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Mermel LA, Rupp ME. Should Blood Cultures Be Drawn Through an Indwelling Catheter? Open Forum Infect Dis 2024; 11:ofae248. [PMID: 38770214 PMCID: PMC11103617 DOI: 10.1093/ofid/ofae248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/30/2024] [Indexed: 05/22/2024] Open
Abstract
There is no practical way to definitively diagnose a catheter-related bloodstream infection in situ if blood cultures are only obtained percutaneously unless there is the rare occurrence of purulent drainage from a central venous catheter insertion site. That is why the Infectious Diseases Society of America guidelines for diagnosis and management of catheter-related bloodstream infections and Infectious Diseases Society of America guidelines for evaluation of fever in critically ill patients both recommend drawing blood cultures from a central venous catheter and percutaneously if the catheter is a suspected source of infection. However, central venous catheter-drawn blood cultures may be more likely to be positive reflecting catheter hub, connector, or intraluminal colonization, and many hospitals in the United States discourage blood culture collection from catheters in an effort to reduce reporting of central-line associated bloodstream infections to the Centers for Disease Control and Prevention. As such, clinical decisions are made regarding catheter removal or other therapeutic interventions based on incomplete and potentially inaccurate data. We urge clinicians to obtain catheter-drawn blood cultures when the catheter may be the source of suspected infection.
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Affiliation(s)
- Leonard A Mermel
- Division of Infectious Diseases, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Epidemiology and Infection Prevention, Lifespan Hospital System, Providence, Rhode Island, USA
| | - Mark E Rupp
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Zhao Z, Wang Y, Kang Y, Wu G, He J, Wang Z, Yang J, Wang Y, Yang X, Jia W. A retrospective study of the detection of sepsis pathogens comparing blood culture and culture-independent digital PCR. Heliyon 2024; 10:e27523. [PMID: 38510040 PMCID: PMC10951527 DOI: 10.1016/j.heliyon.2024.e27523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 02/22/2024] [Accepted: 03/01/2024] [Indexed: 03/22/2024] Open
Abstract
Fast and precise identification of microorganisms in the early diagnosis of sepsis is crucial for enhancing patient outcomes. Digital PCR (dPCR) is a highly sensitive approach for absolute quantification that can be utilized as a culture-independent molecular technique for diagnosing sepsis pathogens. We performed a retrospective investigation on 69 ICU patients suspected of sepsis. Our findings showed that a multiplex dPCR diagnostic kit outperformed blood culture in detecting the 15 most frequent bacteria that cause sepsis. Ninety-two bacterial strains were identified using dPCR at concentrations varying from 34 copies/mL to 105,800 copies/mL. The detection rate of dPCR was much greater than that of BC, with 27.53% (19/69) versus 73.91% (51/69). The sensitivity of dPCR was 63.2%. Our research indicated that dPCR outperforms blood culture in the early detection of sepsis-causing microorganisms. The diagnostic kit can detect a greater variety of pathogens with quantitative data, including polymicrobial infections, and has a quicker processing time. DPCR is a valuable technique that could aid in the proper management of sepsis.
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Affiliation(s)
- Zhijun Zhao
- Medical Laboratory Center, General Hospital of Ningxia Medical University, Yinchuan, China
- Ningxia Key Laboratory of Clinical Pathogenic Microorganisms, Yinchuan, China
| | - Yixuan Wang
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
- Ningxia Key Laboratory of Clinical Pathogenic Microorganisms, Yinchuan, China
| | - Yuting Kang
- Ningxia Key Laboratory of Clinical Pathogenic Microorganisms, Yinchuan, China
| | - Geng Wu
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Jing He
- Department of Research and Development, Rainsure Scientific Co. Ltd., Suzhou, China
| | - Zhanying Wang
- Department of Research and Development, Rainsure Scientific Co. Ltd., Suzhou, China
| | - Ju Yang
- Department of Research and Development, Rainsure Scientific Co. Ltd., Suzhou, China
| | - Yaqi Wang
- Department of Research and Development, Rainsure Scientific Co. Ltd., Suzhou, China
| | - Xiaojun Yang
- Department of Critical Care Medicine, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Wei Jia
- Medical Laboratory Center, General Hospital of Ningxia Medical University, Yinchuan, China
- Ningxia Key Laboratory of Clinical Pathogenic Microorganisms, Yinchuan, China
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Toth C, Miller K, Hart A, Kidd M. Clinical Nurse Specialist Role Advocacy: Quantifying the Financial Contributions Via Development of a Scorecard. CLIN NURSE SPEC 2024; 38:91-97. [PMID: 38364069 DOI: 10.1097/nur.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
PURPOSE/OBJECTIVES The purpose of this article is to guide the clinical nurse specialist in constructing a scorecard to track clinical outcomes and identify the associated financial impact. DESCRIPTION OF THE PROJECT/PROGRAM Creation of a scorecard highlighting the financial impact of the clinical nurse specialist team was used to disseminate financial outcomes to hospital executive stakeholders, allowing the clinical nurse specialist team to demonstrate its clinical and financial value. OUTCOME During development and ongoing maintenance of the scorecard, the clinical nurse specialist team cultivated skills to identify the financial impact of projects. The team also utilized financial implications of individual and group projects to prioritize work. At the end of fiscal year 2022, the clinical nurse specialist team demonstrated revenue generation of $29 890 and cost avoidance of $2 854 807.30. The clinical nurse specialist scorecard was presented quarterly to the chief nursing officer, who shared with executive leadership. CONCLUSION Clinical nurse specialists are positioned to make significant and positive financial impact to organizations. A scorecard presented to executive leadership offers a clinical nurse specialist team a tool to capture and disseminate a clinical nurse specialist team's unique financial contribution at the system level.
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Affiliation(s)
- Chantal Toth
- Author Affiliations: Lead Clinical Nurse Specialist (Ms Toth), Clinical Nurse Specialist, Oncology and Infusion Therapy (Ms Miller), Clinical Nurse Specialist, Sepsis/Emergency Department (Ms Hart), and Clinical Nurse Specialist (Mr Kidd), Reading Hospital-Tower Health, West Reading, Pennsylvania
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Kumthekar I, Urs T, Rajashekar D, Karthik K. Effectiveness of Multimodal Intervention to Improve Blood Culture Collection in a Tertiary Care Hospital. Cureus 2024; 16:e53941. [PMID: 38468984 PMCID: PMC10925844 DOI: 10.7759/cureus.53941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2024] [Indexed: 03/13/2024] Open
Abstract
Introduction and methods Blood culturing has become one of the backbone investigations for septicemia, fever of unknown origin, etc. This study was conducted to test the effect of multimodal interventions on the practical skills of healthcare workers (HCWs), raise awareness regarding the importance of aseptic blood culture collection practices, and increase compliance with the specific steps to be followed. Hence, this current interventional study was aimed at comparing the rate of isolation of contaminants grown among the blood culture specimens, assessing the knowledge, attitude, and practice (KAP) of HCWs collecting the blood culture specimen on various aspects of sample collection, educating the nursing staff regarding blood sample collection using a structured, pre-formed checklist, and emphasizing best practices for blood culture collection. All of the study's objectives were successfully met within the time frame specified. Using a pre-formed checklist and a Google form for KAP analysis eased the calculation. Results On analysis, the blood culture contamination rate in the pre-interventional phase dropped drastically from 6.16% to 3.03% in the post-interventional phase. The educational sessions conducted are a paramount reason for the reduction in the contamination rate. The HCWs were the least compliant towards the eighth step in the checklist (regarding palpation of skin); however, that too increased from 66.93% and 64.51% to a whopping 82.25% and 83.06%, respectively, with a chi-square value of 0.03 and a p-value of 0.85 (not significant). Conclusion Implementation of interventional studies as an audit like this in tertiary care hospitals can result in a significant reduction in blood culture contamination rates and can also improve the compliance of HCWs with blood culture protocols. This, in turn, can overall improve the effectiveness of blood culture (BC) testing and reduce mortality and morbidity in tertiary care hospitals. Further research can be conducted to brainstorm more methods to increase the compliance of HCWs. Better monitoring strategies can also be set to ensure low contamination rates. Additionally, some other methods can be derived to locate the source of contamination within the hospital environment and thus eliminate it. Similar interventions can be conducted for a longer duration of time to further reduce the blood culture contamination rate below 3% (as per the recommendations).
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Affiliation(s)
- Isha Kumthekar
- Department of Microbiology, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, IND
| | - Tejashree Urs
- Department of Microbiology, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, IND
| | - Deepashree Rajashekar
- Department of Microbiology, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, IND
| | - Krishna Karthik
- Department of Microbiology, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, IND
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Wilber EP, Babiker A, Howard-Anderson J, Holdsworth JE, Burd EM, Eldridge MJ, Jacob JT. Effect of an initial specimen diversion device on blood-culture contamination rates and vancomycin usage: A quasi-experimental study. Infect Control Hosp Epidemiol 2024; 45:100-102. [PMID: 37534438 PMCID: PMC10782199 DOI: 10.1017/ice.2023.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/18/2023] [Indexed: 08/04/2023]
Abstract
Initial specimen diversion devices (ISDDs) are a potential solution for reducing blood-culture contamination rates. We report the implementation of an ISDD associated with a sustained reduction in blood-culture contamination rates for >18 months after implementation. We did not observe a clinically significant reduction in inpatient vancomycin usage.
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Affiliation(s)
- Eli P. Wilber
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ahmed Babiker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, AtlantaGeorgia
| | - Jessica Howard-Anderson
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Eileen M. Burd
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, AtlantaGeorgia
| | - M. Jeremy Eldridge
- Department of Emergency Services, Emory University Hospital Midtown, Atlanta, Georgia
| | - Jesse T. Jacob
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Pehlivan J, Douillet D, Jérémie R, Perraud C, Niset A, Eveillard M, Chenouard R, Mahieu R. A clinical decision rule to rule out bloodstream infection in the emergency department: retrospective multicentric observational cohort study. Emerg Med J 2023; 41:20-26. [PMID: 37940371 DOI: 10.1136/emermed-2022-212987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND We aimed to identify patients at low risk of bloodstream infection (BSI) in the ED. METHODS We derived and validated a prediction model to rule out BSI in the ED without the need for laboratory testing by determining variables associated with a positive blood culture (BC) and assigned points according to regression coefficients. This retrospective study included adult patients suspected of having BSI (defined by at least one BC collection) from two European ED between 1 January 2017 and 31 December 2019. The primary end point was the BSI rate in the validation cohort for patients with a negative Bacteremia Rule Out Criteria (BAROC) score. The effect of adding laboratory variables to the model was evaluated as a second step in a two-step diagnostic strategy. RESULTS We analysed 2580 patients with a mean age of 64 years±21, of whom 46.1% were women. The derived BAROC score comprises 12 categorical clinical variables. In the validation cohort, it safely ruled out BSI without BCs in 9% (58/648) of patients with a sensitivity of 100% (95% CI 95% to 100%), a specificity of 10% (95% CI 8% to 13%) and a negative predictive value of 100% (95% CI 94% to 100%). Adding laboratory variables (creatinine ≥177 µmol/L (2.0 mg/dL), platelet count ≤150 000/mm3 and neutrophil count ≥12 000/mm3) to the model, ruled out BSI in 10.2% (58/570) of remaining patients who had been positive on the BAROC score. The BAROC score with laboratory results had a sensitivity of 100% (95% CI 94% to 100%), specificity of 11% (95% CI 9% to 14%) and negative predictive value of 100% (95% CI 94 to 100%). In the validation cohort, there was no evidence of a difference in discrimination between the area under the receiver operating characteristic for BAROC score with versus without laboratory testing (p=0.6). CONCLUSION The BAROC score safely identified patients at low risk of BSI and may reduce BC collection in the ED without the need for laboratory testing.
