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Lounsbury O, O'Hara J, Brent AJ, Higham H. Designing better systems to navigate the sepsis-antimicrobial stewardship tension. THE LANCET. INFECTIOUS DISEASES 2025:S1473-3099(25)00119-7. [PMID: 40222374 DOI: 10.1016/s1473-3099(25)00119-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2024] [Revised: 01/29/2025] [Accepted: 02/14/2025] [Indexed: 04/15/2025]
Abstract
Sepsis is a leading cause of preventable death and requires timely antimicrobial treatment to reduce mortality. Despite extensive sepsis management guidelines, high-income countries continue to have considerable rates of sepsis mortality, indicating a gap between guideline quality, usability, and practical application. Simultaneously, the rise of antimicrobial resistance threatens the efficacy of antimicrobial therapies for infection control, underscoring the tension between sepsis management and antimicrobial stewardship. This Personal View explores how system factors, such as people, environments, tools, technologies, and tasks, influence the sepsis-antimicrobial stewardship tension. With the Systems Engineering Initiative for Patient Safety, we use a case study to highlight how organisational pressures, inadequate diagnostic tools, and sociocultural factors drive the gap between work-as-imagined and work-as-done. These latent safety risks that impede guideline adherence and contribute to unintended antimicrobial use highlight the need to design better systems, not blame individuals for non-compliance. We argue that addressing sepsis and antimicrobial resistance requires a holistic systems approach and that every discipline, including policy makers, clinicians, researchers, and drug developers, should adopt systems thinking in the design of interventions intended to address this problem. This shift is essential to ensuring effective care for patients today while safeguarding the effectiveness of antimicrobials tomorrow.
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Affiliation(s)
- Olivia Lounsbury
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
| | - Jane O'Hara
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK; National Institute for Health and Care Research Yorkshire & Humber Patient Safety Research Collaboration, York, UK
| | - Andrew J Brent
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Helen Higham
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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2
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Morquin D, Lejeune J, Agostini C, Godreuil S, Reynes J, Le Moing V, Lamy B. Time Is of the Essence: Achieving Prompt and Effective Antimicrobial Therapy of Bloodstream Infection With Advanced Hospital Information Systems. Clin Infect Dis 2024; 78:1434-1442. [PMID: 38059510 DOI: 10.1093/cid/ciad744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/28/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023] Open
Abstract
The early administration of appropriate antibiotic therapy is crucial for the survival of patients with bacteremia. Current research focuses on improving analytical times through technology, whereas there have been very few efforts to improve postanalytical times even though they represent 40% of the time between blood taking and appropriate treatment administration. One of the clues is the efficiency and appropriateness of the result communication system. Here, we review all delays in the entire process with the aim of improving time to appropriate treatment administration. We discuss causes for long times to adjust treatment once microbiological results are released. We argue that the pervasive health information system in this organization serves as both a bottleneck and a rigid framework. Finally, we explore how next-generation hospital information systems should be designed to effectively assist the doctors in treating patients with bacteremia.
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Affiliation(s)
- David Morquin
- Département des Maladies Infectieuses et Tropicales, CHU Montpellier, Montpellier, France
- Espace de Recherche et d'Intégration des Outils numériques en Santé (ERIOS), CHU Montpellier, Montpellier, France
| | - Jordan Lejeune
- Département des Maladies Infectieuses et Tropicales, CHU Montpellier, Montpellier, France
| | - Céline Agostini
- Département des Maladies Infectieuses et Tropicales, CHU Montpellier, Montpellier, France
| | - Sylvain Godreuil
- Laboratoire de bactériologie, CHU Montpellier, Université Montpellier, Montpellier, France
| | - Jacques Reynes
- Département des Maladies Infectieuses et Tropicales CHU, CHU Montpellier, Université Montpellier, Montpellier, France
| | - Vincent Le Moing
- Département des Maladies Infectieuses et Tropicales CHU, CHU Montpellier, Université Montpellier, Montpellier, France
| | - Brigitte Lamy
- UFR Médecine, Université Côte d'Azur, CHU de Nice, INSERM, C3M, Nice, France
- UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
- Service de Microbiologie, Assistance publique - Hopitaux de Paris (APHP), Hôpitaux Universitaires Paris Seine Saint-Denis (HUPSSD), Bobigny, France
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3
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Färber J, Kaasch AJ, Schalk E. Shorter time-to-positivity and turnaround time with mycosis blood culture bottles when detecting Candida albicans. Infection 2024; 52:701-703. [PMID: 38393640 PMCID: PMC10955001 DOI: 10.1007/s15010-024-02216-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/13/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Jacqueline Färber
- Medical Faculty, Institute of Medical Microbiology and Hospital Hygiene, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Achim J Kaasch
- Medical Faculty, Institute of Medical Microbiology and Hospital Hygiene, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Enrico Schalk
- Department of Hematology, Oncology and Cell Therapy, Medical Faculty, Otto von Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
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Ali J, Johansen W, Ahmad R. Short turnaround time of seven to nine hours from sample collection until informed decision for sepsis treatment using nanopore sequencing. Sci Rep 2024; 14:6534. [PMID: 38503770 PMCID: PMC10951244 DOI: 10.1038/s41598-024-55635-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
Bloodstream infections (BSIs) and sepsis are major health problems, annually claiming millions of lives. Traditional blood culture techniques, employed to identify sepsis-causing pathogens and assess antibiotic susceptibility, usually take 2-4 days. Early and accurate antibiotic prescription is vital in sepsis to mitigate mortality and antibiotic resistance. This study aimed to reduce the wait time for sepsis diagnosis by employing shorter blood culture incubation times for BD BACTEC™ bottles using standard laboratory incubators, followed by real-time nanopore sequencing and data analysis. The method was tested on nine blood samples spiked with clinical isolates from the six most prevalent sepsis-causing pathogens. The results showed that pathogen identification was possible at as low as 102-104 CFU/mL, achieved after just 2 h of incubation and within 40 min of nanopore sequencing. Moreover, all the antimicrobial resistance genes were identified at 103-107 CFU/mL, achieved after incubation for 5 h and only 10 min to 3 h of sequencing. Therefore, the total turnaround time from sample collection to the information required for an informed decision on the right antibiotic treatment was between 7 and 9 h. These results hold significant promise for better clinical management of sepsis compared with current culture-based methods.
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Affiliation(s)
- Jawad Ali
- Department of Biotechnology, Inland Norway University of Applied Sciences, Holsetgata 22, 2317, Hamar, Norway
| | - Wenche Johansen
- Department of Biotechnology, Inland Norway University of Applied Sciences, Holsetgata 22, 2317, Hamar, Norway
| | - Rafi Ahmad
- Department of Biotechnology, Inland Norway University of Applied Sciences, Holsetgata 22, 2317, Hamar, Norway.
- Institute of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Hansine Hansens Veg 18, 9019, Tromsø, Norway.
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Neser E, Jung P, Halfmann A, Schröder M, Thurner L, Becker SL, Schneitler S. A multi-pronged approach to improve blood culture diagnostics in different clinical departments: a single-centre experience. Infection 2024; 52:183-195. [PMID: 37589812 PMCID: PMC10810936 DOI: 10.1007/s15010-023-02083-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/01/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE Blood culture (BC) diagnostics are influenced by many factors. We performed a targeted interdisciplinary analysis to analyse effects of various measures on BC diagnostics performance. METHODS A diagnostic stewardship initiative was conducted at two intervention and two control wards in a German tertiary level hospital. The initiative comprised staff training on the correct indications and sampling for BC, implementation of information cards, labels to identify the collection site, regular BC bottle feedback including the number of bottles, filling volumes and identified pathogens; and the use of a specific sampling device (BD Vacutainer®). Before and after the interventions, two three-month measurement periods were performed, as well as a one-month follow-up period to assess the sustainability of the conducted measures. RESULTS In total, 9362 BC bottles from 787 patients were included in the analysis. The number of BCs obtained from peripheral venous puncture could be increased at both intervention wards (44.0 vs. 22.2%, 58.3 vs. 34.4%), while arterial sampling could be reduced (30.6 vs. 4.9%). A total of 134 staff members were fully trained. The intervention led to a considerable increase in BC knowledge (from 62.4 to 79.8% correct answers) with differences between the individual professional groups. Relevant reduced contamination rates could be detected at both intervention wards. CONCLUSIONS As knowledge on the correct BC sampling and strategies to reduce contamination varies considerably between clinical departments and healthcare professionals, a targeted training should be adapted to the specific needs of the individual professional groups. An additional filling device is not necessary.
