Strategies for increasing diagnostic yield of community-onset bacteraemia within the emergency department: A retrospective study

Abstract

Bloodstream infections (BSI) are associated with high mortality. Therefore, reliable methods of detection are of paramount importance. Efficient strategies to improve diagnostic yield of bacteraemia within the emergency department (ED) are needed. We conducted a retrospective analysis of all ED encounters in a high-volume, city-centre university hospital within Germany during a five-year study period from October 2013 to September 2018. A time-series analysis was conducted for all ED encounters in which blood cultures (BCs) were collected. BC detection rates and diagnostic yield of community-onset bacteraemia were compared during the study period (which included 45 months prior to the start of a new diagnostic Antibiotic Stewardship (ABS) bundle and 15 months following its implementation). BCs were obtained from 5,191 out of 66,879 ED admissions (7.8%). Bacteraemia was detected in 1,013 encounters (19.5% of encounters where BCs were obtained). The overall yield of true bacteraemia (defined as yielding clinically relevant pathogens) was 14.4%. The new ABS-related diagnostic protocol resulted in an increased number of hospitalised patients with BCs collected in the ED (18% compared to 12.3%) and a significant increase in patients with two or more BC sets taken (59% compared to 25.4%), which resulted in an improved detection rate of true bacteraemia (2.5% versus 1.8% of hospital admissions) without any decrease in diagnostic yield. This simultaneous increase in BC rates without degradation of yield was a valuable finding that indicated success of this strategy. Thus, implementation of the new diagnostic ABS bundle within the ED, which included the presence of a skilled infectious disease (ID) team focused on obtaining BCs, appeared to be a valuable tool for the accurate and timely detection of community-onset bacteraemia.

Antimicrobial resistance of bacteraemia in the emergency department of a German university hospital (2013–2018): potential carbapenem-sparing empiric treatment options in light of the new EUCAST recommendations

“…Major indications for ED physicians to suspect infection, obtain BCs [36], and consider antimicrobial therapy include the following: clinically suspected organ infection with accompanying bacteraemia (such as meningitis, cholecystitis, pyelonephritis, necrotising fasciitis, osteomyelitis, severe pneumonia, endocarditis, vascular graft infection, or prosthetic joint infection), clinically suspected sepsis, defined by published sepsis scores, such as the sepsis-related organ failure assessment score, quickSOFA (qSOFA) [22] or SIRS criteria [37], or detected or reported body core temperature ≥ 38.3 °C.…”

Optimizing the number of blood cultures for lower and middle income countries: a large scale study in a public sector tertiary care teaching hospital of Southern India

“…5 Most guidelines recommend to obtain two to three BC sets over a 24-h period for the optimal detection of BSIs. 3,6,16 Although the isolation rate increases with multiple sampling; the financial and ethical restrictions make this strategy difficult to implement, especially in LMICs and public sector facilities catering to poor people. 7 With the advent of newer CMBCS such as BacT/ALERT VIRTUO, the isolation rate has been reported to be increased.…”

“…Several studies in the literature stated that the diagnostic yield of blood cultures significantly improves with the increase of the number of blood cultures drawn (67%, 80% and 96% with 1, 2 and 3 sets of BCs respectively). 3,6 However, implementing the practice of drawing multiple sets of BCs is extremely difficult, particularly in LMICs, which may be attributed to financial, manpower, ethical and infrastructure-related constraints. The situation is more difficult in public sector settings catering to poor people, where it is often observed that clinicians tend draw only one or two BC bottles, which results in a very poor organism isolation.…”

“…7 While drawing extraordinarily suboptimal specimen (1 BC bottle) definitely has a poor diagnostic yield, at the same time obtaining 3 sets of BCs appears to be far from reality in public sector facilities of LMICs. 6,7 It is also believed that the newer CMBCS such as BacT/ALERT VIRTUO may detect bacteremia at lower levels than older systems like BacT/ALERT. 8,9 Therefore, this study has been undertaken to revisit the BC collection guideline, and to optimize the number of blood cultures needed, for an optimal diagnostic yield in BacT/ALERT VIRTUO system.…”

Impact of a strategy based on unique blood culture sampling on contamination rate and detection of bloodstream infections in critically ill patients

“…However, a UBC strategy has not been evaluated in the intensive care unit (ICU) with the specific problem of a high incidence of fever during the ICU stay. Predicting a BSI in a febrile and critically ill patient (at admission or during ICU stay) is difficult, with only 10% of patients sampled having a BSI [ 1 , 2 , 16 ]. Changing a MS procedure for a UBC strategy without focusing on the ordering rule for BC collection would be associated with an important increase in the total number of collected BC bottles.…”