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Affiliation(s)
- Jonathan Pehlivan
- Service de maladies infectieuses et tropicales, Centre hospitalier universitaire d'Angers, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Delphine Douillet
- Emergency Department, Angers University Hospital, CHU Angers, Angers, France
- UMR MitoVasc CNRS 6015-INSERM 1083, University of Angers, Angers, France
| | - Riou Jérémie
- Micro et Nano médecines translationnelles, MINT, UMR INSERM 1066, UMR CNRS 6021, University of Angers, Angers, France
- Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, CHU Angers, Angers, France
| | - Clément Perraud
- Emergency Department, Angers University Hospital, CHU Angers, Angers, France
| | - Alexandre Niset
- Emergency Department, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Hopital à Bruxelles-Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Matthieu Eveillard
- Laboratoire de Bactériologie, Institut de Biologie en Santé-PBH, CHU Angers, Angers, France
| | - Rachel Chenouard
- Laboratoire de Bactériologie, Institut de Biologie en Santé-PBH, CHU Angers, Angers, France
| | - Rafael Mahieu
- Service de maladies infectieuses et tropicales, Centre hospitalier universitaire d'Angers, CHU Angers Maladies infectieuses et tropicales, Angers, France
- Faculty of Medicine, Université de Nantes, Inserm, CRCINA, SFR ICAT, University of Angers, Angers, France
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Ku TSN, Al Mohajer M, Newton JA, Wilson MH, Monsees E, Hayden MK, Messacar K, Kisgen JJ, Diekema DJ, Morgan DJ, Sifri CD, Vaughn VM. Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship. Infect Control Hosp Epidemiol 2023; 44:1901-1908. [PMID: 37665212 DOI: 10.1017/ice.2023.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the "Four Moments of Antibiotic Decision Making" created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.
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Affiliation(s)
- Tsun Sheng N Ku
- Billings Clinic, Billings, Montana
- Rocky Vista University Montana College of Osteopathic Medicine, Billings, Montana
| | - Mayar Al Mohajer
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Infectious Diseases Section, Baylor St. Luke's Medical Center, Houston, Texas
- Infection Prevention, Diagnostic Stewardship and Antibiotic Stewardship, CommonSpirit Health Texas Division, Houston, Texas
| | - James A Newton
- Department of Antibiotic Stewardship, Washington Regional Medical Center, Fayetteville, Arkansas
| | - Marie H Wilson
- Infection Prevention & Control, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Elizabeth Monsees
- Performance Excellence, Children's Mercy Hospital, Kansas City, Missouri
- University of Missouri School of Medicine, Kansas City, Missouri
| | - Mary K Hayden
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Kevin Messacar
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado/Children's Hospital Colorado, Aurora, Colorado
| | | | - Daniel J Diekema
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Maine Medical Center, Portland, Maine
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
- VA Maryland Healthcare System, Baltimore, Maryland
| | - Costi D Sifri
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Perry C, Alsbrooks K, Mares A, Hoerauf K. Comparison of Clinical, Economic, and Humanistic Outcomes Between Blood Collection Approaches: A Systematic Literature Review. J Healthc Qual 2023; 45:359-370. [PMID: 37788441 PMCID: PMC10624413 DOI: 10.1097/jhq.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND A systematic literature review was performed to understand the prevalence, advantages, and disadvantages of blood collection using different approaches (direct venipuncture or vascular access devices), and interventions used to mitigate the disadvantages. METHODS The review included a broad range of study designs and outcomes. Database searches (Embase, MEDLINE, Cochrane library, and Centre for Reviews and Dissemination) were conducted in March 2021 and supplemented by hand searching. RESULTS One hundred forty-one publications were included. The data indicate that blood sampling from vascular access devices is common in emergency departments, trauma centers, and intensive care units. Studies showed that hemolysis and sample contamination place a considerable economic burden on hospitals. Significant cost savings could be made through enforcing strict aseptic technique, or using the initial specimen diversion technique. CONCLUSIONS Hemolysis and sample contamination are far from inevitable in vascular access device-collected or venipuncture samples; both can be reduced through adherence to strict blood sampling protocols and utilization of the initial specimen diversion technique. Needle-free blood collection devices offer further hope for reducing hemolysis. No publication focused on the difficult venous access population; insertion success rates are likely to be lower (and the benefits of vascular access devices higher) in these patients.
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Callado GY, Lin V, Thottacherry E, Marins TA, Martino MDV, Salinas JL, Marra AR. Diagnostic Stewardship: A Systematic Review and Meta-analysis of Blood Collection Diversion Devices Used to Reduce Blood Culture Contamination and Improve the Accuracy of Diagnosis in Clinical Settings. Open Forum Infect Dis 2023; 10:ofad433. [PMID: 37674630 PMCID: PMC10478151 DOI: 10.1093/ofid/ofad433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/09/2023] [Indexed: 09/08/2023] Open
Abstract
Background Blood culture contamination may lead to misdiagnosis, overutilization of antibiotics, and prolonged length of stay. Blood specimen diversion devices can reduce contamination rates during blood culture collection procedures. We performed a systematic literature review and meta-analysis evaluating the influence of blood specimen diversion devices in blood culture contamination rates. Methods We searched Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Scopus, and Web of Science, from database inception to 1 March 2023, for studies evaluating the impact of a diversion device on blood culture contamination. Blood culture contamination was a positive blood culture with microorganisms not representative of true bacteremia, but rather introduced during collection or processing the blood sample. Random-effects models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 test. Results Of 1768 screened studies, 12 met inclusion criteria for this systematic literature review. Of them, 9 studies were included in the meta-analysis. Studies were substantially heterogeneous, but stratified analyses considering only high-quality studies revealed that venipuncture using a diversion device was associated with a significant reduction in blood culture contamination in comparison to the standard procedure of collection (pooled odds ratio [OR], 0.26 [95% confidence interval {CI}, .13-.54]; I2 = 19%). Furthermore, the stratified analysis showed that the adoption of a diversion device did not reduce the detection of true infection (pooled OR, 0.85 [95% CI, .65-1.11]; I2 = 0%). Conclusions Blood culture diversion devices was associated with decreased contamination rates and could improve quality of care, reduce costs, and avoid unnecessary antibiotic use.
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Affiliation(s)
- Gustavo Yano Callado
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Vivian Lin
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Elizabeth Thottacherry
- Division of Infectious Diseases & Geographic Medicine, Stanford University, Stanford, California, USA
| | - Tássia Aporta Marins
- Faculdade de Medicina, Centro Universitário de Adamantina, Adamantina, São Paulo, Brazil
| | - Marinês Dalla Valle Martino
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Jorge L Salinas
- Division of Infectious Diseases & Geographic Medicine, Stanford University, Stanford, California, USA
| | - Alexandre R Marra
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Wiener-Well Y, Levin PD, Assous MV, Algur N, Barchad OW, Lachish T, Zalut T, Yinnon AM, Ben-Chetrit E. The use of a diversion tube to reduce blood culture contamination: A "real-life" quality improvement intervention study. Am J Infect Control 2023; 51:999-1003. [PMID: 36905985 DOI: 10.1016/j.ajic.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Blood culture contamination is associated with health care costs and potential patient harm. Diversion of the initial blood specimen reduces blood culture contamination. We report results of the "real-life" clinical implementation of this technique. METHODS Following an educational campaign, use of a dedicated diversion tube was recommended prior to all blood cultures. Blood culture sets taken from adults using a diversion tube were defined as "diversion sets," those without, "non-diversion" sets. Blood culture contamination and true positive rates were compared for diversion and nondiversion sets and to nondiversion historical controls. A secondary analysis investigated efficacy of diversion by patient age. RESULTS Out of 20,107 blood culture sets drawn, the diversion group included 12,774 (60.5%) and the nondiversion group 8,333 (39.5%) sets. The historical control group included 32,472 sets. Comparing nondiversion to diversion, contamination decreased by 31% (5.5% [461/8333] to 3.8% [489/12744], P < .0001]. Contamination was also 12% lower in diversion than historical controls [3.8% (489/12744) vs 4.3% (1,396/33,174) P = .02)]. The rate of true bacteremia was similar. In older patients, contamination rate was higher, and the relative reduction associated with diversion decreased (54.3% amongst 20-40-year-olds vs 14.5% amongst >80-year-olds). CONCLUSIONS Use of a diversion tube in the ED reduced blood culture contamination in this large real life observational study. Efficacy decreased with increasing age, which requires further investigation.
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Affiliation(s)
- Yonit Wiener-Well
- Infectious Diseases Unit, Shaare Zedek Medical Center and faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Phillip D Levin
- Intensive Care Unit, Shaare Zedek Medical Center and faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Marc V Assous
- Clinical Microbiology Laboratory, Shaare Zedek Medical Center and faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nurit Algur
- Clinical Microbiology Laboratory, Shaare Zedek Medical Center and faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Orit Wolfovitz Barchad
- Infectious Diseases Unit, Shaare Zedek Medical Center and faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tamar Lachish
- Infectious Diseases Unit, Shaare Zedek Medical Center and faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Todd Zalut
- Emergency Department, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amos M Yinnon
- Infectious Diseases Unit, Shaare Zedek Medical Center and faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eli Ben-Chetrit
- Infectious Diseases Unit, Shaare Zedek Medical Center and faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Tompkins LS, Tien V, Madison AN. Getting to zero: Impact of a device to reduce blood culture contamination and false-positive central-line-associated bloodstream infections. Infect Control Hosp Epidemiol 2023; 44:1386-1390. [PMID: 36539993 PMCID: PMC10507495 DOI: 10.1017/ice.2022.284] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess the impact of initial specimen diversion device (ISDD) on inpatient and emergency department blood culture contamination (BCC), central-line-associated bloodstream infection (CLABSI) standardized infection ratios (SIRs), and antibiotic administration. DESIGN Single-center quasi-experimental prospective cohort study wherein phlebotomists used traditional venipuncture with or without the ISDD while registered nurses (RNs) used traditional venipuncture. METHOD BCC events among phlebotomists and RNs were observed and compared from March 17, 2019, through January 21, 2020, defined by contaminant detection in 1 of 4 bottles for matched sets or 1 of 2 bottles in both subsets for coagulase negative staphylococci. CLABSIs throughout this period were recorded and SIRs were calculated. Enhanced oversight took place through July 21, 2019, with chart review assessing antibiotic use for patients with possible BCC. RESULTS Overall, 24% of blood cultures obtained were from patients in intensive care. Phlebotomists using traditional venipuncture (n = 4,759) had a 2.3% BCC rate; phlebotomists using the ISDD (n = 11,202) had a 0% BCC rate. RNs drew 7,411 BCs with a 0.8% BCC rate. The CLABSI SIR was decreased from 1.103 in 2017 and 0.658 in 2018 to 0.439 in 2019. The CLABSI incidence was 33%-64% of predicted value for each 2019 quarter. This range fell to 18%-37% after the exclusion of likely false-positive results. Among 42 patients with possible BCC under enhanced oversight, 2 patients were treated with prolonged antibiotic courses. CONCLUSIONS ISDD use by phlebotomists was associated with BCC reduction and reduced false-positive CLABSI results. This patient-care quality improvement could constitute sustainable antibiotic stewardship expansion.