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Affiliation(s)
- Elisabeth Neser
- Institute of Medical Microbiology and Hygiene, Saarland University, Kirrberger Strasse, Building 43, 66421, Homburg/Saar, Germany
| | - Philipp Jung
- Institute of Medical Microbiology and Hygiene, Saarland University, Kirrberger Strasse, Building 43, 66421, Homburg/Saar, Germany
| | - Alexander Halfmann
- Institute of Medical Microbiology and Hygiene, Saarland University, Kirrberger Strasse, Building 43, 66421, Homburg/Saar, Germany
| | - Matthias Schröder
- Department of Anaesthesiology, Intensive Care and Analgesic Therapy, Saarland University, Homburg/Saar, Germany
| | - Lorenz Thurner
- Department of Internal Medicine Oncology, Haematology, Clinical Immunology and Rheumatology, Saarland University, Homburg/Saar, Germany
| | - Sören L Becker
- Institute of Medical Microbiology and Hygiene, Saarland University, Kirrberger Strasse, Building 43, 66421, Homburg/Saar, Germany
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Sophie Schneitler
- Institute of Medical Microbiology and Hygiene, Saarland University, Kirrberger Strasse, Building 43, 66421, Homburg/Saar, Germany.
- Clinic for Pneumology and Allergology, Bethanien Hospital, Centre of Sleep Medicine and Respiratory Care, Institute of Pneumology at the University of Cologne, Solingen, Germany.
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Davies PJB, Jones TPW, Macleod M. An assessment of the downstream implications of blood culture collection and transit. Eur J Clin Microbiol Infect Dis 2023:10.1007/s10096-023-04610-z. [PMID: 37131082 DOI: 10.1007/s10096-023-04610-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/21/2023] [Indexed: 05/04/2023]
Abstract
The implications of the variables within the pre-analytical phase of blood culture processing are poorly understood. This study aims to explore the effect of transit times (TT) and culture volume, on time to microbiological diagnosis and patient outcomes. Blood cultures received between 1st March and 31st July 2020/21 were identified. TT, time in incubator (TII), and for positive samples, request to positivity times (RPT) were calculated. Demographic details were recorded for all samples, and culture volume, length of stay (LoS), and 30-day mortality for patients with positive samples. Statistical analysis examined how culture volume and TT effected culture positivity and outcome; in the context of the 4-h national TT target. Totally, 14,375 blood culture bottles were received from 7367 patients; 988 (13.4%) were positive for organisms. There was no significant difference between TT of negative and positive samples. The RPT was significantly lower for samples with TT < 4 h (p < 0.001). Culture bottle volume did not affect RPT (p = 0.482) or TII (p = 0.367). A prolonged TT was associated with a longer length-of-stay in those with a bacteraemia with a significant organism (p = 0.001). We found shorter blood culture transportation time was associated with a significantly faster time of positive culture reporting, while optimal blood culture volume did not make a significant impact. Delays in reporting for significant organisms correspond to a prolonged LoS. Laboratory centralisation makes achieving the 4-h target a logistical challenge; however, this data suggests such targets have significant microbiological and clinical impacts.
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Affiliation(s)
- Peter J B Davies
- Department of Medical Microbiology, Glasgow Royal Infirmary, Glasgow, UK.
| | - Timothy P W Jones
- Department of Medical Microbiology, Glasgow Royal Infirmary, Glasgow, UK
- Department of Infectious Diseases, John Radcliffe Hospital, Oxford, UK
| | - Mairi Macleod
- Department of Medical Microbiology, Glasgow Royal Infirmary, Glasgow, UK
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Rao S, Maradi R, Gupta N, Asok A, Chaudhuri S, Bhatt MT, Maddani SS. Incorporation of plasma Vitamin C levels to modified nutritional risk in critically ill score as the novel Vitamin C nutritional risk in critically ill score in sepsis subjects as an early predictor of multidrug-resistant bacteria: A prospective observational study. Int J Crit Illn Inj Sci 2023; 13:32-37. [PMID: 37180303 PMCID: PMC10167808 DOI: 10.4103/ijciis.ijciis_54_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/14/2022] [Accepted: 09/29/2022] [Indexed: 05/16/2023] Open
Abstract
Background On intensive care unit (ICU) admission, it is difficult to predict which patient may harbor multidrug-resistant (MDR) bacteria. MDR is the nonsusceptibility of bacteria to at least one antibiotic in three or more antimicrobial categories. Vitamin C inhibits bacterial biofilms, and its incorporation into the modified nutritional risk in critically ill (mNUTRIC) scores may help predict MDR bacterial sepsis early. Methods A prospective observational study was conducted on adult subjects with sepsis. Plasma Vitamin C level was estimated within 24 h of ICU admission, and it was incorporated into the mNUTRIC score (designated as Vitamin C nutritional risk in critically ill [vNUTRIC]). Multivariable logistic regression was performed to determine if vNUTRIC was an independent predictor of MDR bacterial culture in sepsis subjects. The receiver operating characteristic curve was plotted to determine the vNUTRIC cutoff score for predicting MDR bacterial culture. Results A total of 103 patients were recruited. The bacterial culture-positive sepsis subjects were 58/103, with 49/58 culture-positive subjects having MDR. The vNUTRIC score on ICU admission in the MDR bacteria group was 6.71 ± 1.92 versus 5.42 ± 2.2 in the non-MDR bacteria group (P = 0.003, Independent Student's t-test). High vNUTRIC score ≥6 on admission is associated with MDR bacteria (P = 0.042 Chi-Square test), and is a predictor of MDR bacteria (P = 0.003, AUC 0.671, 95% confidence interval [0.568-0.775], sensitivity 71%, specificity 48%). Logistic regression showed that the vNUTRIC score is an independent predictor of MDR bacteria. CONCLUSION High vNUTRIC score (≥6) on ICU admission in sepsis subjects is associated with MDR bacteria.
