Effectiveness of practices to reduce blood culture contamination: a Laboratory Medicine Best Practices systematic review and meta-analysis

A multi-pronged approach to improve blood culture diagnostics in different clinical departments: a single-centre experience

PURPOSE

Blood culture (BC) diagnostics are influenced by many factors. We performed a targeted interdisciplinary analysis to analyse effects of various measures on BC diagnostics performance.

METHODS

A diagnostic stewardship initiative was conducted at two intervention and two control wards in a German tertiary level hospital. The initiative comprised staff training on the correct indications and sampling for BC, implementation of information cards, labels to identify the collection site, regular BC bottle feedback including the number of bottles, filling volumes and identified pathogens; and the use of a specific sampling device (BD Vacutainer®). Before and after the interventions, two three-month measurement periods were performed, as well as a one-month follow-up period to assess the sustainability of the conducted measures.

RESULTS

In total, 9362 BC bottles from 787 patients were included in the analysis. The number of BCs obtained from peripheral venous puncture could be increased at both intervention wards (44.0 vs. 22.2%, 58.3 vs. 34.4%), while arterial sampling could be reduced (30.6 vs. 4.9%). A total of 134 staff members were fully trained. The intervention led to a considerable increase in BC knowledge (from 62.4 to 79.8% correct answers) with differences between the individual professional groups. Relevant reduced contamination rates could be detected at both intervention wards.

CONCLUSIONS

As knowledge on the correct BC sampling and strategies to reduce contamination varies considerably between clinical departments and healthcare professionals, a targeted training should be adapted to the specific needs of the individual professional groups. An additional filling device is not necessary.

Sites of blood collection and topical disinfectants associated with contaminated cultures: An ambidirectional cohort study

Background

We aimed to determine whether puncture sites for blood sampling and topical disinfectants are associated with rates of contaminated blood cultures in the emergency department (ED) of a single institution.

Methods

This single-center, ambidirectional cohort study of 548 consecutive patients ≥20 years of age was performed in the ED of a university hospital in Japan over a 13-month period. Pairs of blood samples were collected for aerobic and anaerobic cultures from patients in the ED. Physicians selected puncture sites and topical disinfectants according to their personal preference.

Results

Potential contamination was identified in 110 of the 548 patients (20.1%). One hundred fourteen (20.8%) patients showed true-positive results for bacteremia, and 324 (59.1%) patients showed true-negative results. Multivariate analysis revealed more frequent contamination when puncture sites were disinfected with povidone-iodine (PVI) than with alcohol/chlorhexidine (ACHX) (adjusted risk difference, 19.1%; 95% confidence interval [CI]), 15.7-22.6; p < 0.001). In terms of blood collection sites, femoral and central venous (CV) catheter with PVI disinfection showed more frequent contamination than venous sites with ACHX (adjusted risk differences: 26.6%, 95% CI 21.3-31.9, p < 0.001 and 41.1%, 95% CI 22.2-59.9, p < 0.001, respectively).

Conclusion

Rates of contaminated blood cultures were significantly higher when blood was collected from the CV catheter or femoral sites with PVI as the topical disinfectant.

Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship

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.

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

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.

The use of a diversion tube to reduce blood culture contamination: A "real-life" quality improvement intervention study

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.

Contamination of Blood Cultures From Arterial Catheters and Peripheral Venipuncture in Critically Ill Patients: A Prospective Multicenter Diagnostic Study

BACKGROUND

Collecting blood cultures from indwelling arterial catheters is an attractive option in critically ill adult patients when peripheral venipuncture is difficult. However, whether the contamination proportion of blood cultures from arterial catheters is acceptable compared with that from venipuncture is inconclusive.

RESEARCH QUESTION

Is contamination of blood cultures from arterial catheters noninferior to that from venipuncture in critically ill adult patients with suspected bloodstream infection?

STUDY DESIGN AND METHODS

In this multicenter prospective diagnostic study conducted at five hospitals, we enrolled episodes of paired blood culture collection, each set consisting of blood drawn from an arterial catheter and another by venipuncture, were obtained from critically ill adult patients with cilinical indication. The primary measure was the proportion of contamination, defined as the number of false-positive results relative to the total number of procedures done. The reference standard for true bloodstream infection was blinded assessment by infectious disease specialists. We examined the noninferiority hypothesis that the contamination proportion of blood cultures from arterial catheters did not exceed that from venipuncture by 2.0%.

RESULTS

Of 1,655 episodes of blood culture from December 2018 to July 2021, 590 paired blood culture episodes were enrolled, and 41 of the 590 episodes (6.9%) produced a true bloodstream infection. In blood cultures from arterial catheters, 33 of 590 (6.0%) were positive, and two of 590 (0.3%) were contaminated; in venipuncture, 36 of 590 (6.1%) were positive, and four of 590 (0.7%) were contaminated. The estimated difference in contamination proportion (arterial catheter - venipuncture) was -0.3% (upper limit of one-sided 95% CI, +0.3%). The upper limit of the 95% CI did not exceed the predefined margin of +2.0%, establishing noninferiority (P for noninferiority < .001).

INTERPRETATION

Obtaining blood cultures from arterial catheters is an acceptable alternative to venipuncture in critically ill patients.

CLINICAL TRIAL REGISTRATION

University Hospital Medical Information Network Center (UMIN-CTR); No.: UMIN000035392; URL: https://center6.umin.ac.jp/.

Blood culture collection practices in NICU; A national survey

Background

Sepsis is the leading cause of mortality and morbidity in neonates. Blood cultures are the gold standard in diagnosing neonatal sepsis; however, there are currently no consensus guidelines for blood culture collection in neonates and significant practice variation exists in Neonatal Intensive Care Units (NICUs) globally.

Objective

To examine current practices in obtaining blood cultures in the evaluation of neonatal sepsis in NICUs across Canada.

Methods

A nine-item electronic survey was sent to each of the 29 level-3 NICUs in Canada, which are equipped to provide highly specialized care for newborns.

Results

Responses were received from 90% (26/29) of sites. Sixty-five percent (17/26) of sites have blood culture collection guidelines for the investigation of neonatal sepsis. Forty-eight percent (12/25) of sites routinely target 1.0 mL per culture bottle. In late-onset sepsis (LOS), 58% (15/26) of sites process one aerobic culture bottle, whereas four sites routinely add anaerobic culture bottles. In early-onset sepsis (EOS) in very low birth weight infants (BW <1.5 kg), 73% (19/26) of sites use umbilical cord blood, and 72% (18/25) use peripheral venipuncture. Two sites routinely collect cord blood for culture in EOS. Only one site applies the concept of differential time-to-positivity to diagnose central-line-associated bloodstream infection.