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Affiliation(s)
- Lucy S. Tompkins
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
- Department of Infection Prevention and Control, Stanford Health Care, Stanford, California
| | - Vivian Tien
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Alexandra N. Madison
- Department of Infection Prevention and Control, Stanford Health Care, Stanford, California
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12
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Hancock JA, Campbell S, Jones MM, Wang-Rodriguez J, Klutts JS. Development and validation of a standardized blood culture contamination definition and metric dashboard for a large health care system. Am J Clin Pathol 2023; 160:255-260. [PMID: 37167032 DOI: 10.1093/ajcp/aqad044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 03/23/2023] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVES Blood culture contamination is a major problem in health care, with significant impacts on both patient safety and cost. Initiatives to reduce blood culture contamination require a reliable, consistent metric to track the success of interventions. The objective of our project was to establish a standardized definition of blood culture contamination suitable for use in a Veterans Health Administration (VHA) national data query, then to validate this definition and query. A secondary objective was to construct a national VHA data dashboard to display the data from this query that could be used in VHA quality improvement projects aimed at reducing blood culture contamination. METHODS A VHA microbiology expert work group was formed to generate a standardized definition and oversee the validation studies. The standardized definition was used to generate data for calendar year 2021 using a Structured Query Language data query. Twelve VHA hospital microbiology laboratories compared the data from the query against their own locally derived contamination data and recorded those data in a data collection worksheet that all sites used. Data were collated and presented to the work group. RESULTS More than 50,000 blood culture accessions were in the validation data set, with more than 1,200 contamination events. The overall blood culture contamination rate for the 12 facilities participating was 2.56% with local definitions and data and 2.43% with the standardized definitions and data query. The main differences noted between the 2 data sets were deemed to be issues in local definitions. The query and definition were then converted into a national data dashboard that all VHA facilities can now access. CONCLUSIONS A standardized definition for blood culture contamination and a national data query were validated for enterprise-wide VHA use. To our knowledge, this represents the first reported standardized, validated, and automated approach for calculating and tracking blood culture contamination. This tool will be key in quality initiatives aimed at reducing contamination events in VHA.
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Affiliation(s)
| | - Sheldon Campbell
- VA Connecticut Healthcare System, West Haven, CT, US
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US
| | - Makoto M Jones
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, US
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, US
| | - Jessica Wang-Rodriguez
- National VHA Diagnostics Office, Washington DC, US
- Department of Pathology, University of California San Diego, La Jolla, CA, US
| | - J Stacey Klutts
- National VHA Diagnostics Office, Washington DC, US
- Iowa City VA Healthcare System, Iowa City, IA, US
- University of Iowa Carver College of Medicine, Iowa City, IA, US
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13
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Aiesh BM, Daraghmeh D, Abu-Shamleh N, Joudallah A, Sabateen A, Al Ramahi R. Blood culture contamination in a tertiary care hospital: a retrospective three-year study. BMC Infect Dis 2023; 23:448. [PMID: 37403044 DOI: 10.1186/s12879-023-08428-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 06/26/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Bloodstream infections (BSI) are a leading cause of morbidity and mortality in hospitalized patients worldwide. A blood culture is the primary tool for determining whether a patient has BSI and requires antimicrobial therapy, but it can result in an inappropriate outcome if the isolated microorganisms are deemed contaminants from the skin. Despite the development of medical equipment and technology, there is still a percentage of blood culture contamination. The aims of this study were to detect the blood culture contamination (BCC) rate in a tertiary care hospital in Palestine and to identify the departments with the highest rates along with the microorganisms isolated from the contaminated blood samples. METHOD Blood cultures that were taken at An-Najah National University Hospital between January 2019 and December 2021 were evaluated retrospectively. Positive blood cultures were classified as either true positives or false positives based on laboratory results and clinical pictures. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) version 21. A p-value of less than 0.05 was considered statistically significant for all analyses. RESULTS Out of 10,930 blood cultures performed in the microbiology laboratory from 2019 to 2021, 1479 (13.6%) were identified as positive blood cultures that showed microbial growth. Of these, 453 were blood culture contaminations, representing 4.17% of total blood cultures and 30.63% of the positive blood culture samples. The highest rate of contamination was in the hemodialysis unit (26.49%), followed by the emergency department (15.89%). Staphylococcus epidermidis was the most prevalent (49.2%), followed by Staphylococcus hominis (20.8%) and Staphylococcus haemolyticus (13.2%). The highest annual contamination rate was observed in 2019 (4.78%) followed by 2020 (3.95%) and the lowest was in 2021 (3.79%). The rate of BCC was decreasing, although it did not reach statistically significant levels (P value = 0.085). CONCLUSION The rate of BCC is higher than recommended. The rates of BCC are different in different wards and over time. Continuous monitoring and performance improvement projects are needed to minimize blood culture contamination and unnecessary antibiotic use.
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Affiliation(s)
- Banan M Aiesh
- Infection Control Department, An-Najah National University Hospital, Nablus, Palestine
| | - Duha Daraghmeh
- Department of Pharmacy, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Nasreen Abu-Shamleh
- Department of Pharmacy, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Abdalmenem Joudallah
- Department of Pharmacy, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Ali Sabateen
- Infection Control Department, An-Najah National University Hospital, Nablus, Palestine
| | - Rowa' Al Ramahi
- Department of Pharmacy, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine.
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14
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Mahieu R, Lemarié C, Douillet D, Mercat A, Cormier H, Eveillard M, Dubée V, Riou J, Kouatchet A. Impact of a strategy based on unique blood culture sampling on contamination rate and detection of bloodstream infections in critically ill patients. Ann Intensive Care 2023; 13:13. [PMID: 36867272 PMCID: PMC9984630 DOI: 10.1186/s13613-023-01107-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/05/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Unique blood culture (UBC) has been proposed to limit the number of venipuncture and to decrease the risk of BC contaminations (BCC) without affecting their yield. We hypothesized that a multi-faceted program based on UBC in the ICU may reduce the rate of contaminants with a similar performance for bloodstream infections (BSI) identification. METHODS In a before and after design, we compared the proportion of BSI and BCC. A first 3-year period with multi-sampling (MS) strategy followed by a 4-month washout period, where staff received education and training for using UBC, and a 32-month period, where UBC was routinely used, while education and feedback were maintained. During the UBC period, a large volume of blood (40 mL) was sampled through a unique venipuncture with additional BC collections discouraged for 48 h. RESULTS Of the 4,491 patients included (35% female patients, mean age 62 years) 17,466 BC were collected. The mean volume of blood per bottle collected increased from 2.8 ± 1.8 mL to 8.2 ± 3.9 mL between the MS and UBC periods, P < 0.01. A 59.6% reduction (95% CI 56.7-62.3; P < 0.001) of BC bottles collected per week was observed between the MS and UBC periods. The rate of BCC per patient decreased between the two periods from 11.2% to 3.8% (73.4% reduction; P < 0.001) for the MS and UBC periods, P < 0.001. Meanwhile, the rate of BSI per patient remained stable at 13.2% and 13.2% for the MS and UBC periods, P = 0.98. CONCLUSIONS In ICU patients, a strategy based on UBC reduces the contamination rate of cultures without affecting their yield.
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Affiliation(s)
- Rafael Mahieu
- Department of Infectious Diseases, Angers University Hospital, 4 Rue Larrey, 49933 Cedex, Angers, France. .,CRCINA, Inserm, Univ Angers, Université́ de Nantes, SFR ICAT, 49000, Angers, France.
| | - Carole Lemarié
- grid.411147.60000 0004 0472 0283Laboratoire de Bactériologie, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Delphine Douillet
- grid.411147.60000 0004 0472 0283Emergency Department, Angers University Hospital, Univ Angers, Angers, France ,grid.7252.20000 0001 2248 3363UMR MitoVasc CNRS 6015 - INSERM 1083, Health Faculty, Univ Angers, FCRIN, INNOVTE, Angers, France
| | - Alain Mercat
- grid.411147.60000 0004 0472 0283Department of Medical Intensive Care, University Hospital, Angers, France
| | - Hélène Cormier
- grid.411147.60000 0004 0472 0283Department of Infectious Diseases, Angers University Hospital, 4 Rue Larrey, 49933 Cedex Angers, France
| | - Matthieu Eveillard
- grid.7252.20000 0001 2248 3363CRCINA, Inserm, Univ Angers, Université́ de Nantes, SFR ICAT, 49000 Angers, France ,grid.411147.60000 0004 0472 0283Laboratoire de Bactériologie, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Vincent Dubée
- grid.411147.60000 0004 0472 0283Department of Infectious Diseases, Angers University Hospital, 4 Rue Larrey, 49933 Cedex Angers, France ,grid.7252.20000 0001 2248 3363CRCINA, Inserm, Univ Angers, Université́ de Nantes, SFR ICAT, 49000 Angers, France
| | - Jérémie Riou
- grid.7252.20000 0001 2248 3363MINT, UMR INSERM 1066, UMR CNRS 6021, UNIV Angers, Micro Et Nano Médecines Translationnelles, Angers, France ,grid.411147.60000 0004 0472 0283Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, 49100 Angers, France
| | - Achille Kouatchet
- grid.411147.60000 0004 0472 0283Department of Medical Intensive Care, University Hospital, Angers, France
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15
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Andrei AI, Popescu GA, Popoiu MA, Mihai A, Tălăpan D. Changes in Use of Blood Cultures in a COVID-19-Dedicated Tertiary Hospital. Antibiotics (Basel) 2022; 11. [PMID: 36551351 DOI: 10.3390/antibiotics11121694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/17/2022] [Accepted: 11/23/2022] [Indexed: 11/26/2022] Open
Abstract
Blood cultures should be collected within an hour in the setting of sepsis/septic shock. The contamination rate should be below 3%. Worldwide reports have described an increase in blood contamination rates during the COVID-19 pandemic. We performed a retrospective analysis of the blood cultures collected during a 10-month period (March−December 2020) at NIID “Prof. Dr. Matei Balș”. The results were compared with data from the pre-pandemic period (March−December 2016) and with the existing data in the literature. During the pandemic, there was a significant decrease in the number of blood cultures collected (1274 blood cultures in 2020 vs. 5399 in 2016). The contamination rate was higher in 2020 (11.7%) compared to 2016 (8.2%), p < 0.001. The rate of infectious episodes in which the etiological agent was identified was constant: 11% in 2020 versus 11.9% in 2016, p = 0.479, but there were fewer invasive bacterial/fungal infections: 0.95/1000 patient days in 2020 vs. 2.39/1000 patient days in 2016, p < 0.001. We observed a change in the species distribution. The Gram-negative isolate’s proportion increased from 50.6% to 63.1% and the gram-positive isolate’s proportion decreased from 31.8% to 19%. Collection of a low number of blood cultures and a high contamination rate was identified in our clinic. In order to improve the usefulness of blood cultures as a diagnostic method, at least two sets should be collected in aseptic conditions.