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Affiliation(s)
- Shwethapriya Rao
- Department of Critical Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Ravindra Maradi
- Department of Biochemistry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Nitin Gupta
- Department of Infectious Diseases, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Arjun Asok
- Department of Biochemistry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Souvik Chaudhuri
- Department of Critical Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Margiben Tusharbhai Bhatt
- Department of Critical Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sagar Shanmukhappa Maddani
- Department of Critical Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Roberts T, Chandna A, Watthanaworawit W, Thaiprakong A, Soeng S, Simmalavong M, Phoumin P, Saengchun W, Khatta N, Hinfonthong P, Kaewpundoem N, Lee SJ, Perrone C, Amos B, Turner P, Ashley EA, Ling CL. Impact of delayed processing of positive blood cultures on organism detection: a prospective multi-centre study. BMC Infect Dis 2022; 22:517. [PMID: 35659576 PMCID: PMC9167519 DOI: 10.1186/s12879-022-07504-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Blood cultures remain the gold standard investigation for the diagnosis of bloodstream infections. In many locations, quality-assured processing of positive blood cultures is not possible. One solution is to incubate blood cultures locally, and then transport bottles that flag positive to a central reference laboratory for organism identification and antimicrobial susceptibility testing. However, the impact of delay between the bottle flagging positive and subsequent sub-culture on the viability of the isolate has received little attention. Methods This study evaluated the impact of delays to sub-culture (22 h to seven days) in three different temperature conditions (2–8 °C, 22–27 °C and 35 ± 2 °C) for bottles that had flagged positive in automated detection systems using a mixture of spiked and routine clinical specimens. Ninety spiked samples for five common bacterial causes of sepsis (Escherichia coli, Haemophilus influenzae, Staphylococcus aureus, Streptococcus agalactiae and Streptococcus pneumoniae) and 125 consecutive positive clinical blood cultures were evaluated at four laboratories located in Cambodia, Lao PDR and Thailand. In addition, the utility of transport swabs for preserving organism viability was investigated. Results All organisms were recoverable from all sub-cultures in all temperature conditions with the exception of S. pneumoniae, which was less likely to be recoverable after longer delays (> 46–50 h), when stored in hotter temperatures (35 °C), and from BacT/ALERT when compared with BACTEC blood culture bottles. Storage of positive blood culture bottles in cooler temperatures (22–27 °C or below) and the use of Amies bacterial transport swabs helped preserve viability of S. pneumoniae. Conclusions These results have practical implications for the optimal workflow for blood culture bottles that have flagged positive in automated detection systems located remotely from a central processing laboratory, particularly in tropical resource-constrained contexts. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07504-1.
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Deslandes V, Rafipour D, Gorn I, Sabri E, Sant N, Desjardins M. Effect of delayed entry of blood culture bottles in BACTEC automated blood culture system in the context of laboratory consolidation. Sci Rep 2022; 12:1337. [PMID: 35079040 PMCID: PMC8789921 DOI: 10.1038/s41598-022-05246-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/31/2021] [Indexed: 11/08/2022] Open
Abstract
Delayed entry of blood culture bottles is frequent in consolidated laboratories. A retrospective study evaluated time from insertion to detection and total detection time as a function of preincubation time, and we prospectively looked for false negative results. 69,604 blood culture bottles were reviewed for preincubation time, incubation time and total detection time. Positive cultures for specific bacterial subtypes were reviewed to assess the effect of preincubation time on likelihood of detection. 492 negative blood cultures were prospectively tested by 16S RNA PCR and Staphylococcus-specific PCR for the presence of bacterial DNA. Mean preincubation time for samples collected within the city-limits was 3.94 h versus 9.49-18.89 h for other client sites. Higher preincubation times were partially mitigated by a lower incubation time, with an overall increase in total detection time. A lower odds ratio of recovery of Staphylococcus spp was identified, but not confirmed by terminal subcultures and molecular assays. Prolonged preincubation of blood cultures affects total detection time despite a reduction in incubation time. Successful centralization of microbiological services may depend upon optimization of courier routes for inoculated blood culture bottles. Our data supports consideration for an increase in suggested maximum preincubation times.
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Affiliation(s)
- Vincent Deslandes
- University of Ottawa, Ottawa, ON, Canada.
- The Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.
- Eastern Ontario Regional Laboratory Association (EORLA), Ottawa, ON, Canada.
| | - Darya Rafipour
- Eastern Ontario Regional Laboratory Association (EORLA), Ottawa, ON, Canada
| | - Ivan Gorn
- The Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada
| | - Elham Sabri
- The Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada
| | - Nadia Sant
- University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada
- Eastern Ontario Regional Laboratory Association (EORLA), Ottawa, ON, Canada
| | - Marc Desjardins
- University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada
- Eastern Ontario Regional Laboratory Association (EORLA), Ottawa, ON, Canada
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10
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Berry LL, Letchuman S, Ramani N, Barach P. The High Stakes of Outsourcing in Health Care. Mayo Clin Proc 2021; 96:2879-2890. [PMID: 34412855 DOI: 10.1016/j.mayocp.2021.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/13/2021] [Accepted: 07/06/2021] [Indexed: 11/16/2022]
Abstract
Outsourcing in health care has become increasingly common as health system administrators seek to enhance profitability and efficiency while maintaining clinical excellence. When clinical services are outsourced, however, the outsourcing organization relinquishes control over its most important service value: high-quality patient care. Farming out work to an external service provider can have many unintended results, including inconsistencies in standards of care; harmful medical errors; declines in patient and employee satisfaction; and damage to clinicians' morale and income, and to the health organization's culture, reputation, and long-term financial performance. Research on outsourcing in the areas of emergency medicine, radiology, laboratory services, and environmental services provides concerning evidence of potentially large downsides when outsourcing is driven by short-term cost concerns or is planned without diligently considering all of the ramifications of not keeping key clinical and nonclinical services in-house. To better equip health system leaders for decision-making about outsourcing, we examine this body of literature, identify common pitfalls of outsourcing in specific clinical and nonclinical health services and scenarios, explore alternatives to outsourcing, and consider how outsourcing (when necessary) can be done in a strategic manner that does not compromise the values of the organization and its commitment to patients.
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Affiliation(s)
- Leonard L Berry
- Mays Business School, Texas A&M University, College Station, TX; Institute for Healthcare Improvement, Boston, MA.
| | | | - Nandini Ramani
- Mays Business School, Texas A&M University, College Station, TX
| | - Paul Barach
- Wayne State University School of Medicine, MI; Jefferson College of Population Health, Philadelphia, PA; Interdisciplinary Research Institute for Health Law and Science, Sigmund Freud University, Vienna, Austria
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11
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Blondeau JM, Rankin SC. Diagnostic clinical microbiology. J Vet Pharmacol Ther 2021; 44:250-269. [PMID: 33686661 DOI: 10.1111/jvp.12962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/27/2021] [Accepted: 02/09/2021] [Indexed: 01/07/2023]
Abstract
Technological advancements have changed the way clinical microbiology laboratories are detecting and identifying bacterial, viral, parasitic, and yeast/fungal pathogens. Such advancements have improved sensitivity and specificity and reduce turnaround time to reporting of clinically important results. This article discusses and reviews some traditional methodologies along with some of the technological innovations introduced into diagnostic microbiology laboratories. Some insight to what might be available in the coming years is also discussed.
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Affiliation(s)
- Joseph M Blondeau
- Division of Clinical Microbiology, Royal University Hospital and Saskatchewan Health Authority, Saskatoon, SK, Canada.,Department of Microbiology and Immunology, University of Saskatchewan, Saskatoon, SK, Canada.,Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, SK, Canada.,Department of Ophthalmology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Shelley C Rankin
- Department of Pathobiology, University of Pennsylvania, School of Veterinary Medicine, Philadelphia, PA, USA
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12
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Ling CL, Roberts T, Soeng S, Cusack TP, Dance DAB, Lee SJ, Reed TAN, Hinfonthong P, Sihalath S, Sengduangphachanh A, Watthanaworawit W, Wangrangsimakul T, Newton PN, Nosten FH, Turner P, Ashley EA. Impact of delays to incubation and storage temperature on blood culture results: a multi-centre study. BMC Infect Dis 2021; 21:173. [PMID: 33579205 PMCID: PMC7881545 DOI: 10.1186/s12879-021-05872-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 02/04/2021] [Indexed: 02/07/2023] Open
Abstract
Background Blood cultures are one of the most important tests performed by microbiology laboratories. Many hospitals, particularly in low and middle-income countries, lack either microbiology services or staff to provide 24 h services resulting in delays to blood culture incubation. There is insufficient guidance on how to transport/store blood cultures if delays before incubation are unavoidable, particularly if ambient temperatures are high. This study set out to address this knowledge gap. Methods In three South East Asian countries, four different blood culture systems (two manual and two automated) were used to test blood cultures spiked with five common bacterial pathogens. Prior to incubation the spiked blood culture bottles were stored at different temperatures (25 °C, in a cool-box at ambient temperature, or at 40 °C) for different lengths of time (0 h, 6 h, 12 h or 24 h). The impacts of these different storage conditions on positive blood culture yield and on time to positivity were examined. Results There was no significant loss in yield when blood cultures were stored < 24 h at 25 °C, however, storage for 24 h at 40 °C decreased yields and longer storage times increased times to detection. Conclusion Blood cultures should be incubated with minimal delay to maximize pathogen recovery and timely result reporting, however, this study provides some reassurance that unavoidable delays can be managed to minimize negative impacts. If delays to incubation ≥ 12 h are unavoidable, transportation at a temperature not exceeding 25 °C, and blind sub-cultures prior to incubation should be considered. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-05872-8.