Conclusions

There is significant practice variation in methods used to obtain blood cultures in level-3 NICUs across Canada. Standardization of blood culture collection practices can provide reliable estimates of the true incidence of neonatal sepsis and help to develop appropriate antimicrobial stewardship strategies.

A Quality Improvement Initiative on Reducing Blood Culture Contamination in the Emergency Department

INTRODUCTION

Contaminated blood cultures may have detrimental effects on patients, the organization, and antimicrobial stewardship. Patients in the emergency department may need blood cultures collected before antimicrobial therapy. Contaminated blood culture samples may contribute to prolonged hospital stay and also are associated with delayed or unnecessary antimicrobial therapy. This initiative aims to improve the emergency department's blood culture contamination rate that will eventually benefit the patients who will receive timely and proper antimicrobial therapy, and benefit the organization fiscally.

METHODS

This quality improvement initiative used the Define-Measure-Analyze-Improve-Control (DMAIC) process. The organization targets blood culture contamination rate of ≤2.5%. Control charts were used to study how blood culture contamination rate changed over time. In 2018, a workgroup was formed to work on this initiative. Improved site disinfection using 2% Chlorhexidine gluconate cloth before the standard procedure of blood culture sample collection was initiated. Chi squared test of significance was used to compare blood culture contamination rates 6 months before and during feedback intervention as well as contamination rate from source of blood draw.

RESULTS

Blood culture contamination rates 6 months before and during feedback intervention showed significant decrease (3.52% before intervention and 2.95% after intervention; P < .05). Contamination rates differed significantly based on the source of blood culture draw (7.64% via line, 3.05% via percutaneous venipuncture, and 4.53% via other; P < .01).

DISCUSSION

Blood culture contamination rate continued to decrease with the use of a predisinfection process with 2% Chlorhexidine gluconate cloth before blood sample collection process. Practice improvement also was evident with effective feedback mechanism.

Higher nursing care level is associated with higher incidence of blood culture contamination in the emergency department: A case-control study

Background

Blood culture is critical in treating infectious diseases. This leads to unnecessary intervention, inappropriate antibiotic use, and excess cost. Few studies have tackled patient factors that could possibly affect contamination rates. This study aimed to explore the association between patients' nursing care levels and blood culture contamination.

Methods

This is a single-centered, retrospective, case-control study of adult patients whose blood culture specimens were taken in the emergency department between April 2018 and July 2019. The study was conducted in an acute care community hospital in Japan. The case group included patients with false-positive blood culture results with contamination; the control group included patients with true-positive or true-negative blood culture results without contamination. We randomly selected two control patients per case. Patients' age, gender, nursing care level, ambulance use, housing status, Glasgow Coma Scale, hospital arrival time, and puncture sites were obtained from the patients' medical charts.

Results

Of the 5130 patients, 686 patients got positive blood culture results. Of the 686 patients, 35 patients were included in the case group, and 70 were randomly selected from the noncontaminated group and included in the control. In multivariate analysis, patients with contaminated blood cultures had a higher nursing care level (adjusted odds ratio: 8.50; 95% confidence interval: 1.65-43.7; p = 0.01).

Conclusions

A higher nursing care level is associated with a higher incidence of blood culture contamination in the emergency department. Careful and appropriate procedures are required for patients with a higher nursing care level.

Initial Specimen Diversion Device Utilization Mitigates Blood Culture Contamination Across Regional Community Hospital and Acute Care Facility

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.

Multidrug-Resistant Bacteria Isolated from Blood Culture Samples in a Moroccan Tertiary Hospital: True Bacteremia or Contamination?

Purpose

To demonstrate the relevance of clinico-biological correlation in the interpretation of positive blood cultures (BC) for multidrug-resistant (MDR) bacteria, among adult and pediatric patients, in order to distinguish between true bacteremia (TB) and contaminations and to evaluate the impact on patient management.

Patients and Methods

This six-month study was conducted at Mohammed VI University Hospital in Marrakech. All MDR bacteria isolated from BCs carried out on hospitalized patients during this period were included. For each positive BC to MDR microorganism, demographic and clinical characteristics, laboratory findings, therapeutic and evolution data were collected.

Results

TB was considered in 157 (94.6%) of the 166 positive-culture episodes for MDR bacteria, while 9 (5.4%) were classified as false-positive. Contamination rate was 0.2% (9/3824). TB and contaminations occurred mainly in intensive care units (ICUs), with the neonatal ICU being the most concerned (p = 0.016). Clinical signs of sepsis were present in all TB patients, with a significant difference between the two groups (p = 0.000). CRP values were higher in the TB group (p = 0.000). The most isolated true pathogens were ESBL-producing Enterobacterales (50%) and carbapenem-resistant Enterobacterales (33.3%). They also predominated in contaminated BCs. Isolation of the same microorganism from other sites was significantly associated with TB (p = 0.012). In contrast to the contaminations group, the difference in the clinical course of TB patients, according to whether or not they received appropriate probabilistic antibiotics, was statistically significant (p = 0.000). These patients had longer hospital stays and longer durations of antibiotic therapy. The overall mortality rate was 39.6%.

Conclusion

Distinguishing between MDR-positive BCs representing clinically significant bacteremia or simple contamination requires a careful clinical, biological, and microbiological confrontation of each MDR positive BC in order to avoid unnecessary overuse of broad-spectrum antibiotics and thus reduce resistance selective pressure.

Dual-site blood culture yield and time to positivity in neonatal late-onset sepsis

OBJECTIVE

To determine whether culture yield and time to positivity (TTP) differ between peripheral and central vascular catheter-derived blood cultures (BCx) in neonatal intensive care unit (NICU) patients evaluated for late-onset sepsis.

DESIGN

Single-centre, retrospective, observational study.

SETTING

Level IV NICU.

PARTICIPANTS

The study included infants >72 hours old admitted to NICU in 2007-2019 with culture-confirmed bacteraemia. All episodes had simultaneous BCx drawn from a peripheral site and a vascular catheter ('catheter culture').

MAIN OUTCOME MEASURES

Dual-site culture yield and TTP.