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16
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Russo E, Bolondi G, Gamberini E, Santonastaso DP, Circelli A, Spiga M, Sambri V, Agnoletti V. Increased blood culture contamination rate during COVID-19 outbreak in intensive care unit: A brief report from a single-centre. J Intensive Care Soc 2022; 23:500-502. [PMID: 36751343 PMCID: PMC9679905 DOI: 10.1177/17511437211012152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Emanuele Russo
- Anesthesia and Intensive Care Unit, AUSL Romagna – Bufalini
Hospital, Cesena, Italy,Emanuele Russo, Bufalini Hospital, viale
Ghirotti 286, 47521, Cesena, FC, Italy.
| | - Giuliano Bolondi
- Anesthesia and Intensive Care Unit, AUSL Romagna – Bufalini
Hospital, Cesena, Italy
| | - Emiliano Gamberini
- Anesthesia and Intensive Care Unit, AUSL Romagna – Bufalini
Hospital, Cesena, Italy
| | | | - Alessandro Circelli
- Anesthesia and Intensive Care Unit, AUSL Romagna – Bufalini
Hospital, Cesena, Italy
| | - Martina Spiga
- Anesthesia and Intensive Care Unit, AUSL Romagna – Bufalini
Hospital, Cesena, Italy
| | | | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna – Bufalini
Hospital, Cesena, Italy
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Abstract
A West Virginia regional community hospital incorporated an initial specimen diversion device (ISDD) into conventional blood culture protocol with the objective to bring the hospital-wide blood culture contamination (BCC) rate from a 3.06% preintervention rate to a target performance level below 1%. Emergency department staff, laboratory phlebotomists, and nursing staff on acute-critical care floors were trained on ISDD (Steripath Gen2, Magnolia Medical Technologies, Inc., Seattle, WA) operating procedure and utilized the device for blood culture sample collection with adult patients from September 2020 through April 2021. Of 5642 blood culture sets collected hospital-wide, 4631 were collected with the ISDD, whereas the remaining sets were collected via the conventional method. The ISDD BCC rate of 0.78% differed from the conventional method BCC rate of 4.06% observed during the intervention period (chi-squared test P < 0.00001). The ISDD group attained a sub-1% BCC rate to satisfy the intervention objective.
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Affiliation(s)
- Mark D. Povroznik
- Department of Quality, WVU Medicine: United Hospital Center, Bridgeport, WV
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18
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Lalezari A, Abu Rayya Z, Lellouche J, Yana M, Sharon N. Evaluation of the initial specimen diversion technique (ISDT) for reducing blood culture contamination in children: a prospective randomized controlled trial. J Hosp Infect 2022; 128:96-97. [PMID: 35926665 DOI: 10.1016/j.jhin.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/10/2022] [Accepted: 07/10/2022] [Indexed: 10/16/2022]
Affiliation(s)
- Alon Lalezari
- Pediatric Department, Laniado Hospital, Netanya 4244916, Israel
| | | | - Jonathan Lellouche
- Clinical Laboratories Department, Laniado Hospital, Netanya 4244916, Israel
| | - Moshe Yana
- Pediatric Department, Laniado Hospital, Netanya 4244916, Israel
| | - Nechama Sharon
- Pediatric Department, Laniado Hospital, Netanya 4244916, Israel.
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19
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Sacchetti B, Travis J, Steed LL, Webb G. Identification of the main contributors to blood culture contamination at a tertiary care academic medical center. Infect Prev Pract 2022; 4:100219. [PMID: 35692894 PMCID: PMC9184864 DOI: 10.1016/j.infpip.2022.100219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022] Open
Abstract
Background Blood culture contamination poses an issue to all hospital systems worldwide because of the associated costs of extended length of stays, unnecessary antibiotic therapy, and additional laboratory testing that are preventable with proper handling and collection techniques. Methods In our study, multiple units, staff, and collection methods were compared to determine the primary culprits of contamination from a tertiary care academic medical center, which includes a pediatric hospital and both adult and pediatric emergency departments. Results Over 33 months, 2,083 out of 88,322 total blood cultures collected were contaminated, with an overall contamination rate of 2.4%. A moderate positive correlation was found between the monthly total number of cultures and monthly contamination rate (r = 0.411 P < .01). The most notable factors associated with contamination were found to be phlebotomy teams (2.7%) (P < .01), peripheral draws (2.3%) (P <.01), adult emergency departments (2.6%) (P < .01), and pediatric intensive care units (2.7%) (P < .01). A positive correlation was present between the number of hospital beds per unit and unit contamination rates (r = 0.429 P < .01). Conclusion Our results were used to make recommendations for decreasing the rate of blood culture contamination in this institution, which includes acknowledgement of an overwhelmed staff and mandatory periodic training on acceptable aseptic technique and contamination awareness. Understanding the factors contributing to blood culture contamination can aid efforts to reduce contamination rates.
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20
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Megged O, Dorembus S, Ben-Shalom E, Heiman E. Comparing blood culture contamination rates by different sampling methods in a paediatric emergency department. J Paediatr Child Health 2022; 58:669-673. [PMID: 34668594 DOI: 10.1111/jpc.15812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/25/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
AIM Blood culture contamination (BCC) can cause unnecessary hospitalisations and inappropriate use of antibiotics. The aim of this study was to find risk factors associated with BCCs in children and to compare contamination rates between open and closed blood culture collection systems. METHODS Data were prospectively collected regarding blood cultures obtained in the paediatric emergency department from February 26, 2020, to September 30, 2020, based on the method of drawing blood reported by the obtaining physician. A comparison between contaminated and non-contaminated blood cultures was performed. We also compared the composition of the contaminations in the study period to the same period in 2019. RESULTS A total of 512 blood cultures were included, 33 (6.4%) of which were contaminated. The only parameter that was associated with an increased rate of contamination by 2.34 fold (95% CI 1.1-4.99, P = 0.028) was obtaining blood through an 'open' system, using a syringe connected to a needle in order to draw blood from an open ended needle. The proportion of contaminations originating from oral flora decreased in the study period by 44.7% as compared to the same period in the previous year (13% vs. 23.5%, P = 0.056). CONCLUSIONS 'Open system' method, which is commonly used in paediatric emergency departments for blood culture obtainment, was associated with an increase in BCC. Adherence to blood cultures obtainment guidelines, even at the price of two different blood tests, is important in order to reduce BCC rates in children.
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Affiliation(s)
- Orli Megged
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,The Pediatric Department, Shaare Zedek Medical Center, Jerusalem, Israel.,The Pediatric Infectious Disease Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Sara Dorembus
- The Pediatric Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Efrat Ben-Shalom
- The Pediatric Department, Shaare Zedek Medical Center, Jerusalem, Israel.,The Pediatric Nephrology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Eyal Heiman
- The Pediatric Department, Shaare Zedek Medical Center, Jerusalem, Israel.,The Pediatric Emergency Department, Shaare Zedek Medical Center, Jerusalem, Israel
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21
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Ruby KN, Khan J, Martin IW, Dunbar NM. Application of Standardized Residual Component Culture Criteria for Suspected Septic Transfusion Reactions Would Increase the Component Culturing Rate at a Single Academic Medical Center. Am J Clin Pathol 2022; 158:216-220. [PMID: 35311936 DOI: 10.1093/ajcp/aqac032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The 2019 SCARED study developed the Biomedical Excellence for Safer Transfusion (BEST) criteria in an effort to standardize the decision to culture residual units in the context of suspected septic transfusion reactions (STRs). The goal of this study was to apply the BEST criteria to determine the effect on the transfusion reaction decision to culture. METHODS This retrospective, single-center, cross-sectional study assessed adult transfusion reactions identified in calendar years 2013 to 2020. Reactions following transfusion of RBCs, platelets, and plasma were included, and the decisions to culture following strict application of BEST criteria were compared with decisions to culture in actual practice. RESULTS In total, 1,068 transfusion reactions were reported and 200 (19%) suspected STRs were cultured, all with negative results; 303 (28%) reactions would have been cultured per strict application of the BEST criteria. Concordance between actual culture decision and BEST criteria recommendation was 62% for cultured components and 79% for components that were not cultured. CONCLUSIONS BEST criteria provide objective recommendations of when to culture residual units implicated in suspected STRs, but strict application of these criteria may result in increased culture rates. Clinical correlation to aid in the decision to culture is recommended.
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Affiliation(s)
- Kristen N Ruby
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jenna Khan
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Isabella W Martin
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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22
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Tenderenda A, Łysakowska M, Dargiewicz R, Gawron-Skarbek A. Blood Culture Contamination: A Single General Hospital Experience of 2-Year Retrospective Study. Int J Environ Res Public Health 2022; 19. [PMID: 35270715 DOI: 10.3390/ijerph19053009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 01/25/2023]
Abstract
In the event of blood culture contamination (BCC), blood culture (BC) needs to be repeated. This may delay appropriate treatment, prolong hospitalization and, consequently, increase its costs. The aim of the study was to assess the frequency of BCC and associated factors in a general hospital in Poland based on reports of BC in samples submitted for laboratory testing in 2019−2020. BCC is recognized when bacteria (especially those belonging to natural human microbiota) are isolated from a single sample and no clinical signs indicated infection. True positive BC is confirmed by the growth of bacteria in more than one set of blood samples with the corresponding clinical signs present. The structure of BC sets, microorganisms, and laboratory costs of BCC were analyzed. Out of 2274 total BC cases, 11.5% were true positive BC and 9.5% were BCC. Of all the BCC identified in the entire hospital, 72% was from Internal Medicine (IM) and Intensive Care Unit (ICU) combined. When single sets for BC were used in IM in 2020, the use increased to 85% compared with 2019 (p < 0.05). The predominant isolates were coagulase-negative staphylococci (84%). The estimated extra laboratory costs of BCC exceeded EUR 268,000. The BCC was a more serious problem than expected, including non-recommended using of single BC sets. Compliance with the BC collection procedure should be increased in order to reduce BCC and thus extra hospital costs.
