in Israel [ 30 , 31 ].…”

“…The most common volume diverted by each device was 1.5–2 mL for Steripath [ 21 , 23 , 27–29 ] and 0.15 mL for Kurin [ 20 , 22 ]. Regarding microbial detection techniques, 2 studies used BacTAlert (bioMérieux, Marcy-l’Étoile, France) and matrix-assisted laser desorption/ionization–time of flight (MALDI-TOF) [ 20 , 27 ], 1 study used BacTAlert and polymerase chain reaction [ 25 ], 2 studies used BACTEC (Becton Dickinson, Franklin Lakes, New Jersey) [ 28 , 29 ], 2 studies used BACTEC, MALDI-TOF, and standard biochemical methods [ 30 , 31 ], 1 study used standard biochemical methods [ 26 ], and 4 studies did not report the adopted detection system [ 21–24 ].…”

“…Sample collection was performed by nurses in 3 studies [ 20 , 22 , 23 ], phlebotomists in 3 studies [ 24 , 26 , 28 ], and both nurses and phlebotomists in 6 studies [ 21 , 25 , 27 , 29–31 ]. Resident physicians also aided sample collection in 2 studies [ 30 , 31 ].…”

Effect of an initial specimen diversion device on blood-culture contamination rates and vancomycin usage: A quasi-experimental study

“…These devices have decreased blood-culture contamination rates relative to standard phlebotomy practices in short-term prospective efficacy studies. [2][3][4][5][6] Also, ISDD implementation may decrease the rate of false-positive central-lineassociated bacteremia. 5 However, data are limited regarding whether implementation of ISDDs can result in a sustained reduction in contamination rates or in decreased antimicrobial use.…”

“…[2][3][4][5][6] Also, ISDD implementation may decrease the rate of false-positive central-lineassociated bacteremia. 5 However, data are limited regarding whether implementation of ISDDs can result in a sustained reduction in contamination rates or in decreased antimicrobial use. We hypothesized that ISDD implementation would decrease inpatient vancomycin use as a result of less initial treatment of bacteremia that was ultimately determined to represent contamination.…”