Predicting Bacteremia at the Bedside

Jaimes, Fabián; Arango, Clara; Ruiz, Giovanni; Cuervo, Jorge; Castaño, Juan Carlos; Vélez, Gloria; Upegui, Natalia; Machado, Faber

doi:10.1086/380967

Cited by 91 publications

(60 citation statements)

References 19 publications

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“…These researchers noted that blood cultures were frequently negative at the time of the temperature spike and concluded that, ideally, blood cultures should be drawn some time prior to elevations in temperature. More recently, Jaimes et al found that fever was not a useful independent predictor of bacteremia and needed to be considered in light of other factors, such as hypotension, white blood cell (WBC) counts, and the presence or absence of shaking chills (13).…”

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Timing of Specimen Collection for Blood Cultures from Febrile Patients with Bacteremia

et al. 2008

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Bloodstream infections are an important cause of morbidity and mortality. Physician orders for blood cultures often specify that blood specimens be collected at or around the time of a temperature elevation, presumably as a means of enhancing the likelihood of detecting significant bacteremia. In a multicenter study, which utilized retrospective patient chart reviews as a means of collecting data, we evaluated the timing of blood culture collection in relation to temperature elevations in 1,436 patients with bacteremia and fungemia. The likelihood of documenting bloodstream infections was not significantly enhanced by collecting blood specimens for culture at the time that patients experienced temperature spikes. A subset analysis based on patient age, gender, white blood cell count and specific cause of bacteremia generally also failed to reveal any associations.Bloodstream infections (BSIs) occur more than 200,000 times annually in the United States, with associated mortality rates of 35 to 60% (20,33,34). Prompt administration of appropriate antimicrobial therapy plays an important role in reducing the mortality associated with this condition (9,12,14, 15,16,18,22,26,31). In patients with bacteremia, the optimization of therapy is ultimately predicated on rapid documentation of positive blood cultures, expeditious performance of in vitro antimicrobial susceptibility tests, and timely reporting of results (2,23,33). Numerous factors influence the likelihood of detecting bacteremia. These factors include the volume of blood specimens cultured and the number of blood cultures performed (1,8,10,11,17,21,25,27,29). The conventional practice has been to obtain blood specimens at or around the time of a temperature elevation as a means of enhancing the likelihood of documenting bacteremia (5, 32). This practice is based on the principle that the presence of organisms in the intravascular space leads to the elaboration of cytokines, which in turn causes body temperatures to rise.The value of attempting to time the collection of blood for culture around temperature elevations is complicated by the fact that many patients with bacteremia, especially those that are elderly, may be hypothermic at the time that they are bacteremic or may be unable to mount a febrile response to infection (7). Furthermore, there are numerous causes of fever other than bacteremia, e.g., ischemia, drug reactions, immunological conditions, and malignancy (4). This issue is further complicated by the observation made more than 50 years ago by Bennett and Beeson: bacteremia actually precedes temperature elevations by 1 or 2 h (3). These researchers noted that blood cultures were frequently negative at the time of the temperature spike and concluded that, ideally, blood cultures should be drawn some time prior to elevations in temperature. More recently, Jaimes et al. found that fever was not a useful independent predictor of bacteremia and needed to be considered in light of other factors, such as hypotension, white blood cell (WBC) counts, an...

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Timing of Specimen Collection for Blood Cultures from Febrile Patients with Bacteremia

et al. 2008

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“…Yet, on the other hand, around 90% of BC taken in our study were negative, suggesting a limited ability to identify patients with BSI using clinical judgement. This difficulty of clinically predicting bacteraemia has previously been recognised (Jaimes et al, 2004). Improved systems for identifying and treating sepsis are needed.…”

Section: Discussionmentioning

confidence: 99%

The effect of a quality improvement programme reducing blood culture contamination on the detection of bloodstream infection in an emergency department