RESULTS

Among 179 episodes of late-onset bacteraemia (among 167 infants) with concurrently drawn peripheral and catheter BCx, the majority (67%, 120 of 179) were positive from both sites, compared with 17% (30 of 179) with positive catheter cultures only and 16% (29 of 179) with positive peripheral cultures only. 66% (19 of 29) of episodes with only positive peripheral BCx grew coagulase-negative Staphylococcus, while 34% (10 of 29) were recognised bacterial pathogens. Among 120 episodes with both peripheral and catheter BCx growth, catheter cultures demonstrated bacterial growth prior to paired peripheral cultures in 78% of episodes (93 of 120, p<0.001). The median TTP was significantly shorter in catheter compared with peripheral cultures (15.0 hours vs 16.8 hours, p<0.001). The median elapsed time between paired catheter and peripheral culture growth was 1.3 hours.

CONCLUSION

Concurrently drawn peripheral and catheter BCx had similar yield. While a majority of episodes demonstrated dual-site BCx growth, a small but important minority of episodes grew virulent pathogens from either culture site alone. While dual-site culture practices may be useful, clinicians should balance the gain in sensitivity of bacteraemia detection against additive contamination risk.

Effect of the introduction of a management bundle for blood culture collection

BACKGROUND

Inappropriate blood collection subjected to blood culture (BC) causes BC contamination and may complicate the diagnose is of infectious diseases. Therefore, we developed a bundle based on the guideline recommendations for appropriate blood collection and examined the effects of bundle introduction.

METHODS

We performed a retrospective analysis of BC samples to determine the contamination rates before and after introducing the BC bundle. We also analyzed the correlation between the compliance rate of the bundle and contamination rate, and between each bundle element and contamination.

RESULTS

After the introduction of the bundle, the contamination rate was significantly reduced from 5.4% ± 0.9% to 1.7± 0.7% (P < .01). The compliance rate of the bundle was significantly associated with a lower contamination rate (P < .01). Multivariable logistic regression showed that collection from superficial veins of the cubital fossa (odds ratio [OR], 0.25; 95% confidence interval [CI], 0.13-0.51, P < .01) and disinfection of the skin at the blood collection site with 1% chlorhexidine alcohol swab (OR, 0.41; 95% CI, 0.25-0.68, P < .01) were significantly associated with lower contamination.

CONCLUSIONS

This study suggests that the introduction of the BC bundle significantly reduced the contamination rate, and bundle compliance was associated with a lower contamination rate.

Blood Culture Contamination Rate as a Quality Indicator - a Prospective Observational Study

Introduction: Blood culture test is the gold standard test to diagnose bloodstream infections, but contamination is the main problem in this valuable test. False positive results in blood cultures are mainly due to contamination that occurs mostly during pre-analytical procedures like sample collection and sometimes during sample processing. Materials and method:Our prospective observational study was undertaken at St. Theresa Hospital, Hyderabad, India, during January 2020-June 2020. Blood cultures received from inpatient departments (IPD) and outpatient departments (OPD) are included. Sample size: The contamination rate was calculated by dividing the total number of contaminated blood cultures by the total number of cultures multiplied by 100. Results:Blood culture contamination rate is 2.4%, which is within the limit as per the standard guideline. Conclusion:Contamination occurred mainly due to improper disinfection of the skin and environmental contamination.

Clinical decision rule for obtaining peripheral blood cultures in febrile oncology patients

BACKGROUND

The utility of peripheral blood cultures in pediatric oncology patients presenting with fever is controversial. A recent systematic review showed that about one in 40 bloodstream infections (BSIs) would be missed if only central venous line (CVL) cultures are obtained.

OBJECTIVE

To derive a clinical decision rule for obtaining peripheral blood cultures in pediatric oncology patients presenting to a pediatric emergency department (PED) with fever and a CVL.

DESIGN/METHOD

A retrospective chart review was performed on pediatric oncology patients referred to the PED for fever while on therapy. Logistic regression with a random intercept was used to determine independent predictors of BSI and generate a prediction model for obtaining peripheral blood cultures. The decision rule was generated from the best performance as measured by a receiver operator curve. Bootstrapping analysis was performed for internal validation.

RESULTS

Predictors that were significant and independently associated with positive peripheral blood cultures included vasopressor support (odds ratio [OR] 16.5, 95% confidence interval [CI]: 2.80-97.71), acute myeloid leukemia (AML) diagnosis (OR 6.9, 95% CI: 1.81-25.98), hypotension (OR 4.0, 95% CI: 1.05-15.17), mucositis (OR 8.2, 95% CI: 2.48-27.01), and maximum temperature in PED ≥39°C (OR 6.6, 95% CI: 2.36-18.20). The area under the curve (AUC) for this model was 0.90 (95% CI: 0.82-0.97) in the derivation cohort and 0.90 (95% CI: 0.81-0.98) after the internal validation.

CONCLUSIONS

We derived a clinical prediction model for deciding when to obtain peripheral blood cultures in febrile oncology patients with CVLs on active therapy. Future studies should focus on prospective and external validation of this diagnostic prediction tool.

Comparing blood culture contamination rates by different sampling methods in a paediatric emergency department

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.

Unresolved issues in the epidemiology and diagnosis of bacteremia: an opinion paper

Bacteremia is an important cause of morbidity and mortality worldwide and, despite the diagnostic and therapeutic advances of the last decades, the evidence supporting many diagnostic aspects of bacteremia is scarce. Information on the epidemiological evolution of this entity is limited and many methodological aspects of blood culture collection and analysis are under discussion. Furthermore, the recommendations of the main scientific societies on many of these aspects are variable and, in many cases, have not been updated recently. In this scenario, we have arranged a series of questions on different aspects of bacteremia and reviewed the literature trying to find proper answers for them. We offer our opinion on the topics where the evidence was weak. The topics covered include epidemiological aspects of bacteremia, indications for blood culture extraction, methods for obtaining and incubating samples, or ways of transmitting results from the microbiology laboratory. We do not intend to summarize the current clinical practice guidelines, nor will we deal with the therapeutic management of this entity. The aim of this paper is to review the current perspective on the diagnosis of bacteremia with a critical approach, to point out the gaps in the literature, to offer the opinion of a team dedicated to infectious diseases and clinical microbiology, and to identify some areas of knowledge on which future studies should focus.