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Affiliation(s)
- Clare L Ling
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
| | - Tamalee Roberts
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Sona Soeng
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Tomas-Paul Cusack
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Present address: Department of Infection, University Hospital Southampton, Southampton, UK
| | - David A B Dance
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Sue J Lee
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Thomas A N Reed
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia.,Present address: London North West University Healthcare NHS Trust, Northwick Park Hospital, London, UK
| | - Pattaraporn Hinfonthong
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Somsavanh Sihalath
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Amphone Sengduangphachanh
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Wanitda Watthanaworawit
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Tri Wangrangsimakul
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul N Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Francois H Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Paul Turner
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
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Elvy J, Walker D, Haremza E, Ryan K, Morris AJ. Blood culture quality assurance: what Australasian laboratories are measuring and opportunities for improvement. Pathology 2020; 53:520-529. [PMID: 33358375 DOI: 10.1016/j.pathol.2020.09.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/26/2020] [Accepted: 09/07/2020] [Indexed: 10/22/2022]
Abstract
Blood cultures are among the most important specimen types received and processed by the microbiology laboratory. Several publications list which variables should be measured to ensure quality. We undertook a qualitative structured questionnaire of Australian and New Zealand clinical microbiology laboratories to document current blood culture practices and to determine whether expected quality standards are being met. Questions included a wide range of pre-analytical, analytical, and post-analytical aspects of blood cultures from adults. The responses from 71 laboratories were analysed. Compliance was high for use of a biological safety cabinet (90%), incubating for 5 days (86%), and commenting on likely contaminants (85%). While Gram stains were reported within 2 hours during normal hours (93%), reporting was slower after hours (59%), p<0.001. The volume of blood collected for a clinical episode was poorly monitored with only 11% (n=8) of laboratories regularly auditing the number of blood culture sets and 3% (n=2) monitoring adequacy of fill. Most laboratories received blood cultures from off-site with just 34% (n=21) meeting guidance for loading bottles onto the analyser within 4 hours. More laboratories met standards for loading bottles onto the analyser during working hours than after hours: 87% vs 56%, p<0.001. Most laboratories did not monitor the contamination rate, 56% (n=40), and only 27% (n=19) knew their rate was below the guidance threshold of less than -3%. Considerable opportunities exist to improve quality assurance of blood culture practice in Australia and New Zealand, especially for the most critical aspect affecting culture sensitivity, the volume of blood collected.
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Affiliation(s)
- Juliet Elvy
- The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP), Sydney, NSW, Australia; Department of Microbiology, Wellington Southern Community Laboratories, Wellington Hospital, Wellington, New Zealand; Department of Microbiology, Medlab Nelson Marlborough, Nelson, New Zealand.
| | - Debra Walker
- The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP), Sydney, NSW, Australia
| | - Elizabeth Haremza
- The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP), Sydney, NSW, Australia
| | - Katherine Ryan
- The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP), Sydney, NSW, Australia
| | - Arthur J Morris
- The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP), Sydney, NSW, Australia; Clinical Microbiology Laboratory, LabPLUS, Auckland City Hospital, Auckland, New Zealand
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Effect of delayed entry on performance of the BACT/ALERT FAN PLUS bottles in the BACT/ALERT VIRTUO blood culture system. Eur J Clin Microbiol Infect Dis 2020; 40:699-705. [PMID: 33034779 PMCID: PMC7979663 DOI: 10.1007/s10096-020-04042-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/15/2020] [Indexed: 02/08/2023]
Abstract
Delayed entry of patient blood culture samples into a microbial detection system is unavoidable at times, due to off-shift staffing or transporting samples to centralized laboratories. Pre-incubation time and temperature of blood culture bottles are the most critical factors impacting recovery and detection of microorganisms. A total of 1377 BACT/ALERT® (BTA) Fastidious Antimicrobial Neutralization (FAN® PLUS) bottles (FA PLUS, FN PLUS, and PF PLUS) were tested after delayed entry times of 24 and 36 h at 20–25 °C (room temperature, RT) prior to loading into the BACT/ALERT® VIRTUO® microbial detection system (VIRTUO). Clinically relevant organisms were inoculated into bottles with 5–84 colony forming units (CFU) per bottle, and human blood (0 to 10 mL), and then loaded into the VIRTUO. When bottles were loaded without delay, a mean time to detection (TTD) of 9.6 h was observed. For delayed bottles, the TTD reported by the VIRTUO was added to the 24-h and 36-h delay times and resulted in average time to results of 32.5 h and 42.5 h, respectively. The FAN PLUS bottles in conjunction with the VIRTUO produced acceptable results when delays up to 24 h at 20–25 °C occur in loading.
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15
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De Plato F, Fontana C, Gherardi G, Privitera GP, Puro V, Rigoli R, Viaggi B, Viale P. Collection, transport and storage procedures for blood culture specimens in adult patients: recommendations from a board of Italian experts. Clin Chem Lab Med 2020; 57:1680-1689. [PMID: 31348753 DOI: 10.1515/cclm-2018-1146] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 06/24/2019] [Indexed: 12/23/2022]
Abstract
Bloodstream infections (BSIs) remain a potentially life-threatening condition. The gold standard for the diagnosis of BSI is still blood cultures (BCs), and the diagnostic yield depends on clinical and technical factors that have an impact on collection and transportation. Hence, monitoring of the entire pre-analytical process from blood collection to transportation to the microbiology laboratory is critical. To optimize the clinical impact of the diagnostic and therapeutic procedures, a multidisciplinary approach and univocal protocols are mandatory. A board of specialists discussed the available evidence on the pre-analytical process and produced the present document to guide physicians and nurses on the ideal execution of BC: (1) timing and preparation for blood collection; (2) skin antisepsis; (3) blood volume; (4) sampling method and safety; (5) medium to be used; (6) time to BC transportation; and (7) quality assurance and quality management.