Robertson

Russell

Inverarity

2014

Journal of Infection Prevention

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Background: Contaminated blood cultures (BC) generate avoidable costs and prolong hospital stays. To measure our hospital's performance against the recommended standard of <3% BC contamination, we performed a prospective study. Methods:We prospectively determined the frequency of contaminated and genuinely positive BC hospital-wide over seven months.Results: Overall, 73 of 1,829 blood cultures reviewed were contaminated (4.0%). However, distribution of contamination was not uniform. Finding a consistently higher incidence of contamination (11.7%) in our emergency department (ED) than elsewhere in the hospital (2.5%), we adopted a collaborative quality improvement strategy targeted to the ED. A combination of education, modified BC packs and regular feedback of BC results was associated with a significant reduction in contamination (7.4%, p=0.01) over the next six months. Our data suggests that contaminated BC were more likely to have been taken during regular day time hours (odds ratio (OR) 2.7, p=0.012), rather than overnight and were not associated with influxes of new junior medical staff. We found no evidence that the incidence of true bloodstream infection (12.8%) diagnosed by our ED was adversely affected by our intervention (10.7%, p=0.35). Conclusions:Using a simple and inexpensive collaborative intervention we reduced BC contamination without adversely affecting the detection of genuine BSI

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“…Traditionally, it was perceived that drawing blood around the time of a temperature spike would increase the likelihood of recovery of an organism. However, the presence of fever lacks the ability to independently predict BSI; rather, other findings must be taken into account, including hypotension and elevated white blood cells (23). To our knowledge, there are currently no pediatric studies available on this subject.…”

Section: Blood Culture Collectionmentioning

confidence: 99%

Diagnosis of Bloodstream Infections in Children

Bard

TeKippe

2016

J Clin Microbiol

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Identification of bloodstream infections is among the most critical tasks performed by the clinical microbiology laboratory. While the criteria for achieving an adequate blood culture specimen in adults have been well described, there is much more ambiguity in pediatric populations. This minireview focuses on the available pediatric literature pertaining to the collection of an optimal blood culture specimen, including timing, volume, and bottle selection, as well as rapid diagnostic approaches and their role in the management of pediatric bloodstream infections. Blood cultures remain the mainstay of laboratory diagnosis of bloodstream infections (BSIs) in infants and children. Recovery of a pathogen is advantageous, as it confirms the diagnosis of bacteremia and allows for identification and susceptibility testing on the organism to optimize antimicrobial therapy and duration. A negative blood culture is just as important, as it rules out cases of bacteremia and prompts continued investigation of other infectious or noninfectious etiologies or cessation of unnecessary empirical antimicrobial therapy.The spectrum of pathogens causing pediatric BSI varies widely by age, presenting symptoms, and immune status. In 1979, an evaluation of pediatric blood culture found Haemophilus influenzae to be the most prevalent organism followed by Streptococcus pneumoniae and Staphylococcus aureus (1). Today, H. influenzae and S. pneumoniae are rare bloodstream pathogens due to widespread vaccination. A 2012 study of infants of Ͻ3 months of age found the leading causes of bacteremia to be Escherichia coli, group B Streptococcus (Streptococcus agalactiae), and S. aureus (2). The rate of BSI in otherwise healthy children drops precipitously after the first few months of life, but if occurring, the most common pathogens are S. aureus, S. pneumoniae due to communityacquired pneumonia, and Neisseria meningitidis in adolescents. Immunocompromised children are susceptible to a broad range of bloodstream pathogens, including all of those previously mentioned as well as Pseudomonas aeruginosa and Candida spp. (3).The majority of studies related to the laboratory diagnosis of BSI focus on the adult population. Thus, this minireview will be devoted to children and the multifactorial aspects involved in obtaining an optimal pediatric blood culture specimen, including timing, volume, and bottle selection. Lastly, a discussion on the rapid diagnostic approaches currently available and their impact on pediatric management and outcomes will be reviewed. BLOOD CULTURE COLLECTIONFactors that may influence the recovery of pathogens from the blood include the timing of blood collection, number of sets collected, and blood volume. It is well accepted that the volume of blood collected is the single most important factor. Evidence from both adult and pediatric studies show that the probability of recovering a pathogen from blood culture increases with the volume of blood obtained. In addition, the time to detection inversely correlates with the volum...

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Predicting Bacteremia at the Bedside

Cited by 91 publications

References 19 publications

Timing of Specimen Collection for Blood Cultures from Febrile Patients with Bacteremia

Timing of Specimen Collection for Blood Cultures from Febrile Patients with Bacteremia

The effect of a quality improvement programme reducing blood culture contamination on the detection of bloodstream infection in an emergency department

Diagnosis of Bloodstream Infections in Children

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