Excess mortality attributable to antimicrobial-resistant bacterial bloodstream infection at a tertiary-care hospital in Indonesia

The burden of antimicrobial-resistant (AMR) infections in low and middle-income countries (LMICs) is largely unknown. Here, we evaluate attributable mortality of AMR infections in Indonesia. We used routine databases of the microbiology laboratory and hospital admission at Dr. Wahidin Sudirohusodo Hospital, a tertiary-care hospital in South Sulawesi from 2015 to 2018. Of 77,752 hospitalized patients, 8,341 (10.7%) had at least one blood culture taken. Among patients with bacteriologically confirmed bloodstream infections (BSI), the proportions of patients with AMR BSI were 78% (81/104) for third-generation cephalosporin-resistant (3GCR) Escherichia coli, 4% (4/104) for 3GCR plus carbapenem-resistant E. coli, 56% (96/171) for 3GCR Klebsiella pneumoniae, 25% (43/171) for 3GCR plus carbapenem-resistant K. pneumoniae, 51% (124/245) for methicillin-resistant Staphylococcus aureus, 48% (82/171) for carbapenem-resistant Acinetobacter spp., and 19% (13/68) for carbapenem-resistant Pseudomonas aeruginosa. Observed in-hospital mortality of patients with AMR BSI was 49.7% (220/443). Compared with patients with antimicrobial-susceptible BSI and adjusted for potential confounders, the excess mortality attributable to AMR BSI was -0.01 (95% CI: -15.4, 15.4) percentage points. Compared with patients without a BSI with a target pathogen and adjusted for potential confounders, the excess mortality attributable to AMR BSI was 29.7 (95%CI: 26.1, 33.2) percentage points. This suggests that if all the AMR BSI were replaced by no infection, 130 (95%CI: 114, 145) deaths among 443 patients with AMR BSI might have been prevented. In conclusion, the burden of AMR infections in Indonesian hospitals is likely high. Similar large-scale evaluations should be performed across LMICs to inform interventions to mitigate AMR-associated mortality.

Regression discontinuity of blood culture contamination rate after changing of disinfectants: retrospective observational study

Blood cultures are indispensable for detecting life-threatening bacteremia. Little is known about associations between contamination rates and topical disinfectants for blood collection in adults. We sought to determine whether a change in topical disinfectants was associated with the rates of contaminated blood cultures in the emergency department of a single institution. This single-center, retrospective observational study of consecutive patients aged 20 years or older was conducted in the emergency department (ED) of a university hospital in Japan between August 1, 2018 and September 30, 2020. Pairs of blood samples were collected for aerobic and anaerobic culture from the patients in the ED. Physicians selected topical disinfectants according to their personal preference before September 1, 2019; alcohol/chlorhexidine gluconate (ACHX) was mandatory thereafter, unless the patient was allergic to alcohol. Regression discontinuity analysis was used to detect the effect of the mandatory usage of ACHX on rates of contaminated blood cultures. We collected 2141 blood culture samples from 1097 patients and found 164 (7.7%) potentially contaminated blood cultures. Among these, 445 (20.8%) were true bacteremia and 1532 (71.6%) were true negatives. Puncture site disinfection was performed with ACHX for 1345 (62.8%) cases and with povidone-iodine (PVI) for 767 (35.8%) cases. The regression discontinuity analysis showed that mandatory ACHX usage was significantly associated with lower rates of contaminated blood cultures by 9.6% (95% confidence interval (CI): 5.0%–14.2%, P < 0.001). Rates of contaminated blood cultures were significantly lower when ACHX was used as the topical disinfectant.

Culture Ordering for Patients with New-onset Fever: A Survey of Pediatric Intensive Care Unit Clinician Practices

INTRODUCTION

Accurate assessment of infection in critically ill patients is vital to their care. Both indiscretion and under-utilization of diagnostic microbiology testing can contribute to inappropriate antibiotic administration or delays in diagnosis. However, indiscretion in diagnostic microbiology cultures may also lead to unnecessary tests that, if false-positive, would incur additional costs and unhelpful evaluations. This quality improvement project objective was to assess pediatric intensive care unit (PICU) clinicians' attitudes and practices around the microbiology work-up for patients with new-onset fever.

METHODS

We developed and conducted a self-administered electronic survey of PICU clinicians at a single institution. The survey included 7 common clinical vignettes of PICU patients with new-onset fever and asked participants whether they would obtain central line blood cultures, peripheral blood cultures, respiratory aspirate cultures, cerebrospinal fluid cultures, urine cultures, and/or urinalyses.

RESULTS

Forty-seven of 54 clinicians (87%) completed the survey. Diagnostic specimen ordering practices were notably heterogeneous. Respondents unanimously favored a decision-support algorithm to guide culture specimen ordering practices for PICU patients with fever (100%, N = 47). A majority (91.5%, N = 43) indicated that a decision-support algorithm would be a means to align PICU and consulting care teams when ordering culture specimens for patients with fever.

CONCLUSION

This survey revealed variability of diagnostic specimen ordering practices for patients with new fever, supporting an opportunity to standardize practices. Clinicians favored a decision-support tool and thought that it would help align patient management between clinical team members. The results will be used to inform future diagnostic stewardship efforts.

Bringing the clinical laboratory into the strategy to advance diagnostic excellence

OBJECTIVES

Clinical laboratory testing provides essential data for making medical diagnoses. Generating accurate and timely test results clearly communicated to the treating clinician, and ultimately the patient, is a critical component that supports diagnostic excellence. On the other hand, failure to achieve this can lead to diagnostic errors that manifest in missed, delayed and wrong diagnoses.

CONTENT

Innovations that support diagnostic excellence address: 1) test utilization, 2) leveraging clinical and laboratory data, 3) promoting the use of credible information resources, 4) enhancing communication among laboratory professionals, health care providers and the patient, and 5) advancing the use of diagnostic management teams. Integrating evidence-based laboratory and patient-care quality management approaches may provide a strategy to support diagnostic excellence. Professional societies, government agencies, and healthcare systems are actively engaged in efforts to advance diagnostic excellence. Leveraging clinical laboratory capabilities within a healthcare system can measurably improve the diagnostic process and reduce diagnostic errors.

SUMMARY

An expanded quality management approach that builds on existing processes and measures can promote diagnostic excellence and provide a pathway to transition innovative concepts to practice.

