Major article
Multidisciplinary team review of best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremias, reducing contamination, and eliminating false-positive central line–associated bloodstream infections

https://doi.org/10.1016/j.ajic.2015.06.030Get rights and content

Highlights

  • A prime reason for ensuring proper collection of blood cultures is to maximize the identification of true pathogens.

  • False-negative blood culture results are primarily caused by improper blood volume and number of sets.

  • Improper collection of blood cultures may lead to contamination of the sample (ie, false-positive result).

  • False-positive results are avoided with evidence-based interventions that may be implemented as a bundle.

  • Contamination of the blood culture sample may lead to over-reporting of central line–associated bloodstream infections.

Background

A literature search was conducted using keywords for articles published in English from January 1990 to March 2015. Using criteria related to blood culture collection and handling, the search yielded 101 articles. References used also included Microbiology Laboratory standards, guidelines, and textbook information.

Results

The literature identified diverse and complex issues surrounding blood culture practices, including the impact of false-positive results, laboratory definition of contamination, effect on central line–associated bloodstream infection (CLABSI) reporting, indications for collecting blood cultures, drawing from venipuncture sites versus intravascular catheters, selection of antiseptics, use of needleless connectors, inoculation of blood culture bottles, and optimizing program management in emergency departments, education, and implementation of bundled practice initiatives.

Conclusion

Hospitals should optimize best practice in the collection, handling, and management of blood culture specimens, an often overlooked but essential component in providing optimal care of patients in all settings and populations, reducing financial burdens, and increasing the accuracy of reportable CLABSI. Although universal concepts exist in blood culture practices, some issues require further research to determine benefit. Institutions undertaking a review of their blood culture programs are encouraged to use a checklist that addresses elements that encompass the research contained in this review.

Section snippets

Background

This article reports the findings of a project aimed at identifying evidence-based best practices in the preanalytical collection and handling phase5 and program management component of BC processing as spearheaded by members of the Blood Culture Task Force of Stony Brook University Hospital. The task force was initially formed as a subgroup of the hospital-wide effort to reduce CLABSI, later expanded to include quality improvement in the identification of true pathogens and decreasing

Enhancing the recovery of true pathogens (ie, avoidance of false-negative BCs)

The identification of true pathogens and subsequent antibiotic sensitivities provide the clinician with vital information for providing optimal treatment. The need to properly obtain blood for microbiologic culture takes on even greater significance when institutions consider that sepsis is currently the most costly hospital condition ($20.29 billion) among inpatients,6 has accounted for a 32% increase in hospitalizations in recent years,7 and is the leading cause of admission to a hospital for

Review of the literature

The evidence presented in this article was generated using a literature search for articles and other publications that addressed best practices in BC collection and handling; occurrence of false-negatives and the effect on the recovery of true pathogens, false-positives, and the effect on CLABSIs; and quality improvement programs. The search was conducted using Medline, PubMed, and Ovid for articles published in English (January 1990-March 2015) using the keywords blood culture, blood culture

Clinical indications for BCs

BCs should be obtained for specific clinical indications.47 An in-depth review of the literature by Willems et al indicates that BCs should be obtained in any patient with fever (≥38°C), hypothermia (≤38°C), leukocytosis, an absolute granulocytopenia, or a combination of these markers. Specific conditions in which BCs need to be drawn include sepsis, meningitis, suspected catheter-related bacteremia, infectious endocarditis, arthritis, osteomyelitis, and fever of unknown origin. BCs may be

ED interventions

It has been estimated that up to 50% of all BCs drawn in hospitals originate in an ED. Periods of increasing crowding in EDs have been associated with significant increases of BCC, suggesting that lapses in proper collection techniques by health care workers were contributory.135 Table 3 summarizes studies that have reported successful strategies in reducing contamination rates and other associated outcomes in EDs.53, 71, 78, 79, 136, 137, 138, 139, 140, 141, 142 A common practice in Pediatric

Conclusion

The currently available body of research indicates that improper collection of BCs is associated with suboptimal treatment of patients, increased financial burdens, and potential over-reporting of CLABSI. Best practices in the collection and handling of BC specimens require a thorough understanding of a variety of issues, including appropriate indications for drawing BCs, criteria for drawing from venipuncture sites versus intravascular catheters, selection and appropriate application of

Acknowledgments

We thank Lynn Hadaway, MEd, RN-BC, CRNI, Terry Murphy, BS, RN, CRN, CRNI, VA-BC, Wm. Dan Roberts, ACNP, PhD, and Francina Singh, RN, BScN, MPh, CIC, for their review and insights.

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    Conflicts of interest: None to report.

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