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23
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Sastry A, Shaji R, Madigubba H, Priyadarshi K, Anandh P, Nathan B, Vivekanandan M. Effectiveness of multimodal intervention to improve blood culture collection in the emergency department. J Glob Infect Dis 2022; 14:10-16. [PMID: 35418732 PMCID: PMC8996457 DOI: 10.4103/jgid.jgid_138_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/20/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction: The blood culture (BC) contamination was a significant problem in our hospital, especially in the emergency department (ED). The study, therefore, was undertaken to improve the BC collection in the ED. Methods: The study was conducted for 1 year divided into two phases of 6 months each: Preintervention phase and intervention phase (regular and phlebotomist groups). The interventions comprised implementing standard protocol for BC collection and conducting educational sessions. In preintervention and regular groups, the BCs were collected by interns and technicians, while dedicated phlebotomist did so in the phlebotomist group. Data were analyzed and interpreted for the contamination rate as well as compliance in adequate filling of the requisition form. Statistical Package for the Social Sciences (SPSS) version 22. A value of P < 0.005 was considered statistically significant, and P < 0.01 was considered statistically significant. Results: In the preintervention group, 13.7% of specimens were reported as contaminated which was reduced to 4.2% and 3.2% in the regular and phlebotomist group, respectively, after intervention. Compliance of health-care workers to various elements of BC collection protocol was also found to be significantly improved in the intervention phase compared to the preintervention phase (P < 0.001). Conclusions: Implementation of this multimodal intervention resulted in a drastic reduction in BC contamination and improvement in compliance to BC collection protocol and filling of various parameters in the BC requisition form, thus improving the overall effectiveness of BC testing. It was also noted that the contamination rate was further reduced by implementing dedicated phlebotomist.
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24
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Nielsen LE, Nguyen K, Wahl CK, Huss JL, Chang D, Ager EP, Hamilton L. Initial Specimen Diversion Device® Reduces Blood Culture Contamination and Vancomycin Use in Academic Medical Center. J Hosp Infect 2021; 120:127-133. [PMID: 34780808 DOI: 10.1016/j.jhin.2021.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In suspected bloodstream infections, accurate blood culture results are critical to timely diagnoses and appropriate antibiotic administration. AIM An Initial Specimen Diversion Device®, Steripath®, (Magnolia Medical Technologies, Seattle, WA) was evaluated for efficacy in reducing blood culture contamination at Brooke Army Medical Center (6.8% six-month contamination rate prior to intervention) in a six-month quality improvement project. METHODS Blood cultures in the emergency department were collected using either Steripath® or the standard method. 20 mL of blood was cultured into an aerobic and anaerobic medium and incubated for five days using an automated microbial detection system immediately after collection. Positive bottles were Gram stained and plated. Rapid molecular PCR identification was performed on all first positive bottles within a blood culture set for each admission or ED visit. Speciation was deduced during antimicrobial sensitivity testing using the Vitek-2 instrument. FINDINGS Seven (7/1016, 0.69%) contamination events occurred when using Steripath® vs. 53 (53/800, 6.6%) contamination events when using the standard method. Steripath® use was associated with a 90% lower incidence of blood culture contamination vs. the standard method. Post-study, Steripath® use was implemented as standard practice hospital-wide, and a retrospective data analysis attributed a 31.4% decrease in vancomycin days of therapy to Steripath® adoption. CONCLUSION Using Steripath® significantly decreased blood culture contamination events for bacterial bloodstream infections compared to the standard method. Subsequent adoption of Steripath® reduced overall vancomycin usage. With widescale implementation Steripath® could bolster antibiotic stewardship, mitigating antibiotic resistance caused by unnecessary antibacterial treatments.
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Affiliation(s)
- Lindsey E Nielsen
- Department of Pathology and Area Laboratory Services, Brooke Army Medical Center, San Antonio, TX
| | - Ken Nguyen
- Department of Pathology and Area Laboratory Services, Brooke Army Medical Center, San Antonio, TX
| | - Clinton K Wahl
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX
| | - Jodi L Huss
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX
| | | | - Edward P Ager
- Department of Pathology and Area Laboratory Services, Brooke Army Medical Center, San Antonio, TX
| | - Lynette Hamilton
- Department of Pathology and Area Laboratory Services, Brooke Army Medical Center, San Antonio, TX
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Yamamoto K, Mezaki K, Ohmagari N. Simple indictor of increased blood culture contamination rate by detection of coagulase-negative staphylococci. Sci Rep 2021; 11:17538. [PMID: 34475478 PMCID: PMC8413347 DOI: 10.1038/s41598-021-96997-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/19/2021] [Indexed: 12/04/2022] Open
Abstract
Coagulase-negative staphylococci (CoNS) are the most frequent contaminating bacteria; therefore, we aimed to investigate an indicator of CoNS to predict the increase in blood culture contamination rate (ConR). We performed a retrospective study of selected patients, who underwent blood culture testing. Contamination was defined as the presence of either one of two or more sets of skin-resident bacteria, except for cases with a low likelihood of contamination based on clinical aspects. We calculated the monthly ConR [(total number of contaminated cases per month)/(total number of blood culture sets collected per month) × 100] and analysed the ConR prediction ability using the following four indicators: the number of CoNS-positive sets of blood cultures, cases with at least one CoNS-positive blood culture set, cases with only one CoNS-positive blood culture set, and cases of contamination by CoNS. Cases with CoNS-positive blood cultures correlated with ConR (r = 0.85). Although the area under the receiver operating characteristic curve for the number of cases with ConR ≥ 2.5 differed significantly from that of the number of cases contaminated by CoNS, the negative predictive value was high, reaching up to 95.5% (95% confidential interval 87.3–99.1). The number of CoNS-positive cases could help predict an increase in ConR ≥ 2.5.
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Affiliation(s)
- Kei Yamamoto
- Disease Control and Prevention Center/Travel Clinic, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Kazuhisa Mezaki
- Clinical Laboratory Department, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center/Travel Clinic, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
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Allen E, Cavallaro A, Keir AK. A Quality Improvement Initiative to Reduce Blood Culture Contamination in the Neonatal Unit. Pediatr Qual Saf 2021; 6:e413. [PMID: 34046542 DOI: 10.1097/pq9.0000000000000413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 12/07/2020] [Indexed: 11/25/2022] Open
Abstract
Peripheral blood culture contamination (BCC) can lead to an initiation of unnecessary antimicrobial treatment, further laboratory tests, increased length of stay, and increased costs. This study describes a 12-month quality improvement (QI) program to reduce the BCC rate in a neonatal unit by 50%. Methods The QI team focused on standardizing processes to align with best practices using process mapping and cause and effect diagrams. Plan-Do-Study-Act (PDSA) 1: inoculation of blood culture bottles with the introduction of transfer device; PDSA 2: preparation of the skin for peripheral intravenous cannula insertion; PDSA 3: aseptic technique education package; and PDSA 4: optimizing blood volume of blood collected for culture. The team used statistical process control methodology to detect special cause variation. Results Compliance with the standard processes as part of PSDA 1 improved from a mean level of 50% to 100% and for PDSA 2 improved from a mean level of 50% to 95%. After implementation of PDSA 3, scores on a relevant knowledge test increased from a mean of 39% (pretraining test; n = 10) to 92% (posttraining test; n = 10) (P < 0.001). Postimplementation of the processes for PDSA 4, a minimum of 1 mL was collected in 94% of blood culture collection events (n = 450) (mean 1.1 mL; range 0.5-3.5 mL). Special cause variation occurred after the implementation of the PDSA cycles. During the baseline period, the BCC rate was 2.0% and decreased to 1.0% postinterventions implementation. Conclusions Interventions focused on standardizing practices around collection of blood cultures in neonates were associated with fewer contaminants.This study is reported according to the SQUIRE 2.0 guidelines.
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Zimmerman FS, Karameh H, Ben-Chetrit E, Zalut T, Assous M, Levin PD. Modification of Blood Test Draw Order to Reduce Blood Culture Contamination: A Randomized Clinical Trial. Clin Infect Dis 2021; 71:1215-1220. [PMID: 31570942 DOI: 10.1093/cid/ciz971] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/28/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Blood culture contamination leads to unnecessary interventions and costs. It may be caused by bacteria in deep skin structures unsusceptible to surface decontamination. This study was designed to test whether diversion of blood obtained at venipuncture into a lithium heparin tube prior to aspiration of blood culture reduces contamination. METHODS The order of blood draws for biochemistry and blood cultures was randomized. Following standard disinfection and venipuncture, blood was either aspirated into a sterile lithium heparin tube before blood culture bottles (diversion group) or blood cultures first and then lithium heparin tube (control group). All study personnel were blinded with the exception of the phlebotomist. RESULTS After exclusions, 970 blood culture/biochemistry sets were analyzed. Contamination occurred in 24 of 480 (5.0%) control vs 10 of 490 (2.0%) diversion group cultures (P = .01). True pathogens were identified in 26 of 480 (5.4%) control vs 18 of 490 (3.7%) diversion cultures (P = .22). Despite randomization, demographic differences were apparent between the 2 groups. A post hoc analysis of 637 cultures from 610 medical patients admitted from home neutralized demographic differences. Culture contamination remained more frequent in the control vs diversion group (17/312 [5%] vs 7/325 [2%]; P = .03). Fewer diversion group patients were admitted to hospital (control: 200/299 [66.9%] vs diversion: 182/311 [58.5%]; P = .03), and length of stay was shorter (control: 30 hours [interquartile range {IQR}, 6-122] vs diversion: 22 [IQR, 5-97]; P = .02). CONCLUSIONS Use of lithium heparin tubes for diversion prior to obtaining blood cultures led to a 60% decrease in contamination. This technique is easy and inexpensive and might decrease overall hospital length of stay. CLINICAL TRIALS REGISTRATION NCT03966534.
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Affiliation(s)
- Frederic S Zimmerman
- Critical Care Unit, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Hani Karameh
- Department of Geriatrics, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Eli Ben-Chetrit
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Todd Zalut
- Department of Emergency Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Marc Assous
- Laboratory of Clinical Microbiology and Immunology, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Phillip D Levin
- Critical Care Unit, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Klucher JM, Davis K, Lakkad M, Painter JT, Dare RK. Risk factors and clinical outcomes associated with blood culture contamination. Infect Control Hosp Epidemiol 2021;:1-7. [PMID: 33896442 DOI: 10.1017/ice.2021.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine patient-specific risk factors and clinical outcomes associated with contaminated blood cultures. DESIGN A single-center, retrospective case-control risk factor and clinical outcome analysis performed on inpatients with blood cultures collected in the emergency department, 2014-2018. Patients with contaminated blood cultures (cases) were compared to patients with negative blood cultures (controls). SETTING A 509-bed tertiary-care university hospital. METHODS Risk factors independently associated with blood-culture contamination were determined using multivariable logistic regression. The impacts of contamination on clinical outcomes were assessed using linear regression, logistic regression, and generalized linear model with γ log link. RESULTS Of 13,782 blood cultures, 1,504 (10.9%) true positives were excluded, leaving 1,012 (7.3%) cases and 11,266 (81.7%) controls. The following factors were independently associated with blood-culture contamination: increasing age (adjusted odds ratio [aOR], 1.01; 95% confidence interval [CI], 1.01-1.01), black race (aOR, 1.32; 95% CI, 1.15-1.51), increased body mass index (BMI; aOR, 1.01; 95% CI, 1.00-1.02), chronic obstructive pulmonary disease (aOR, 1.16; 95% CI, 1.02-1.33), paralysis (aOR 1.64; 95% CI, 1.26-2.14) and sepsis plus shock (aOR, 1.26; 95% CI, 1.07-1.49). After controlling for age, race, BMI, and sepsis, blood-culture contamination increased length of stay (LOS; β = 1.24 ± 0.24; P < .0001), length of antibiotic treatment (LOT; β = 1.01 ± 0.20; P < .001), hospital charges (β = 0.22 ± 0.03; P < .0001), acute kidney injury (AKI; aOR, 1.60; 95% CI, 1.40-1.83), echocardiogram orders (aOR, 1.51; 95% CI, 1.30-1.75) and in-hospital mortality (aOR, 1.69; 95% CI, 1.31-2.16). CONCLUSIONS These unique risk factors identify high-risk individuals for blood-culture contamination. After controlling for confounders, contamination significantly increased LOS, LOT, hospital charges, AKI, echocardiograms, and in-hospital mortality.