OUTLOOK

There are increasing opportunities for clinical laboratory professionals and organizations to be part of a strategy to improve diagnoses.

Real World Evaluation of the Impact of Implementation of the VIRTUO Blood Culture System in a Tertiary Care Hospital

The bioMerieux BACT/ALERT VIRTUO (VIRTUO) blood culture system used in combination with resin-containing media may enhance the growth of microorganisms. Our objective was to assess the impact of transitioning to the VIRTUO system in comparison to the VersaTREK blood culture system at a tertiary care medical center. We retrospectively reviewed all blood cultures performed at a 1250-bed academic medical center between January-December 2018 (VersaTREK) and January-December 2019 (VIRTUO). Blood culture positivity rates and contamination rates were compared pre- versus post-VIRTUO implementation. Of 101,438 blood cultures performed during the study period, 48,839 (48.1%) were processed pre-implementation and 52,599 (51.9%) post-implementation. The blood culture positivity rate increased from 8.1% pre-implementation to 11.7% post-implementation (p<0.001). Staphylococcus aureus was the most frequently isolated species in both time periods and had higher recovery rate post-implementation (1.5% of all blood cultures obtained pre- vs. 3.4% post-implementation, p<0.001). A higher recovery rate in the post-implementation period was also noted for coagulase-negative staphylococci (1.9% pre- vs. 2.7% post-implementation, p<0.001), as well as modest but statistically significant changes for E. coli (0.8% vs. 1.0%, p<0.001), K. pneumoniae (0.4% vs. 0.5%, p=0.005) and Candida albicans. (0.1% vs. 0.2%, p=0.038). The inpatient blood culture contamination rate was higher post-implementation (1.5% pre- vs. 1.9% post-implementation, p<0.001). The VIRTUO blood culture system was associated with a higher observed proportion of positive blood cultures compared to the previous VersaTREK system. Future studies are needed to assess whether an increased rate of positive blood cultures is associated with changes in clinical outcomes.

Investigation of Antimicrobial Susceptibilities Among Bacteria Isolated from Blood Cultures in Hospitalized Patients, Tehran, Iran

Background: Bacteremia is the status, which is detected via a positive blood culture test with no contamination. Centers for Disease Control and Prevention (CDC) indicates that direct medical procedures and total costs are significantly high. Antibiotic resistance can play a major role in the costs, which are related to the long duration of treatment. Objectives: The aim of this study was to investigate the rate and profiles of antimicrobial susceptibility of blood culture isolates from Tehran, Iran. Methods: In the current cross-sectional study, a total of 5,000 blood culture samples were collected from patients hospitalized in the Loghman General Hospital, Tehran, Iran, with positive blood culture results from 2012 to 2013. Susceptibility to antimicrobial agents was analyzed using National Committee for Clinical Laboratory Standards guidelines. Results: Coagulase-negative staphylococci (38.8%), Staphylococcus aureus (20.5%), Acinetobacter (11.9%), and Escherichia coli (11.7%) were the most frequent bacteria isolated from the blood cultures, collectively accounting for > 80% of the isolates. Of isolated microorganisms, 63.75% and 36.24% belonged to Gram-positive and Gram-negative bacteria, respectively. Moreover, 88% of the isolates were MRSA (oxacillin-/methicillin-resistant), and 7% were VRE (vancomycin-resistant). Conclusions: The most frequent isolated organisms were Gram-positive bacteria, and the rate of MDR (multi-drug resistance) was high. The results of the current study obviously indicate the misuse of antibiotic in society. National surveillance studies in Iran will be useful for clinicians to choose the right empirical treatment and will help control and prevent infections caused by resistant organisms.

Modification of Blood Test Draw Order to Reduce Blood Culture Contamination: A Randomized Clinical Trial

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.

Central Line Care and Management: Adopting Evidence-Based Nursing Interventions

Central line-associated bloodstream infections occur not only in the intensive care unit but also the non-intensive care units of the hospital. The purpose of this article is to review current evidence to guide perianesthesia nurses in the care of a patient with a central vascular access device (CVAD). The CVAD bundle focuses on five key elements: hand hygiene, maximal sterile barrier, chlorhexidine antiseptic, catheter site selection, and daily evaluation of the need for the device. Once the CVAD is placed, evidence-based care and maintenance are the responsibility of the nurse. Ensuring proper maintenance and care of a CVAD falls within nursing practice and interventions can significantly reduce the patient's risk of central line-associated bloodstream infection. The single most crucial step a nurse can take to help prevent central line-associated bloodstream infections is performing proper hand hygiene. Other interventions focus on dressing management, bathing practices, access of intravenous infusion sets, blood draws, and management of port line occlusions. Familiarity and adoption of best practice interventions in the maintenance and care of patients with CVADs will help the perianesthesia nurse protect patients and prevent harm.

Sites of blood collection and topical antiseptics associated with contaminated cultures: prospective observational study

We aimed to determine whether puncture sites for blood sampling and topical disinfectants are associated with rates of contaminated blood cultures in the emergency department (ED) of a single institution. This single-center, prospective observational study of 249 consecutive patients aged ≥ 20 years proceeded in the ED of a university hospital in Japan during 6 months. Pairs of blood samples were collected for aerobic and anaerobic culture from all patients in the ED. Physicians selected puncture sites and topical disinfectants according to their personal preference. We found 50 (20.1%) patients with potentially contaminated blood cultures. Fifty-six (22.5%) patients were true bacteremia and 143 (57.4%) patients were true negatives. Multivariate analysis associated more frequent contamination when puncture sites were disinfected with povidone-iodine than with alcohol/chlorhexidine (adjusted risk difference, 12.9%; 95% confidence interval [CI] 8.8–16.9; P < 0.001). Sites of blood collection were also associated with contamination. Femoral and central venous with other sites were associated with contamination more frequently than venous sites (adjusted risk difference), 13.1% (95% CI 8.2–17.9; P < 0.001]) vs. 17.3% (95% CI 3.6–31.0; P = 0.013). Rates of contaminated blood cultures were significantly higher when blood was collected from femoral sites and when povidone-iodine was the topical antiseptic.