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Affiliation(s)
- Francesca De Plato
- Società Italiana Farmacologia Ospedaliera, Milan, Italy; and Local Health Authority ASL of Teramo, Teramo, Italy
| | - Carla Fontana
- Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy.,Microbiology and Virology Laboratory, Polyclinic of Tor Vergata, Rome, Italy
| | - Giovanni Gherardi
- Department of Medicine, Laboratory of Clinical Microbiology, University Campus Biomedico, Rome 00128, Italy
| | - Gaetano Pierpaolo Privitera
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.,University Hygiene and Epidemiology Complex Operative Unit and Clinical Risk Functional Area Coordinator, University Hospital Pisana, Pisa, Italy
| | - Vincenzo Puro
- National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
| | - Roberto Rigoli
- Department of Clinical Pathology, Local Health and Social Care Facility, No. 2, Marca Trevigiana, Treviso, Italy
| | - Bruno Viaggi
- Neuroanesthesia and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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16
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Johnsson ATA, Wong AYW, Özenci V. The impact of delayed analysis of positive blood cultures on the performance of short-term culture followed by MALDI-TOF MS. J Microbiol Methods 2020; 177:106027. [PMID: 32805364 DOI: 10.1016/j.mimet.2020.106027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/06/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Short-term culture followed by MALDI-TOF MS is one of the most widely used methods for fast identification of microorganisms from blood cultures. The method identifies the vast majority of bloodstream infection pathogens in 2-6 h after positive blood culture. Transport time of blood culture bottles to laboratories is a major problem affecting total turnaround time. Therefore, many central laboratories establish satellite blood culture systems in other clinics and hospitals to allow blood culture bottles to be incubated immediately after sampling. However, positive blood culture bottles still need to be transported to the clinical microbiology laboratory for analysis. The aim of this study was to investigate how delayed analysis of positive blood culture bottles would affect the short-term culture followed by MALDI-TOF MS method. MATERIALS/METHODS To simulate the effect of transportation and delayed analysis of blood culture bottles, 51 simulated blood culture bottles were incubated for 0, 2, 4 and 24 h at room temperature. After each time interval, a 2 to 4 h short-term culture followed by MALDI-TOF MS was performed. In addition, 257 prospective clinical positive blood culture bottles were analysed with the same method after a 24 h incubation at room temperature. RESULTS In simulated samples, all (120/120) Gram-negative bacteria and 77/84 (91.6%) Gram-positive bacteria were accurately identified at species-level after a 2 h short-term culture, regardless of the duration of simulated transport time. In the clinical samples, 100/116 (86.2%) Gram-negative, and 44/141 (31.2%) Gram-positive bacteria were accurately identified at species-level after a 2 h short-term culture. After contaminants were excluded, 39/71 (54.9%) Gram-positive bacteria could be identified after 2 h. After a 4 h short-term culture, 112/116 (96.6%) Gram-negative, and 108/141 (76.6%) Gram-positive bacteria were accurately identified at species-level. Of the clinically relevant Gram-positive bacteria, 68/71 (95.8%) were identified at species-level after 4 h. CONCLUSIONS Short-term culture followed by MALDI-TOF MS can provide fast and accurate results for identification of clinically relevant bacteria, despite long transportation times from satellite laboratories. The present data shows that the method can be used for identification of microorganisms from positive blood cultures transported from satellite blood culture systems.
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Affiliation(s)
| | - Alicia Y W Wong
- Department of Clinical Microbiology, Karolinska University Hospital Stockholm, Sweden
| | - Volkan Özenci
- Department of Clinical Microbiology, Karolinska University Hospital Stockholm, Sweden; Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.
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17
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Penton ME, Otto C, Hammerschlag MR. Outsourcing Microbiology Services in Medical Centers: Is It Worth It? J Pediatric Infect Dis Soc 2020; 9:293-297. [PMID: 30989191 DOI: 10.1093/jpids/piz019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/04/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Outsourcing of microbiology laboratory services is a growing trend in US medical centers. Data on the actual impact of outsourcing on patient care, safety, and medical education, including costs, are limited. The objective of this study was to examine the published literature on the potential benefits and harms when medical centers outsource common microbiology services. METHODS We conducted a 16-step literature search of PubMed and Embase. Articles were selected for full-text review if their content matched our key questions: (1) What are the potential benefits of outsourcing core microbiology laboratory testing? (2) What are the potential harms to patient care and medical education when medical centers outsource essential microbiology services? RESULTS The initial search yielded 6111 unique published articles; 36 were selected for full-text review, which resulted in the identification of 8 articles that addressed our key questions (2 editorials, 3 editorials with observational data, 1 survey, 1 case series, and 1 study of blood culture transport). These articles described a variety of issues, including longer turnaround times for blood cultures that resulted in delays in diagnosis and treatment, errors that resulted in patient morbidity, limited cost savings, and communication barriers. CONCLUSIONS In this study, with the exception of the blood culture transport study, we found no published prospective studies that quantified the effects of outsourcing microbiology services on patient care, patient safety, or medical education. However, these largely anecdotal reports suggest that outsourcing microbiology services may have a detrimental impact on medical education, especially infectious disease training programs.
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Affiliation(s)
- Manuel E Penton
- Department of Pediatrics, Division of Pediatric Infectious Diseases, SUNY Downstate Medical Center, Brooklyn, New York
| | - Caitlin Otto
- Department of Pathology, Division of Pediatric Infectious Diseases, SUNY Downstate Medical Center, Brooklyn, New York
| | - Margaret R Hammerschlag
- Department of Pediatrics, Division of Pediatric Infectious Diseases, SUNY Downstate Medical Center, Brooklyn, New York
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Abstract
BACKGROUND In newborns at risk for early-onset sepsis, empiric antibiotics are often initiated while awaiting the results of blood cultures. The duration of empiric therapy can be guided by the time to positivity (TTP) of blood cultures. The objective of the study was to determine the TTP of neonatal blood cultures for early-onset sepsis and the factors which may impact TTP. METHODS Observational study of blood cultures growing pathogenic species obtained within 72 hours of birth from infants born at 23-42 weeks gestation, at 19 hospitals in Northern California, Boston, and Philadelphia. TTP was defined as the time from blood culture collection to the time organism growth was reported by the microbiology laboratory. RESULTS A total of 594 blood cultures growing pathogenic bacteria were identified. Group B Streptococcus and Escherichia coli accounted for 74% of blood culture isolates. Median TTP was 21.0 hours (interquartile range, 17.1-25.3 hours). Blood cultures were identified as positive by 24 hours after they were obtained in 68% of cases; by 36 hours in 94% of cases; and by 48 hours in 97% of cases. Neither the administration of maternal intrapartum antibiotic prophylaxis, gestational age <35 weeks, nor blood culture system impacted median TTP. CONCLUSIONS Pathogens are isolated by 36 hours after blood culture collection in 94% of neonatal early blood cultures, regardless of maternal antibiotic administration. TTP information can inform decisions regarding the duration of empiric neonatal antibiotic therapies.
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19
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Lamy B, Sundqvist M, Idelevich EA. Bloodstream infections – Standard and progress in pathogen diagnostics. Clin Microbiol Infect 2020; 26:142-150. [DOI: 10.1016/j.cmi.2019.11.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022]
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20
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Schwarzenbacher J, Kuhn SO, Vollmer M, Scheer C, Fuchs C, Rehberg S, Balau V, Hahnenkamp K, Bohnert JA, Gründling M. On-site blood culture incubation shortens the time to knowledge of positivity and microbiological results in septic patients. PLoS One 2019; 14:e0225999. [PMID: 31826003 PMCID: PMC6905563 DOI: 10.1371/journal.pone.0225999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 11/19/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction To determine whether on-site incubation of blood cultures at the intensive care unit (ICU) improves not only the time to incubation but also time to positivity, time to knowledge of positivity and time to results (identification and antibiotic susceptibility testing). Methods This observational single-centre study in ICU patients with severe sepsis and septic shock investigated the impact of blood culture incubation immediately on-site at the ICU (ICU group) by comparison with traditional processing in a remote laboratory (LAB group) on different time intervals of blood culture diagnostics from obtaining blood to clinician notification of final result. The effect of on-site incubation was evaluated in Kaplan-Meier estimates for the time to positivity, time to knowledge of positivity and time to microbiological results and a linear mixed model was built. Results A total of 3,549 blood culture sets from 657 ICU patients were analysed: 2,381 in the LAB group and 1,168 in the ICU group. Overall, 660 (18.6%) blood culture sets were positive and 2,889 (81.4%) sets remained negative. On-site incubation was associated with reduced time to knowledge of positivity (46.9 h [CI 43.4–50.8 h] vs. 28.0 h [CI 23.6–32.2 h], p < 0.001) and reduced time to result (61.4 h [CI 58.4–64.8 h] vs. 42.1 h [CI 39.1–47.5 h], p < 0.001). In blood cultures processed instantaneously at the ICU compared to incubation in the remote laboratory within 4 h, the time to microbiological result was significantly reduced by 8.5 h (p < 0.001). Pre-existing anti-infective therapy had no significant impact on diagnostic time intervals. Conclusions Instantaneous incubation of blood cultures in the ICU compared to incubation in a remote laboratory significantly improves time to knowledge to positivity and time to result. These effects are even more pronounced during off-hours of the microbiological laboratory. The results underline the importance of 24/7 diagnostics to provide round-the-clock processing of blood culture samples in patients with sepsis and septic shock and an immediate to communication of the results to the clinicians.