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Buzard BA, Evans P, Schroeder T. Evaluation of an Initial Specimen Diversion Device (ISDD) on Rates of Blood Culture Contamination in the Emergency Department. Kans J Med 2021; 14:73-76. [PMID: 33763182 PMCID: PMC7984743 DOI: 10.17161/kjm.vol1413804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 01/05/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Blood cultures are the gold standard for identifying bloodstream infections. The Clinical and Laboratory Standards Institute recommends a blood culture contamination rate of less than 3%. Contamination can lead to misdiagnosis, increased length of stay and hospital costs, unnecessary testing, and antibiotic use. These reasons led to the development of initial specimen diversion devices (ISDD). The purpose of this study was to evaluate the impact of an initial specimen diversion device on rates of blood culture contamination in the emergency department. Methods This was a retrospective, multi-site study including patients who had blood cultures drawn in an emergency department. February 2018 to April 2018, when an ISDD was not utilized, was compared with June 2019 to August 2019, when an ISDD was being used. The primary outcome was total blood culture contamination. Secondary outcomes were total hospital cost, hospital and intensive care unit length of stay, vancomycin duration of use, vancomycin serum concentrations obtained, and repeat blood cultures obtained. Results A statistically significant difference was found in blood culture contamination rates in the pre-ISDD group vs. the ISDD group (7.47% vs. 2.59%, p < 0.001). None of the secondary endpoints showed a statistically significant difference. Conclusions Implementation of an ISDD reduced blood culture contamination. When implementing the ISDD to a healthcare system, compliance is important and will affect contamination rates dramatically.
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Affiliation(s)
| | - Patrick Evans
- Ascension Via Christi St. Francis Hospital, Wichita, KS
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Arenas M, Boseman GM, Coppin JD, Lukey J, Jinadatha C, Navarathna DH. Asynchronous Testing of 2 Specimen-Diversion Devices to Reduce Blood Culture Contamination: A Single-Site Product Supply Quality Improvement Project. J Emerg Nurs 2021; 47:256-264.e6. [PMID: 33431137 DOI: 10.1016/j.jen.2020.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/13/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Blood culture contamination above the national threshold has been a consistent clinical issue in the ED setting. Two commercially available devices were examined that divert an initial small volume of the specimen before the collection of blood culture to reduce skin contamination. METHODS Prospectively, 2 different blood culture-diversion devices were made available in the unit supplies to ED clinicians at a single site during 2 different periods of time as a follow-up strategy to an ongoing quality improvement project. Blood samples were collected in the emergency department over a period of 16 months. A retrospective record review study was conducted comparing the use of the 2 specimen-diversion devices with no device (control group) for blood culture contamination rates. The main outcome of monthly blood culture contamination per device was tested using a Bayesian Poisson multilevel regression model. RESULTS A total of 4030 blood samples were collected and analyzed from November 2017 to February 2019. The model estimated that the mean incidence of contaminated blood draws in the device A group was 0.29 (0.14-0.55) times the incidence of contaminated draws in the control group. The mean incidence of contaminated blood draws in the device B group was 0.23 (0.13-0.37) times the incidence of contaminated draws in the control group, suggesting that initial-diversion methods reduced blood culture contamination. CONCLUSION Initial specimen-diversion devices supplement present standard phlebotomy protocols to bring down the blood culture contamination rate.
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Abstract
Given the large number of patients seen in the emergency department (ED) and concerns with antibiotic overprescribing, the ED is an important setting to target for antimicrobial stewardship (AS) initiatives. The ED is positioned between ambulatory and inpatient settings, making AS collaboration with clinicians and other health care providers in the hospital, long-term care facilities, and ambulatory settings critical to success. This article details ED-focused AS strategies on empiric antimicrobial selection, prompt administration, preventing ED return and readmissions, suggested collaborations between ED AS leadership and other key partners, and potential future strategies for expansion.
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Zimmet AN, Clark MT, Gadrey SM, Bell TD, Zimmet AM, Moorman JR, Moore CC. Pathophysiologic Signatures of Bloodstream Infection in Critically Ill Adults. Crit Care Explor 2020; 2:e0191. [PMID: 33063017 DOI: 10.1097/CCE.0000000000000191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: Bloodstream infection is associated with high mortality rates in critically ill patients but is difficult to identify clinically. This results in frequent blood culture testing, exposing patients to additional costs as well as the potential harms of unnecessary antibiotics. The purpose of this study was to assess whether the analysis of bedside physiologic monitoring data could accurately describe a pathophysiologic signature of bloodstream infection in patients admitted to the ICU. Design: Development of a statistical model using physiologic data from a retrospective observational cohort. Setting: University of Virginia Medical Center (Charlottesville, VA), a tertiary-care academic medical center. Patients: Critically ill patients consecutively admitted to either the medical or surgical/trauma ICUs with available physiologic monitoring data between February 2011 and June 2015. Interventions: None. Measurements and Main Results: We analyzed 9,954 ICU admissions with 144 patient-years of vital sign and electrocardiography waveform data, totaling 1.3 million hourly measurements. There were 15,577 blood culture instances, with 1,184 instances of bloodstream infection (8%). The multivariate pathophysiologic signature of bloodstream infection was characterized by abnormalities in 15 different physiologic features. The cross-validated area under the receiver operating characteristic curve was 0.78 (95% CI, 0.69–0.85). We also identified distinct signatures of Gram-negative and fungal bloodstream infections, but not Gram-positive bloodstream infection. Conclusions: Signatures of bloodstream infection can be identified in the routine physiologic monitoring data of critically ill adults. This may assist in identifying infected patients, maximizing diagnostic stewardship, and measuring the effect of new therapeutic modalities for sepsis.
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Abstract
The optimal care of septic patients depends on the successful recovery of clinically relevant microorganisms from blood cultures and the timely reporting of organism identification and antimicrobial susceptibility testing (AST) results. Many preanalytic factors play a critical role in culturing microorganisms, and advancements in blood culture instrument technology have reduced the time to positive results. Additionally, rapid organism identification and AST results directly from positive blood culture broth via new methods help to further shorten the time from empiric to targeted treatment. This article summarizes the current state of blood culture methods, including preanalytic, analytical, and postanalytic factors that are available to clinical microbiology laboratories.
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Affiliation(s)
- Mark D Gonzalez
- Microbiology, Section Director of Infectious Disease Serology, Children's Healthcare of Atlanta, 1405 Clifton Road, Northeast, Atlanta, GA 30322, USA
| | - Timothy Chao
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University Hospital, 132 South 10th Street, Room 285, Philadelphia, PA 19107, USA. https://twitter.com/tim_hf_chao
| | - Matthew A Pettengill
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, 117 South 11th Street, Pavilion Building Suite 207, Philadelphia, PA 19107-4998, USA.
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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: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Halstead DC, Sautter RL, Snyder JW, Crist AE, Nachamkin I. Reducing Blood Culture Contamination Rates: Experiences of Four Hospital Systems. Infect Dis Ther 2020; 9:389-401. [PMID: 32350778 PMCID: PMC7237585 DOI: 10.1007/s40121-020-00299-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Blood cultures (BCs) frequently become contaminated during the pre-analytic phase of collection leading to downstream ramifications. We present a summary of performance improvement (PI) interventions provided by four hospital systems and common factors that contributed to decreased blood culture contamination (BCC) rates. METHODS Each hospital independently formed a multidisciplinary team and action plan for implementation of their intervention, focusing on the use of educational and training tools. Their goal was to significantly decrease their BCC rates. Pre- and post-intervention data were compared during the sustainment period to determine their success. RESULTS All hospitals met their goals of post-intervention BCC rates and with most achieving and sustaining BCC rates ≤ 1.0-2.0%. CONCLUSION Our report highlights how four hospitals independently achieved their objective to decrease their BCC rate with the support of a multidisciplinary team. We propose a benchmark for BCC rates of 1.5 to < 2.0% as achievable and sustainable.
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Affiliation(s)
- Diane C Halstead
- Division of Infectious Disease Diagnostic Laboratory Service, Southeastern Pathology Associates at Baptist MD Anderson Cancer Center, Jacksonville, FL, USA
| | - Robert L Sautter
- Department of Microbiology, Carolinas Pathology Group, Charlotte, NC, USA
| | - James W Snyder
- Division of Microbiology and Molecular Diagnostics, University of Louisville, Louisville, KY, USA
| | - Arthur E Crist
- Department of Laboratory Services, York Laboratory Associates at WellSpan Health System, York Hospital, York, PA, USA
| | - Irving Nachamkin
- Perelman School of Medicine, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA.
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Hemeg HA, Almutairi AZ, Alharbi NL, Alenezi RF, Alturkostani MA, Ozbak HA, Islam FA. Blood culture contamination in a tertiary care hospital of Saudi Arabia. A one-year study. Saudi Med J 2020; 41:508-515. [PMID: 32373918 PMCID: PMC7253833 DOI: 10.15537/smj.2020.5.25052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objectives: To monitor blood culture contamination (BCC) rates in a tertiary care hospital in Saudi Arabia. Methods: Blood cultures submitted to the Microbiology Laboratory of King Fahad Hospital, Madina, Saudi Arabia between January and December 2017 were analyzed prospectively. Positive blood cultures were either designated as true bacteremia with confirmed bloodstream infection or BCC. Results: Among 5,536 blood cultures from 2201 patients, 364 (6.6%) mirrored BCC. There was an upward trend in contamination rates in specific months. With respect to total blood cultures from respective units over a one-year period, medical ward contributed to the highest contamination rate (10.3%). Blood culture contamination rate in the wards ranged from 4.5-10.3%, with a higher contamination rate in elderly, aged 60-80 years. Staphylococcus epidermidis (S. epidermidis) was the most frequent contaminant (44.5%). Conclusion: The escalated contamination rates in September to October may be attributed to difficulty in sampling blood by the less competent nurses during annual pilgrimage season. High influx of patients and shortage of trained nurses may have resulted in increased incidence in December-January and March-April. The prevalence of skin-resident S. epidermidis may be due to improper aseptic conditions. Ours is the first report on evaluation of BCC rates in Madina and call for renewed efforts in this direction.