Prevalence and Predictors of Bacterial Contamination in Excisional Lymph Node Biopsies: Implications for Diagnosis and Management

Routine tissue handling exposes lymph node specimens to microbial contamination that can confound microbiological culture results and interfere with diagnosis. The scope and impact of this problem remain poorly understood. We combined over 13 years of lymph node pathology, culture data, and patient records to define the prevalence, predisposing factors, microbiology, and clinical management of false-positive lymph node cultures at a large academic medical center. Nearly one third (31.9%) of 216 cultured lymph nodes yielded bacterial growth. Approximately 90% of positive bacterial cultures grew 1 of 2 common skin-resident taxa-coagulase-negative Staphylococcus and Cutibacterium acnes-with well-documented predispositions for contamination in other clinical settings. Lymph nodes excised from axillary, cervical, and inguinal regions yielded higher positive culture rates than nodes excised from the mediastinum, suggesting proximity to the skin surface may increase contamination risk. Accordingly, cultures from thoracoscopic pulmonary resections displayed contamination rates over 5-fold lower than those from percutaneously accessed lymph nodes. Lymph nodal tissue allocated for culture in the operating room yielded unexpectedly high contamination rates, significantly higher than cultures sent from the frozen section processing area. A significant minority of contamination events were noted in the clinical record and prompted antibiotic therapy on multiple occasions. Collectively, our results illuminate the risk factors contributing to bacterial contamination and argue that routine lymph node bacterial cultures provide minimal clinical benefit for adult patients. This widespread bacterial contamination also warrants cautious implementation of increasingly sensitive molecular microbiology tools for excised tissues.

Reducing Blood Culture Contamination in the Emergency Department

BACKGROUND

Blood culture contamination results in delayed or unnecessary treatments, increased morbidity risk, extended lengths of hospital stay, and increased health care costs. Collecting 2 sets of blood cultures from separate sites helps differentiate bloodstream infections (BSIs) from contamination.

LOCAL PROBLEM

Blood culture contamination rates trailed the national threshold of less than 3% in one southeastern US emergency department (ED). Same-site and single-set collection issues were also identified.

METHODS

This pre-/postintervention quality improvement study included 1137 patients (preintervention: n = 560; postintervention: n = 577) of all ages with blood culture orders in a 13-bed tertiary care ED.

INTERVENTIONS

A staff educational program, blood culture collection checklist with protocol, and monthly collective and individual feedback were implemented.

RESULTS

Blood culture contamination rates decreased from 3.39% to 2.6%. Same-site collection rates decreased from 15.13% to 4.14%.

CONCLUSIONS

The interventions effectively reduced blood culture contamination rates and same-site blood culture collections in the ED, enhancing the quality of care for patients with BSIs.

Asynchronous Testing of 2 Specimen-Diversion Devices to Reduce Blood Culture Contamination: A Single-Site Product Supply Quality Improvement Project

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.

Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room

Aim and objective

To reduce the incidence of infiltration and phlebitis by 50% over 2 months among children admitted to the emergency room (ER) of a tertiary care hospital.

Materials and methods

The study was conducted in the pediatric ER of a tertiary care hospital in North India. All children aged >28 days, receiving intravenous (IV) medication and/or fluids, were enrolled between June (2017) and September (2017). Existing practices of IV line insertion and maintenance were observed and recorded. The visual infusion phlebitis score and infiltration assessment scale were to grade the extent of two. The intervention classified as “IV line insertion and maintenance bundle” included the introduction of low-cost mobile sterile compartment trays, audit and feedback, organizational change, introduction of infection control nurse and quality improvement (QI) team formations were implement in different Plan-Do-Study-Act (PDSA) cycles. Reduction in the “incidence of phlebitis and infiltration” was outcome measures while “scores on checklist of IV line insertion and IV line maintenance and administration of drugs” were process measures.

Result

The process measures, for IV line insertion, maintenance and administration of drugs through IV line, revealed an increase in scores on the checklist. There was a significant decrease in the incidence of infiltration and phlebitis from 82.9 and 96.1% to 45 and 55%, respectively, postimplementation of all PDSA cycles.

Conclusion

Multifaceted QI IV line insertion and maintenance bundle reduced the incidence of infiltration and phlebitis. These interventions when integrated into daily work bundles along with continuous education and motivation help in sustaining the goal and attaining long-term success.

How to cite this article

Singh N, Kalyan G, Kaur S, Jayashree M, Ghai S. Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room. Indian J Crit Care Med 2021;25(5):557–565.

Suspected Neonatal Sepsis: Tenth Clinical Consensus of the Ibero-American Society of Neonatology (SIBEN)

Suspected neonatal sepsis is one of the most common diagnoses made in newborns (NBs), but very few NBs actually have sepsis. There is no international consensus to clearly define suspected neonatal sepsis, but each time that this suspected diagnosis is assumed, blood samples are taken, venous accesses are used to administer antibiotics, and the mother-child pair is separated, with prolonged hospital stays. X-rays, urine samples, and a lumbar puncture are sometimes taken. This is of concern, as generally <10% and no more than 25%-30% of the NBs in whom sepsis is suspected have proven neonatal sepsis. It seems easy to start antibiotics with suspicion of sepsis, but stopping them is difficult, although there is little or no support to maintain them. Unfortunately, the abuse of antibiotics in inpatient and outpatient NBs is foolish. Its negative impact on neonatal health and the economy is a public health problem of epidemiological and even epidemic proportions. This manuscript is a shortened version of the 10^th Clinical Consensus of the Ibero-American Society of Neonatology (SIBEN) on suspected neonatal sepsis at the end of 2018, updated with publications from its completion to February 2020. This manuscript describes useful strategies for everyday neonatal practice when neonatal sepsis is suspected, along with important aspects about the indisputable value of clinical evaluation of the NB and about obtaining and interpreting blood cultures, urine cultures, and other cultures. Likewise, the low value of laboratory tests in suspected neonatal sepsis is demonstrated with evidence and clinical recommendations are made on the appropriate use of antibiotics.

Reducing Blood Culture Contamination Rates: Experiences of Four Hospital Systems

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.

Blood culture contamination in the emergency department: An integrative review of strategies to prevent blood culture contamination

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.

Effect of a bundle-approach intervention against contamination of blood culture in the emergency department

BACKGROUND

To prevent contamination when taking blood culture, there are various effective interventions. Whether there is greater efficacy by using a combination of these interventions has not been widely evaluated.