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Affiliation(s)
| | - Sven-Olaf Kuhn
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
- * E-mail:
| | - Marcus Vollmer
- Institute of Bioinformatics, University Medicine Greifswald, Greifswald, Germany
| | - Christian Scheer
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
| | - Christian Fuchs
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
| | - Sebastian Rehberg
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, Protestant Hospital of the Bethel Foundation, Bielefeld, Germany
| | - Veronika Balau
- IMD Labor Greifswald, MVZ Labor Greifswald GmbH, Greifswald, Germany
| | - Klaus Hahnenkamp
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
| | - Jürgen A. Bohnert
- Friedrich Loeffler Institute of Microbiology, University Hospital Greifswald, Greifswald, Germany
| | - Matthias Gründling
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
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21
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Idelevich EA, Reischl U, Becker K. New Microbiological Techniques in the Diagnosis of Bloodstream Infections. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:822-832. [PMID: 30678752 DOI: 10.3238/arztebl.2018.0822] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 10/04/2017] [Accepted: 10/12/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND When a bloodstream infection is suspected, the preliminary and definitive results of culture-based microbiological testing arrive too late to have any influence on the initial choice of empirical antibiotic treatment. METHODS This review is based on pertinent publications retrieved by a selective search of the literature and on the authors' clinical and scientific experience. RESULTS A number of technical advances now enable more rapid microbiological diagnosis of bloodstream infections. DNA- based techniques for the direct detection of pathogenic organisms in whole blood have not yet become established in routine use because of various limitations. On the other hand, matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry (MS) has become available for routine use in clinical laboratories and has markedly shortened the time to diagnosis after blood samples that have been cultured in automated blood-culture systems turn positive. Further developments of this technique now enable it to be used directly for blood cultures that have been flagged positive, as well as for subcultures that have been incubated for only a short time on a solid nutrient medium. The microbial biomass of the subculture can also be used in parallel for more rapid susceptibility testing with conventional methods, or, in future, with MALDI-TOF MS. CONCLUSION The potential of all of these new techniques will only be realizable in practice if they are optimally embedded in the diagnostic process and if sufficient attention is paid to pre-analytical issues, particularly storage and transport times.
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22
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Özenci V, Strålin K. Clinical implementation of molecular methods in detection of microorganisms from blood with a special focus on PCR electrospray ionization mass spectrometry. Expert Rev Mol Diagn 2019; 19:389-395. [PMID: 30979356 DOI: 10.1080/14737159.2019.1607728] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The ongoing improvement and development of state-of-the-art diagnostic methods indicate that we are in an era of revolution in clinical microbiological diagnosis of infectious diseases. Non-culture-based methods have the possibility to play a central role in delivering personalized microbiological diagnoses of severe infections. The PCR electrospray ionization mass spectrometry (PCR/ESI-MS) system is built on the principle of universal detection and specific identification. The performance studies using PCR/ESI-MS on whole blood samples, as well as our experiences, indicate that this method provides useful clinical information. These types of modern molecular methods deserve further development for broad implementation into clinical practices. Areas covered: The review describes briefly hitherto developed molecular assays in detection of microorganisms directly from whole blood and focuses on the clinical implementation of PCR/ESI-MS. Expert opinion: The detection of an extensive broad-spectrum of microorganisms directly from whole blood samples with a series of tests that are run automatically with a turn-around time of 8 h would be a desirable diagnostic tool for the clinical microbiology laboratories. We believe that the clinical experience with PCR-ESI MS may guide the development and establishment of similar state-of-the-art diagnostic technologies in medicine in the future.
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Affiliation(s)
- Volkan Özenci
- a Department of Clinical Microbiology , Karolinska University Hospital , Stockholm , Sweden.,b Division of Clinical Microbiology, Department of Laboratory Medicine , Karolinska Institutet , Stockholm , Sweden
| | - Kristoffer Strålin
- c Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden.,d Unit of Infectious Diseases, Department of Medicine Huddinge , Karolinska Institutet , Stockholm , Sweden
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23
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Idelevich EA, Seifert H, Sundqvist M, Scudeller L, Amit S, Balode A, Bilozor A, Drevinek P, Kocak Tufan Z, Koraqi A, Lamy B, Mareković I, Miciuleviciene J, Müller Premru M, Pascual A, Pournaras S, Saegeman V, Schønheyder HC, Schrenzel J, Strateva T, Tilley R, Wiersinga WJ, Zabicka D, Carmeli Y, Becker K. Microbiological diagnostics of bloodstream infections in Europe-an ESGBIES survey. Clin Microbiol Infect 2019; 25:1399-1407. [PMID: 30980927 DOI: 10.1016/j.cmi.2019.03.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/21/2019] [Accepted: 03/24/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES High-quality diagnosis of bloodstream infections (BSI) is important for successful patient management. As knowledge on current practices of microbiological BSI diagnostics is limited, this project aimed to assess its current state in European microbiological laboratories. METHODS We performed an online questionnaire-based cross-sectional survey comprising 34 questions on practices of microbiological BSI diagnostics. The ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis (ESGBIES) was the primary platform to engage national coordinators who recruited laboratories within their countries. RESULTS Responses were received from 209 laboratories in 25 European countries. Although 32.5% (68/209) of laboratories only used the classical processing of positive blood cultures (BC), two-thirds applied rapid technologies. Of laboratories that provided data, 42.2% (78/185) were able to start incubating BC in automated BC incubators around-the-clock, and only 13% (25/192) had established a 24-h service to start immediate processing of positive BC. Only 4.7% (9/190) of laboratories validated and transmitted the results of identification and antimicrobial susceptibility testing (AST) of BC pathogens to clinicians 24 h/day. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry from briefly incubated sub-cultures on solid media was the most commonly used approach to rapid pathogen identification from positive BC, and direct disc diffusion was the most common rapid AST method from positive BC. CONCLUSIONS Laboratories have started to implement novel technologies for rapid identification and AST for positive BC. However, progress is severely compromised by limited operating hours such that current practice of BC diagnostics in Europe complies only partly with the requirements for optimal BSI management.
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Affiliation(s)
- E A Idelevich
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - H Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany; German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - M Sundqvist
- Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - L Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS, Policlinico San Matteo Pavia Fondazione IRCCS, Pavia, Italy
| | - S Amit
- Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, Jerusalem, Israel
| | - A Balode
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - A Bilozor
- Microbiology Laboratory, Diagnostic Clinic, East-Tallinn Central Hospital, Tallinn, Estonia
| | - P Drevinek
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Z Kocak Tufan
- Infectious Diseases and Clinical Microbiology Department, Medical School of Ankara Yildirim Beyazit University, Ankara, Turkey
| | - A Koraqi
- Clinical Microbiology Laboratory, University Hospital Centre 'Mother Theresa', Tirana, Albania
| | - B Lamy
- Laboratory of Clinical Microbiology, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, INSERM U1065 (C3M), Nice, France
| | - I Mareković
- Department of Clinical and Molecular Microbiology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - M Müller Premru
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - A Pascual
- Unidad de Enfermedades Infecciosas, Microbiologia y Medicina Preventiva, Hospital Universitario Virgen Macarena, Departamento de Microbiología, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - S Pournaras
- Laboratory of Clinical Microbiology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - V Saegeman
- Department of Infection Control and Epidemiology, University Hospitals Leuven, Leuven, Belgium
| | - H C Schønheyder
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark
| | - J Schrenzel
- Bacteriology Laboratory, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - T Strateva
- Department of Medical Microbiology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - R Tilley
- Department of Microbiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - W J Wiersinga
- Department of Infectious Diseases and Centre for Experimental Molecular Medicine, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - D Zabicka
- National Medicines Institute, Warsaw, Poland
| | - Y Carmeli
- Division of Epidemiology, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - K Becker
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany.