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Affiliation(s)
- Hassan A Hemeg
- Department of Medical Laboratories Technology, Faculty of Applied Medical Sciences, Taibah University, Madina, Kingdom of Saudi Arabia. E-mail.
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Bool M, Barton MJ, Zimmerman PA. Blood culture contamination in the emergency department: An integrative review of strategies to prevent blood culture contamination. Australas Emerg Care 2020; 23:157-65. [PMID: 32253130 DOI: 10.1016/j.auec.2020.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/27/2020] [Accepted: 02/20/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Blood culture collection remains the gold standard to diagnose bacteraemia. Current evidence suggests that the emergency department (ED) often has blood culture contamination (BCC) rates above the recommended 3%, contributing to increased hospital length of stay, unnecessary or inappropriate antimicrobial treatment, and increased economic burden. The aim of this review is to identify effective strategies to improve blood culture collection in EDs to decrease contamination rates and improve patient safety. METHODS An integrative literature review methodology was utilised to conduct a structured search of contemporary literature using CINAHL, Embase, Medline, Pubmed and Scopus databases. All eligible literature was screened with those included in the final review collated and appraised using a quality assessment tool. RESULTS Eleven reports were included in the final review, which identified bundled approaches, education and feedback, equipment and technique, and stakeholder engagement as strategies that improve BCC rates in the ED. CONCLUSIONS All studies reported a reduction in BCC rates regardless of the strategies implemented. A bundled approach yielded the most significant results and was identified to be practical, inexpensive, and adaptable. Further research focusing on specific aspects of a bundled approach may be beneficial to understand which strategies are most effective.
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Salcedo DT, Powell EA, Smulian AG, Powers-Fletcher MV. Actual Clinical Practice Related to Contaminated Blood Cultures May Limit the Cost Savings Associated with Interventions To Reduce Contamination Rates. J Clin Microbiol 2020; 58:e01796-19. [PMID: 31996447 DOI: 10.1128/JCM.01796-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Affiliation(s)
- Karsten Becker
- Friedrich Loeffler-Institute of Medical Microbiology, University Medicine Greifswald, Greifswald, Germany
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Anna Both
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Samira Weißelberg
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Heilmann
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
- Interdisciplinary Center for Clinical Research (IZKF), University of Münster, Münster, Germany
| | - Holger Rohde
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Arena F, Argentieri M, Bernaschi P, Fortina G, Kroumova V, Pecile P, Rassu M, Spanu T, Rossolini GM, Fontana C. Compliance of clinical microbiology laboratories with recommendations for the diagnosis of bloodstream infections: Data from a nationwide survey in Italy. Microbiologyopen 2020; 9:e1002. [PMID: 32012494 PMCID: PMC7142361 DOI: 10.1002/mbo3.1002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/09/2020] [Accepted: 01/09/2020] [Indexed: 12/17/2022] Open
Abstract
In 2014, the Italian Working Group for Infections in Critically Ill Patient of the Italian Association of Clinical Microbiologists updated the recommendations for the diagnostic workflow for bloodstream infections (BSI). Two years after publication, a nationwide survey was conducted to assess the compliance with the updated recommendations by clinical microbiology laboratories. A total of 168 microbiologists from 168 laboratories, serving 204 acute care hospitals and postacute care facilities, were interviewed during the period January–October 2016 using a questionnaire consisting of nineteen questions which assessed the level of adherence to various recommendations. The most critical issues were as follows: (a) The number of sets of blood cultures (BC) per 1,000 hospitalization days was acceptable in only 11% of laboratories; (b) the minority of laboratories (42%) was able to monitor whether BCs were over or under‐inoculated; (c) among the laboratories monitoring BC contamination (80%), the rate of contaminated samples was acceptable in only 12% of cases;(d) the Gram‐staining results were reported within 1 hr since BC positivity in less than 50% of laboratories. By contrast, most laboratories received vials within 2–4 hr from withdrawal (65%) and incubated vials as soon as they were received in the laboratory (95%). The study revealed that compliance with the recommendations is still partial. Further surveys will be needed to monitor the situation in the future.
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Affiliation(s)
- Fabio Arena
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy.,IRCCS Don Carlo Gnocchi Foundation, Florence, Italy
| | - Marta Argentieri
- Microbiology Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Paola Bernaschi
- Microbiology Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Giacomo Fortina
- Italian Work Group for Infections in Critically Ill Patient (GliPac-AMCLI), Milan, Italy
| | - Vesselina Kroumova
- Infection Control Unit, University Hospital "Maggiore della Carità", Novara, Italy
| | - Patrizia Pecile
- Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Mario Rassu
- Microbiology and Virology Lab, AULS 8 Berica, S. Bortolo Hospital, Vicenza, Italy
| | - Teresa Spanu
- Institute of Microbiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Gian Maria Rossolini
- Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Carla Fontana
- Department Experimental Medicine, University of Rome Tor Vergata, Rome, Italy.,Microbiology and Virology Lab, Tor Vergata University Hospital, Rome, Italy
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41
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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: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [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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42
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Doern GV, Carroll KC, Diekema DJ, Garey KW, Rupp ME, Weinstein MP, Sexton DJ. Practical Guidance for Clinical Microbiology Laboratories: A Comprehensive Update on the Problem of Blood Culture Contamination and a Discussion of Methods for Addressing the Problem. Clin Microbiol Rev 2019; 33:e00009-19. [PMID: 31666280 PMCID: PMC6822992 DOI: 10.1128/cmr.00009-19] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
In this review, we present a comprehensive discussion of matters related to the problem of blood culture contamination. Issues addressed include the scope and magnitude of the problem, the bacteria most often recognized as contaminants, the impact of blood culture contamination on clinical microbiology laboratory function, the economic and clinical ramifications of contamination, and, perhaps most importantly, a systematic discussion of solutions to the problem. We conclude by providing a series of unanswered questions that pertain to this important issue.
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Affiliation(s)
- Gary V Doern
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Karen C Carroll
- Division of Medical Microbiology, Department of Pathology, John Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel J Diekema
- Division of Infectious Diseases, Department of Medicine and Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Mark E Rupp
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Melvin P Weinstein
- Department of Pathology and Laboratory Medicine, Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Daniel J Sexton
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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43
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Lalezari A, Cohen MJ, Svinik O, Tel-Zur O, Sinvani S, Al-Dayem YA, Block C, Moses AE, Oster Y, Salameh S, Strahilevitz J. A simplified blood culture sampling protocol for reducing contamination and costs: a randomized controlled trial. Clin Microbiol Infect 2019; 26:470-474. [PMID: 31539635 DOI: 10.1016/j.cmi.2019.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Blood culture contamination carries risks for patients, such as unnecessary antimicrobial therapy and other additional hazards and costs. One method shown to be effective in reducing contamination is initial blood specimen diversion during collection. We hypothesized that initial blood specimen diversion without a designated device or procedure would suffice for reduction in blood culture contamination rate. METHODS From 1 September 2017 through to 6 September 2018, we conducted a randomized controlled trial to assess the effect of an initial-specimen diversion technique (ISDT) on the rate of blood-culture contamination by changing the order of sampling using regular vacuum specimen tubes instead of commercially available sterile diversion devices. We included adults from whom the treating physician planned to take blood cultures and additional blood chemistry tests. Additionally, we evaluated the potential economic benefits of an ISDT. This was a researcher-initiated trial, Clinicaltrials.gov NCT03088865. RESULTS In all, 756 patients were enrolled. This method, compared with the standard procedure in use at our medical centre, reduced contamination by 66% (95% CI 17%-86%), from 20/400 (5%) with the standard method to 6/356 (1.6%) with the ISDT, without compromising detection of true bloodstream infection and at no additional cost. Hospital-wide implementation of ISDT was associated with a 1.1% saving in hospitalization days. CONCLUSIONS We offer this novel approach as a simple, cost-effective measure to reduce risks to patient safety from contaminated blood cultures, without the need for using costly devices.
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Affiliation(s)
- A Lalezari
- Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - M J Cohen
- Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - O Svinik
- Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - O Tel-Zur
- Department of Emergency Medicine, Hadassah Medical Centre, Jerusalem, Israel
| | - S Sinvani
- Department of Emergency Medicine, Hadassah Medical Centre, Jerusalem, Israel
| | - Y Abed Al-Dayem
- Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, The Hebrew University, Jerusalem, Israel
| | - C Block
- Hadassah-Hebrew University School of Medicine, Jerusalem, Israel; Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, The Hebrew University, Jerusalem, Israel
| | - A E Moses
- Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, The Hebrew University, Jerusalem, Israel
| | - Y Oster
- Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, The Hebrew University, Jerusalem, Israel
| | - S Salameh
- Department of Emergency Medicine, Hadassah Medical Centre, Jerusalem, Israel
| | - J Strahilevitz
- Hadassah-Hebrew University School of Medicine, Jerusalem, Israel; Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, The Hebrew University, Jerusalem, Israel.
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44
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Dempsey C, Skoglund E, Muldrew KL, Garey KW. Economic health care costs of blood culture contamination: A systematic review. Am J Infect Control 2019; 47:963-967. [PMID: 30795840 DOI: 10.1016/j.ajic.2018.12.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/12/2018] [Accepted: 12/12/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Blood culture contamination with gram-positive organisms is a common occurrence in patients suspected of bloodstream infections, especially in emergency departments. Although numerous research studies have investigated the cost implications of blood culture contamination, a contemporary systematic review of the literature has not been performed. The aim of this project was to perform a systematic review of the published literature on the economic costs of blood culture contamination. METHODS PubMed was searched (January 1, 1978, to July 15, 2018) using the search terms "blood culture contamination" or "false-positive blood cultures." Articles were title searched and abstracts were reviewed for eligible articles that reported immediate or downstream economic costs of blood culture contamination. RESULTS AND DISCUSSION The PubMed search identified 151 relevant articles by title search, with 49 articles included after abstract review. From the studies included, overall blood culture contamination rates ranged from 0.9%-41%. Up to 59% of patients received unnecessary treatment with parenteral vancomycin as a result of blood culture contamination, resulting in increased pharmacy charges between $210 and $12,611 per patient. Increases in total laboratory charges between $2,397 and $11,152 per patient were reported. Attributable hospital length of stay increases due to blood culture contamination ranged from 1-22 days. CONCLUSIONS This systematic review of the literature identified several areas of health care expenditure associated with blood culture contamination. Interventions to reduce the risk of blood culture contamination would avoid downstream economic costs.
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Affiliation(s)
- Casey Dempsey
- University of Houston College of Pharmacy, Department of Pharmacy Practice and Translational Research, Houston, TX
| | - Erik Skoglund
- University of Houston College of Pharmacy, Department of Pharmacy Practice and Translational Research, Houston, TX; Baylor St. Luke's Medical Center, Departments of Pharmacy and Microbiology, Houston, TX
| | - Kenneth L Muldrew
- Baylor St. Luke's Medical Center, Departments of Pharmacy and Microbiology, Houston, TX; Baylor College of Medicine, Department of Pathology & Immunology and Internal Medicine, Houston, TX; University of Texas MD Anderson Cancer Center, Department of Microbiology, Houston, TX
| | - Kevin W Garey
- University of Houston College of Pharmacy, Department of Pharmacy Practice and Translational Research, Houston, TX; Baylor St. Luke's Medical Center, Departments of Pharmacy and Microbiology, Houston, TX.