METHODS

Our six-element intervention bundle aimed to prevent contamination of blood culture in our emergency department (ED). Elements were: use of 1% chlorhexidine alcohol, alcohol wiping, hand hygiene, using sterile gloves, using holed sterile cover, and selection of upper extremities as the site of venipuncture. We compared the contamination rate of blood culture between the pre- and the post-intervention periods among all cases with two or more blood cultures taken in our ED. We also evaluated the rate of patients receiving vancomycin among all those transferred to the hospital from the ED.

RESULTS

During the pre- and post-intervention periods, 460 and 450 cases were included in analysis, respectively. Contamination of blood culture occurred in 29 pre-intervention cases (6.3%) and five post-interventional cases (1.1%) (relative risk 0.18, 95% confidence interval 0.07 to 0.45; P < 0.001). After bundle implementation, there was significant increase in adherence to using 1% chlorhexidine alcohol, alcohol wiping, hand hygiene, and using holed sterile covers. Among patients admitted to hospital, fewer patients received vancomycin during the post-intervention period than in the pre-intervention period (5.4% vs. 3.2%, P = 0.03).

CONCLUSIONS

Our intervention bundle dramatically reduced the contamination rate when drawing blood culture in our ED.

Compliance of clinical microbiology laboratories with recommendations for the diagnosis of bloodstream infections: Data from a nationwide survey in Italy

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.

Neonatal Sepsis Epidemiology in a Rural Province in Southeastern Cambodia, 2015-2017

Neonatal sepsis is the second most prevalent cause of neonatal deaths in low- and middle-income countries, and many countries lack epidemiologic data on the local causes of neonatal sepsis. During April 2015-November 2016, we prospectively collected 128 blood cultures from neonates admitted with clinical sepsis to the provincial hospital in Takeo, Cambodia, to describe the local epidemiology. Two percent (n = 3) of positive blood cultures identified were Gram-negative bacilli (GNB) and were presumed pathogens, whereas 10% (n = 13) of positive blood cultures identified were likely contaminants, consistent with findings in other published studies. No group B Streptococcus was identified in any positive cultures. The presence of GNB as the primary pathogens could help influence local treatment guidelines.

Pathogens causing central-line-associated bloodstream infections in acute-care hospitals-United States, 2011-2017

OBJECTIVE

To describe pathogen distribution and rates for central-line-associated bloodstream infections (CLABSIs) from different acute-care locations during 2011-2017 to inform prevention efforts.

METHODS

CLABSI data from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) were analyzed. Percentages and pooled mean incidence density rates were calculated for a variety of pathogens and stratified by acute-care location groups (adult intensive care units [ICUs], pediatric ICUs [PICUs], adult wards, pediatric wards, and oncology wards).

RESULTS

From 2011 to 2017, 136,264 CLABSIs were reported to the NHSN by adult and pediatric acute-care locations; adult ICUs and wards reported the most CLABSIs: 59,461 (44%) and 40,763 (30%), respectively. In 2017, the most common pathogens were Candida spp/yeast in adult ICUs (27%) and Enterobacteriaceae in adult wards, pediatric wards, oncology wards, and PICUs (23%-31%). Most pathogen-specific CLABSI rates decreased over time, excepting Candida spp/yeast in adult ICUs and Enterobacteriaceae in oncology wards, which increased, and Staphylococcus aureus rates in pediatric locations, which did not change.

CONCLUSIONS

The pathogens associated with CLABSIs differ across acute-care location groups. Learning how pathogen-targeted prevention efforts could augment current prevention strategies, such as strategies aimed at preventing Candida spp/yeast and Enterobacteriaceae CLABSIs, might further reduce national rates.

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

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.

Successful Reduction of Blood Culture Contamination in an Emergency Department by Monitoring and Feedback

Background:

Blood Culture (BC) contamination is a common problem in the Emergency Department (ED) and is associated with prolonged length of patient stay and excess costs.

Objective:

The study aimed to investigate the impact of monthly monitoring and feedback of BC results on contamination rates.

Methods:

Data from a previous study showed that the contamination rate in the ED consistently exceeded the recommended level. This triggered an ad hoc Quality Improvement team to develop and implement a corrective action plan. In 2017, BC contamination rates were reported to the ED on a monthly basis. In response to this, ED staff conducted intensified educational workshops, followed by private counselling and competency assessment of nurses who collected contaminated BCs.

Results:

A total of 12 educational workshops were conducted in February and March, 2017. The intervention resulted in >60% reduction in the contamination rate, from 8.6% baseline level to less than 3%. Of the 2660 BC sets drawn in 2017 from 1318 patients, 128 (4.8%) were contaminated, accounting for 39.5% of the total number of positive cultures. Sixty percent of the contaminated BCs grew Coagulase-negativeStaphylococcusspecies; other contaminants includedCorynebacteriumspp.,Micrococcusspp.,Propionibacteriumspp.,viridansStreptococcus, andNeisseriaspp.

Conclusion:

Continuous monitoring and feedback of contamination rates reduced BC contamination.

Reducing blood culture contaminations by use of hair nets and face masks

We have read the article by Sanders et al. with great interest. We appreciate the authors for their stewardship to decrease blood culture contamination rate. We would like to address the etiological distribution before and after the addition of hair nets and masks in the study. We would expect oral streptococci to decrease proportionally by using masks, but this rate did not decrease (4.7% versus 6.3%). We think that if a control group was formed in which face masks and hair nets were not used during the intervention 2 and 3 phase, similar low contamination rates would have been obtained. Strict hand hygiene, proper use of gloves, proper skin antisepsis, and nonpalpation of the disinfected area are crucial to prevent contamination. In conclusion, skin contamination constitutes a significant proportion of false culture positivity rates and is still a major problem.

[Training student nurses in taking blood cultures]

In cases of septic shock, high quality blood cultures are essential for identifying the causative agent and adapting the antibiotic treatment. Student nurses are relatively unfamiliar with recent guidelines on collecting blood cultures. Improving how they are taught during initial training, a key moment for the learning of best care practices, should help to optimise the global management of septic shock.

Reducing blood culture contamination using an initial specimen diversion device

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.

Drawing blood from peripheral intravenous cannula compared with venepuncture: A systematic review and meta-analysis

AIMS

To synthesize the evidence evaluating if blood samples are similar when obtained from peripheral intravenous cannula compared with venepuncture.

DESIGN

A systematic review and meta-analysis was undertaken.

DATA SOURCES

Searches were conducted in databases for English language studies between January 2000-December 2018.