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Wolk DM, Johnson JK. Rapid Diagnostics for Blood Cultures: Supporting Decisions for Antimicrobial Therapy and Value-Based Care. J Appl Lab Med 2018; 3:686-697. [PMID: 31639736 DOI: 10.1373/jalm.2018.028159] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/07/2018] [Indexed: 01/05/2023]
Abstract
Bacteremia and sepsis are critically important syndromes with high mortality, morbidity, and associated costs. Bloodstream infections and sepsis are among the top causes of mortality in the US, with >600 deaths each day. Most septic patients can be found in emergency medicine departments or critical care units, settings in which rapid administration of targeted antibiotic therapy can reduce mortality. Unfortunately, routine blood cultures are not rapid enough to aid in the decision of therapeutic intervention at the onset of bacteremia. As a result, empiric, broad-spectrum treatment is common-a costly approach that may fail to target the correct microbe effectively, may inadvertently harm patients via antimicrobial toxicity, and may contribute to the evolution of drug-resistant microbes. To overcome these challenges, laboratorians must understand the complexity of diagnosing and treating septic patients, focus on creating algorithms that rapidly support decisions for targeted antibiotic therapy, and synergize with existing emergency department and critical care clinical practices put forth in the Surviving Sepsis Guidelines.
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Affiliation(s)
- Donna M Wolk
- Laboratory Medicine, Geisinger Diagnostic Medicine Institute, Danville, PA;
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
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25
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Blondeau JM, Idelevich EA. The 24-h clinical microbiology service is essential for patient management. Future Microbiol 2018; 13:1625-1628. [PMID: 30426774 DOI: 10.2217/fmb-2018-0228] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Joseph M Blondeau
- Department of Clinical Microbiology, Royal University Hospital & Saskatchewan Health Authority; Saskatoon, Saskatchewan, Canada.,Departments of Microbiology & Immunology, Pathology & Ophthalmology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Evgeny A Idelevich
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
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How to: accreditation of blood cultures' proceedings. A clinical microbiology approach for adding value to patient care. Clin Microbiol Infect 2018; 24:956-963. [PMID: 29410246 DOI: 10.1016/j.cmi.2018.01.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 01/08/2018] [Accepted: 01/11/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Quality assurance and quality management are driving forces for controlling blood culture best practices but should not be disconnected from the end-point target, i.e. patient value. AIMS This article is intended to help microbiologists implement blood culture accreditation that is actually beneficial to patient management. SOURCES Experience from a nationwide taskforce for promoting quality assurance and competence in clinical microbiology laboratories, guidelines on blood culture. CONTENT Experience in blood culture accreditation according to International standard ISO 15189 standards is provided in this review, with a particular focus on critical points that are specific to blood culture (e.g. excluding strain identification or antimicrobial susceptibility testing). Blood culture test method verification is based on risk analysis, and evaluation of the test method's performance is based on the literature review and suppliers' data. In addition, blood culture performance relies largely on the quality of its pre-analytical phase, and the test method should be monitored based on key performance indicators such as the volume of blood cultured, the contamination rate and time to transportation. Other critical key indicators include the rate of false-positive signals, the rate of positive blood cultures, the ecology associated with positive results, and the timely communication of the results to the ward during the post-analytical phase. Finally, a critical analysis of quality controls and of the tools needed to improve blood culture monitoring in the future is provided. IMPLICATION Appropriate quality assurance should focus on patient value rather than technical details to provide an appropriate clinical service.
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Köck R, Wüllenweber J, Horn D, Lanckohr C, Becker K, Idelevich EA. Implementation of short incubation MALDI-TOF MS identification from positive blood cultures in routine diagnostics and effects on empiric antimicrobial therapy. Antimicrob Resist Infect Control 2017; 6:12. [PMID: 28101334 PMCID: PMC5237541 DOI: 10.1186/s13756-017-0173-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/10/2017] [Indexed: 12/29/2022] Open
Abstract
Background Results of blood culture (BC) diagnostics should be swiftly available to guide treatment of critically ill patients. Conventional BC diagnostics usually performs species identification of microorganisms from mature solid medium colonies. Species identification might be speed up by using matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) of biomass from shortly incubated solid media. Methods This single-center analysis compared the applicability of MALDI-TOF-based species identification from shortly incubated cultures in laboratory routine vs. conventional diagnostics and assessed its effects of on empiric antibiotic therapy. Results Median time between detection of BCs as “positive” by incubators and further processing (e.g. microscopy) was 6 h 21 min. Median time between microscopy and result reporting to the ward was 15 min. Including 193 BCs, MALDI-TOF from shortly incubated biomass resulted in significantly faster (p > 0.001) species identification. Species results became available for clinicians after a median of 188 min (231 min for Gram-positive bacteria, 151 min for Gram-negative bacteria) compared to 909 min (n = 192 BCs) when conventional diagnostics was used. For 152/179 bacteremia episodes (85%) empiric antibiotic therapy had already been started when the microscopy result was reported to the ward; microscopy led to changes of therapies in 14/179 (8%). In contrast, reporting the bacterial species (without antibiogram) resulted in therapeutic adjustments in 36/179 (20%). Evaluating these changes revealed improved therapies in 26/36 cases (72%). Conclusions Species identification by MALDI-TOF MS from shortly incubated subcultures resulted in adjustments of empiric antibiotic therapies and might improve the clinical outcome of septic patients. Electronic supplementary material The online version of this article (doi:10.1186/s13756-017-0173-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robin Köck
- Institute of Medical Microbiology, University Hospital Münster, Domagkstr. 10, 48149 Münster, Germany ; Present address: Institute of Hospital Hygiene, University of Oldenburg, European Medical School Oldenburg-Groningen, Rahel-Straus-Str. 10, 26133 Oldenburg, Germany
| | - Jörg Wüllenweber
- Institute of Medical Microbiology, University Hospital Münster, Domagkstr. 10, 48149 Münster, Germany
| | - Dagmar Horn
- Pharmacy Department, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Christian Lanckohr
- Department for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Karsten Becker
- Institute of Medical Microbiology, University Hospital Münster, Domagkstr. 10, 48149 Münster, Germany
| | - Evgeny A Idelevich
- Institute of Medical Microbiology, University Hospital Münster, Domagkstr. 10, 48149 Münster, Germany
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Venturelli C, Righi E, Borsari L, Aggazzotti G, Busani S, Mussini C, Rumpianesi F, Rossolini GM, Girardis M. Impact of Pre-Analytical Time on the Recovery of Pathogens from Blood Cultures: Results from a Large Retrospective Survey. PLoS One 2017; 12:e0169466. [PMID: 28046040 PMCID: PMC5207733 DOI: 10.1371/journal.pone.0169466] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 12/16/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Prompt identification of bloodstream pathogens is essential for optimal management of patients. Significant changes in analytical methods have improved the turnaround time for laboratory diagnosis. Less attention has been paid to the time elapsing from blood collection to incubation and to its potential effect on recovery of pathogens. We evaluated the performance of blood cultures collected under typical hospital conditions in relation to the length of their pre-analytical time. METHODS We carried out a large retrospective study including 50,955 blood cultures collected, over a 30-month period, from 7,035 adult septic patients. Cultures were accepted by the laboratory only during opening time (Mon-Fri: 8am-4pm; Sat: 8am-2pm). Samples collected outside laboratory hours were stored at room temperature at clinical wards. All cultures were processed by automated culture systems. Day and time of blood collection and of culture incubation were known for all samples. RESULTS A maximum pre-analytical interval of 2 hours is recommended by guidelines. When the laboratory was open, 57% of cultures were processed within 2 h. When the laboratory was closed, 4.9% of cultures were processed within 2 h (P<0.001). Samples collected when the laboratory was closed showed pre-analytical times significantly longer than those collected when laboratory was open (median time: 13 h and 1 h, respectively, P<0.001). The prevalence of positive cultures was significantly lower for samples collected when the laboratory was closed compared to open (11% vs 13%, P<0.001). The probability of a positive result decreased of 16% when the laboratory was closed (OR:0.84; 95%CI:0.80-0.89, P<0.001). Further, each hour elapsed from blood collection to incubation resulted associated with a decrease of 0.3% (OR:0.997; 95%CI:0.994-0.999, P<0.001) in the probability of a positive result. DISCUSSION Delayed insertions of cultures into automated systems was associated with lower detection rates, with potentially important consequences for patients. In each hospital setting the logistic factors able to shorten pre-analytical time should be carefully investigated and specifically targeted.