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45
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Wilson ML. Critical factors in the recovery of pathogenic microorganisms in blood. Clin Microbiol Infect 2019; 26:174-179. [PMID: 31377231 DOI: 10.1016/j.cmi.2019.07.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 07/15/2019] [Accepted: 07/20/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The critical factors for optimal recovery of microbial pathogens from blood are not only the basis for how we perform blood cultures on a daily basis, but are also important for development of all current blood-culture systems. Because much of this research was conducted and published between 1975 and 2010 there is a general sense that many physicians and scientists may not be familiar with it, but it is critical for performing and interpreting blood cultures. OBJECTIVES To review the critical factors in the laboratory recovery and isolation of pathogenic microorganisms in blood. SOURCES Literature review of published papers, select reviews and updated guidelines. CONTENT This review focuses on the critical factors that affect the recovery isolation of pathogenic microorganisms from individuals with bloodstream infections. Contemporary blood-culture systems, and current methods for blood-culture collection, have been designed to incorporate these critical factors so as to optimize recovery and isolation of pathogens while minimizing contamination. IMPLICATIONS It is important for microbiologists and practitioners to understand how and why these critical factors affect current blood-culture practices to improve patient management. Future research should emphasize which of these critical factors will still play a role in the era of molecular diagnostic tests, which will no longer be relevant, and which new critical factors have yet to be defined.
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Affiliation(s)
- M L Wilson
- Department of Pathology & Laboratory Services, Denver Health, Denver, CO, USA; Department of Pathology, University of Colorado School of Medicine, Aurora, CO, USA.
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46
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Zimmerman FS, Assous MV, Zevin S, Wiener-Well Y. Reducing blood culture contamination using an initial specimen diversion device. Am J Infect Control 2019; 47:822-826. [PMID: 30638673 DOI: 10.1016/j.ajic.2018.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/02/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES False positive blood cultures result from contamination, consuming laboratory resources and causing unnecessary antibiotic treatment and prolonged hospital stay. Skin disinfection reduces contamination; however, bacteria colonizing human skin are also found in tissues deep into the skin surface. A diversion device diverts the initial 1-2 mL of blood to remove any potentially contaminated skin plug. This study investigates the effect of the device on culture contamination in hospitalized patients. METHODS In this prospective controlled pragmatic study, blood cultures were obtained using an initial specimen diversion device, either via integrated needle or attachment to a newly placed intravenous catheter. Cultures taken using standard methods served as the control. RESULTS Six hundred seventy-one blood cultures were obtained. Two hundred seven cultures were taken using an initial specimen diversion device, with 2 (1.0%) contaminated cultures. Four hundred sixty-four cultures were taken without the device, with 24 (5.2%) contaminated cultures (P < .008). No significant difference was shown in the rate of true-positive cultures. CONCLUSIONS The use of a diversion device was associated with reduced culture contamination in hospitalized patients over a 6-month period, without concomitant reduction in true-positive cultures. This intervention may result in a reduction in costs, antibiotic use, and duration of hospital stay.
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47
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Ombelet S, Barbé B, Affolabi D, Ronat JB, Lompo P, Lunguya O, Jacobs J, Hardy L. Best Practices of Blood Cultures in Low- and Middle-Income Countries. Front Med (Lausanne) 2019; 6:131. [PMID: 31275940 PMCID: PMC6591475 DOI: 10.3389/fmed.2019.00131] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/29/2019] [Indexed: 12/25/2022] Open
Abstract
Bloodstream infections (BSI) have a substantial impact on morbidity and mortality worldwide. Despite scarcity of data from many low- and middle-income countries (LMICs), there is increasing awareness of the importance of BSI in these countries. For example, it is estimated that the global mortality of non-typhoidal Salmonella bloodstream infection in children under 5 already exceeds that of malaria. Reliable and accurate diagnosis of these infections is therefore of utmost importance. Blood cultures are the reference method for diagnosis of BSI. LMICs face many challenges when implementing blood cultures, due to financial, logistical, and infrastructure-related constraints. This review aims to provide an overview of the state-of-the-art of sampling and processing of blood cultures, with emphasis on its use in LMICs. Laboratory processing of blood cultures is relatively straightforward and can be done without the need for expensive and complicated equipment. Automates for incubation and growth monitoring have become the standard in high-income countries (HICs), but they are still too expensive and not sufficiently robust for imminent implementation in most LMICs. Therefore, this review focuses on "manual" methods of blood culture, not involving automated equipment. In manual blood cultures, a bottle consisting of a broth medium supporting bacterial growth is incubated in a normal incubator and inspected daily for signs of growth. The collection of blood for blood culture is a crucial step in the process, as the sensitivity of blood cultures depends on the volume sampled; furthermore, contamination of the blood culture (accidental inoculation of environmental and skin bacteria) can be avoided by appropriate antisepsis. In this review, we give recommendations regarding appropriate blood culture sampling and processing in LMICs. We present feasible methods to detect and speed up growth and discuss some challenges in implementing blood cultures in LMICs, such as the biosafety aspects, supply chain and waste management.
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Affiliation(s)
- Sien Ombelet
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.,Department of Microbiology and Immunology, KULeuven, Leuven, Belgium
| | - Barbara Barbé
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Dissou Affolabi
- Centre National Hospitalier Universitaire-Hubert Koutoucou Maga, Cotonou, Benin
| | | | - Palpouguini Lompo
- Clinical Research Unit of Nanoro, Institut de Recherche en Science de la Santé, Nanoro, Burkina Faso
| | - Octavie Lunguya
- National Institute for Biomedical Research, Kinshasa, Democratic Republic of the Congo.,Department of Medical Biology, Cliniques Universitaires, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.,Department of Microbiology and Immunology, KULeuven, Leuven, Belgium
| | - Liselotte Hardy
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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MacVane SH, Raux BR, Smith TT. Evaluation of rapid polymerase chain reaction-based organism identification of gram-positive cocci for patients with a single positive blood culture. Eur J Clin Microbiol Infect Dis 2019; 38:1471-1479. [PMID: 31079314 DOI: 10.1007/s10096-019-03574-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 04/29/2019] [Indexed: 11/28/2022]
Abstract
For patients with a single-positive blood culture growing gram-positive cocci, organism identification can provide supportive information for differentiating contamination from infection. We investigated the effect of a rapid blood culture identification panel (BCID) on vancomycin-prescribing patterns and patient outcomes for single positive blood culture (PBC) growing gram-positive cocci. Adult patients with single-positive blood culture growing gram-positive cocci with conventional organism identification (pre-BCID) were compared with organism identification by BCID (post-BCID). Antimicrobial Stewardship Program (ASP) review of PBC was performed in both study groups. Vancomycin prescribing patterns were studied. Secondary endpoints were the incidence of nephrotoxicity, length of stay (LOS), readmission rate, mortality, and hospital costs. A total of 188 patients (86 pre-BCID, 102 post-BCID) were included. Organism identification was known 21 h sooner in the post-BCID group (P < 0.001). Coagulase-negative staphylococci were the most commonly isolated organisms (73%). In patients where vancomycin was deemed unnecessary (n = 133), vancomycin use (51% pre-BCID vs 36% post-BCID; P = 0.09) and time from culture positivity to vancomycin discontinuation (1.5 vs. 1.7 days; P = 0.92) did not differ between groups. We found no differences in the development of nephrotoxicity, LOS, readmission, mortality, or hospital costs. Earlier identification of single positive blood culture growing gram-positive cocci did not significantly influence prescribing patterns of vancomycin. However, baseline antimicrobial stewardship review of single positive blood culture growing gram-positive cocci may have lessened the opportunity for detectable differences. Larger studies, accounting for the impact of ASP intervention, should be performed to determine the value of each individual component.
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Affiliation(s)
- Shawn H MacVane
- Department of Pharmacy, South Carolina College of Pharmacy Residency Program, Medical University of South Carolina, Charleston, SC, USA. .,Division of Infectious Diseases, South Carolina College of Pharmacy Residency Program, Medical University of South Carolina, Charleston, SC, USA. .,Accelerate Diagnostics Inc, 3950 S Country Club Rd #470, Tucson, AZ, 85714, USA.
| | - Brian R Raux
- Medical Center/South Carolina College of Pharmacy Residency Program, Medical University of South Carolina, Charleston, SC, USA
| | - Tiffeny T Smith
- Department of Pharmacy, South Carolina College of Pharmacy Residency Program, Medical University of South Carolina, Charleston, SC, USA.,Division of Infectious Diseases, South Carolina College of Pharmacy Residency Program, Medical University of South Carolina, Charleston, SC, USA
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49
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Geisler BP, Jilg N, Patton RG, Pietzsch JB. Model to evaluate the impact of hospital-based interventions targeting false-positive blood cultures on economic and clinical outcomes. J Hosp Infect 2019; 102:438-44. [PMID: 30928573 DOI: 10.1016/j.jhin.2019.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 03/21/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Blood culture contamination (BCC) increases length of stay (LOS) and leads to unnecessary antimicrobial therapy and/or hospital-acquired conditions (HACs). AIM To quantify the magnitude of additional LOS, costs to hospitals and society, and harm to patients attributable to BCC. METHODS A retrospective matched survival analysis was performed involving hospitalized patients with septicaemia-compatible symptoms. BCC costs, HACs and potential savings were calculated based on the primary LOS data, a modified Delphi process and published sources. The cost analysis compared standard care with interventions for reducing BCC, and estimated annual economic and clinical consequences for a typical hospital and for the USA as a whole. FINDINGS Patients with BCC experienced a mean increase in LOS of 2.35 days (P=0.0076). Avoiding BCC would decrease costs by $6463 [$4818 from inpatient care (53% of which was from reduced LOS) and 26% from reduced antibiotic use]. Annually, in a typical 250- to 400-bed hospital, employing phlebotomists would save $1.3 million and prevent 24 HACs (including two cases of Clostridium difficile infection); based on clinical efficacy evidence, use of the studied initial specimen diversion device (ISDD) would save $1.9 million and prevent 34 HACs (including three cases of C. difficile infection). In the USA, the respective strategies would prevent 69,300 and 102,900 HACs (including 6000 and 8900 cases of C. difficile infection) and save $5 and $7.5 billion. CONCLUSION Costs and clinical burdens associated with false-positive cultures are substantial and can be reduced by available interventions, including phlebotomists and use of ISDD.
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Abstract
Studies published between 1999 and 2011 demonstrated increased blood culture contamination with catheter-drawn cultures compared with percutaneously-drawn cultures. Studies published between 2012 and 2015 reported that use of antiseptic barrier caps on central venous catheter hubs significantly reduces the incidence of catheter-drawn blood culture contamination. Local guidelines regarding sites for blood culture collection should reflect institution-level blood culture contamination rates for percutaneously-drawn and catheter-drawn cultures using currently available technologies that reduce contamination at both sites.
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