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Affiliation(s)
- Claudia Venturelli
- Microbiology and Virology Laboratory, University Hospital of Modena, Modena, Italy
| | - Elena Righi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- * E-mail:
| | - Lucia Borsari
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Gabriella Aggazzotti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Busani
- Anesthesia and Intensive Care Unit, University Hospital of Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Rumpianesi
- Microbiology and Virology Laboratory, University Hospital of Modena, Modena, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Massimo Girardis
- Anesthesia and Intensive Care Unit, University Hospital of Modena and University of Modena and Reggio Emilia, Modena, Italy
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Banerjee R, Özenci V, Patel R. Individualized Approaches Are Needed for Optimized Blood Cultures. Clin Infect Dis 2016; 63:1332-1339. [PMID: 27558570 DOI: 10.1093/cid/ciw573] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 08/14/2016] [Indexed: 01/12/2023] Open
Abstract
Many strategies and technologies are available to improve blood culture (BC)-based diagnostics. The ideal approach to BCs varies between healthcare institutions. Institutions need to examine clinical needs and practices in order to optimize BC-based diagnostics for their site. Before laboratories consider offering rapid matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-ToF MS) or expensive rapid panel-based molecular BC diagnostics, they should optimize preanalytical, analytical, and postanalytical processes and procedures surrounding BC systems. Several factors need to be considered, including local resistance rates, antibiotic prescribing patterns, patient- and provider-types, laboratory staffing, and personnel available to liaise with clinicians to optimize antibiotic use. While there is much excitement surrounding new high-technology diagnostics, cost-neutral benefits can be realized by optimizing existing strategies and using available tools in creative ways. Rapid BC diagnostics should be implemented in a manner that optimizes impact. Strategies to optimize these BC diagnostics in individual laboratories are presented here.
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Affiliation(s)
- Ritu Banerjee
- Department of Pediatric Infections Diseases, Vanderbilt University, Nashville, Tennessee
| | - Volkan Özenci
- Division of Clinical Microbiology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology.,Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Lamy B, Dargère S, Arendrup MC, Parienti JJ, Tattevin P. How to Optimize the Use of Blood Cultures for the Diagnosis of Bloodstream Infections? A State-of-the Art. Front Microbiol 2016; 7:697. [PMID: 27242721 PMCID: PMC4863885 DOI: 10.3389/fmicb.2016.00697] [Citation(s) in RCA: 236] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/26/2016] [Indexed: 11/13/2022] Open
Abstract
Bloodstream infection (BSI) is a major cause of death in developed countries and the detection of microorganisms is essential in managing patients. Despite major progress has been made to improve identification of microorganisms, blood culture (BC) remains the gold standard and the first line tool for detecting BSIs. Consensus guidelines are available to ensure optimal BSI procedures, but BC practices often deviate from the recommendations. This review provides an update on clinical and technical issues related to blood collection and to BC performance, with a special focus on the blood sample strategy to optimize the sensitivity and specificity of BCs.
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Affiliation(s)
- Brigitte Lamy
- Laboratoire de Bactériologie, CHU Montpellier Montpellier, France
| | | | - Maiken C Arendrup
- Unit for Mycology, Department of Microbiology & Infection Control, Statens Serum Institut Copenhagen, Denmark
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Bignardi GE, Berrington A, Koerner R, Settle C. Immediate incubation of blood cultures is critical to bring about better bacteremia outcomes. J Infect 2014; 70:546. [PMID: 25530468 DOI: 10.1016/j.jinf.2014.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 12/13/2014] [Indexed: 11/19/2022]
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Identification of microorganisms by FilmArray and matrix-assisted laser desorption ionization-time of flight mass spectrometry prior to positivity in the blood culture system. J Clin Microbiol 2014; 52:3230-6. [PMID: 24951811 DOI: 10.1128/jcm.01084-14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In this study, we investigated the performance of the FilmArray and matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) in identifying microorganisms from blood culture (BC) bottles prior to positivity. First, we used simulated BacT/Alert FA Plus BC bottles with five each for Escherichia coli and Staphylococcus aureus isolates. The FilmArray identified all 10 isolates before BC positivity with 9/10 at 5 h and 1 at 7.5 h after incubation in the BC system. MALDI-TOF MS failed to identify the isolates prior to positivity. When the bottles were incubated for 2.5 h at room temperature (RT) before we put them into the BC system, the FilmArray identified 6/10 at 2.5 h and the remaining 4 at 5 h. Finally, we tested simulated BC bottles after incubation at RT. Interestingly, 9/10 isolates were identified with the FilmArray after 8 h of incubation at RT. Second, we studied clinical BC bottles in quadruplicate. When three-fourths of the parallel bottles signaled positive, the FilmArray was run on the fourth nonsignaled bottle and was found to be positive in 14/15 such cases. Third, we analyzed the performance of the FilmArray in the identification of microorganisms from clinical BC bottles before incubation in the system. Two milliliters of broth from 400 BC bottles was collected after arrival at the laboratory and stored at -70°C. Sixteen bottles later signaled positive in the system. When the frozen broth from these bottles was analyzed, the FilmArray identified all the microorganisms in 8/16 bottles prior to incubation in the BC system. This study shows that the FilmArray can identify microorganisms from BC bottles prior to positivity and in some cases even prior to incubation in the BC system.
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Clinical evaluation of the FilmArray blood culture identification panel in identification of bacteria and yeasts from positive blood culture bottles. J Clin Microbiol 2013; 51:4130-6. [PMID: 24088863 DOI: 10.1128/jcm.01835-13] [Citation(s) in RCA: 204] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The FilmArray platform (FA; BioFire, Salt Lake City, UT) is a closed diagnostic system allowing high-order multiplex PCR analysis with automated readout of results directly from positive blood cultures in 1 h. In the present study, we evaluated the clinical performance of the FilmArray blood culture identification (BCID) panel, which includes 19 bacteria, five yeasts, and three antibiotic resistance genes. In total, 206 blood culture bottles were included in the study. The FilmArray could identify microorganisms in 153/167 (91.6%) samples with monomicrobial growth. Thirteen of the 167 (7.8%) microorganisms were not covered by the FilmArray BCID panel. In 6/167 (3.6%) samples, the FilmArray detected an additional microorganism compared to blood culture. When polymicrobial growth was analyzed, the FilmArray could detect all target microorganisms in 17/24 (71%) samples. Twelve blood culture bottles that yielded a positive signal but showed no growth were also negative by FilmArray. In 3/206 (1.5%) bottles, the FilmArray results were invalid. The results of the FilmArray were reproducible, as demonstrated by the testing and retesting of five bottles in the same day and a longitudinal follow-up of five other blood cultures up to 4 weeks. The present study shows that the FilmArray is a rapid identification method with high performance in direct identification of bacteria and yeasts from positive blood culture bottles.
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