REVIEW METHODS

The search adhered to the Meta-analysis of Observational Studies in Epidemiology guidelines. The methodological quality of studies was assessed using Joanna Briggs critical appraisal instruments. The overall quality of the evidence was assessed using the GRADE.

RESULTS

Sixteen studies were identified. Findings suggest haemolysis rates are higher in blood sampled from peripheral intravenous cannula. However, haemolysis rates may be lower if a peripheral intravenous cannula blood sampling protocol is followed. For equivalence of blood test results, even though some results were outside the laboratory, allowable error and were outside the Bland-Altman Level of Agreement, none of these values would have required clinical intervention. With regard to the contamination rates of blood cultures, the results were equivocal.

CONCLUSION

Further research is required to inform the evidence for best practice recommendations, including, if a protocol for drawing blood from a peripheral cannula is of benefit for specific patient populations and in other settings.

IMPACT

Venepuncture can provoke pain, anxiety and cause trauma to patients. Guidelines recommend blood samples from peripheral intravenous cannula be taken only on insertion. Anecdotal evidence suggests drawing blood from existing cannulas may be a common practice. Further research is required to resolve this issue.

A Laboratory Medicine Best Practices Systematic Review and Meta-analysis of Nucleic Acid Amplification Tests (NAATs) and Algorithms Including NAATs for the Diagnosis of Clostridioides (Clostridium) difficile in Adults

The evidence base for the optimal laboratory diagnosis of Clostridioides (Clostridium) difficile in adults is currently unresolved due to the uncertain performance characteristics and various combinations of tests. This systematic review evaluates the diagnostic accuracy of laboratory testing algorithms that include nucleic acid amplification tests (NAATs) to detect the presence of C. difficile The systematic review and meta-analysis included eligible studies (those that had PICO [population, intervention, comparison, outcome] elements) that assessed the diagnostic accuracy of NAAT alone or following glutamate dehydrogenase (GDH) enzyme immunoassays (EIAs) or GDH EIAs plus C. difficile toxin EIAs (toxin). The diagnostic yield of NAAT for repeat testing after an initial negative result was also assessed. Two hundred thirty-eight studies met inclusion criteria. Seventy-two of these studies had sufficient data for meta-analysis. The strength of evidence ranged from high to insufficient. The uses of NAAT only, GDH-positive EIA followed by NAAT, and GDH-positive/toxin-negative EIA followed by NAAT are all recommended as American Society for Microbiology (ASM) best practices for the detection of the C. difficile toxin gene or organism. Meta-analysis of published evidence supports the use of testing algorithms that use NAAT alone or in combination with GDH or GDH plus toxin EIA to detect the presence of C. difficile in adults. There is insufficient evidence to recommend against repeat testing of the sample using NAAT after an initial negative result due to a lack of evidence of harm (i.e., financial, length of stay, or delay of treatment) as specified by the Laboratory Medicine Best Practices (LMBP) systematic review method in making such an assessment. Findings from this systematic review provide clarity to diagnostic testing strategies and highlight gaps, such as low numbers of GDH/toxin/PCR studies, in existing evidence on diagnostic performance, which can be used to guide future clinical research studies.

Best Practices of Blood Cultures in Low- and Middle-Income Countries

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.

Bacteremia after professional mechanical plaque removal in patients with chronic periodontitis

OBJECTIVE

The aim of this study was to investigate the characteristics of bacteremia caused by professional mechanical plaque removal (PMPR) in two groups of patients with generalized moderate chronic periodontitis.

MATERIALS AND METHODS

Venous blood samples were taken at multiple time points for one hour following PMPR in fifty patients with generalized moderate chronic periodontitis. Subjects consisted of two groups, one group was receiving supportive periodontal therapy (SPT, n = 25) and the other group was receiving initial periodontal therapy (IPT, n = 25). Blood samples were processed and analyzed for cultivable microflora. Pertinent clinical parameters were recorded for each patient in both groups.

RESULTS

Bacteremia was detected in 10 of 25 SPT and 8 of 25 IPT patients (p = 0.796). In both groups, the prevalence of bacteremia was dependent on the time of blood sampling and varied in magnitude between <10²  CFU/ml and 10⁶  CFU/ml. Sixteen different bacterial species were identified in both groups, mostly Actinomyces naeslundii (SPT n = 3, IPT n = 4) and Streptococcus spp. (SPT n = 6, IPT n = 2). In regression models, Grade II furcation involvement (p = 0.004) and Gingival Bleeding Index (p = 0.036) had affected the occurrence of bacteremia but in the SPT group only.

CONCLUSION

Professional mechanical plaque removal was associated with bacteremia regardless of whether a patient was receiving SPT or IPT.

Drawing blood cultures through intravascular catheters: Controversy and update

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.

The effectiveness of interventions to reduce peripheral blood culture contamination in acute care: a systematic review protocol

BACKGROUND

Blood cultures are an integral part of the diagnosis of bacteremia in unwell patients. The treatment of bacteremia involves the rapid and accurate identification of the causative agent grown from the blood cultures collected. Contamination of blood cultures with non-pathogenic microbes such as skin commensals causes false positive results and subsequent unnecessary and potentially harmful interventions. While guidelines for blood culture quality recommend no more than 2-3% contamination rate, rates up to 12% are reported in the literature. There have been a number of methods proposed to reduce the contamination of blood cultures, including educational interventions, changing of skin cleansing preparations and introduction of blood culture collection packs in acute care settings. This protocol outlines methods to identify and evaluate interventions to reduce blood culture contamination in the acute care setting.

METHODS

The reviewers will conduct a systematic search of literature in CINHAL, PubMed, EMBASE and the Cochrane Central register of controlled trials. Unpublished works will be identified in ProQuest Dissertations and Theses. Articles will be assessed for relevance based on their title and abstract. Remaining relevant citations will have their full text retrieved and assessed against eligibility criteria. All studies that meet the eligibility criteria will have their methodological quality appraised. Assessments for relevance and methodological quality will be conducted independently by two reviewers. If appropriate, data will be analysed using the Mantel-Haenszel method under a random effects model. Heterogeneity of the studies will be assessed using the I 2 and chi-squared statistic. Meta-analysis will be attempted if the data is suitable.

DISCUSSION

This review will identify and summarise the interventions previously described in the literature aimed at reducing peripherally collected blood culture contamination rates in acute care. These findings have the potential to lead to multifaceted interventions based on previous evidence to reduce blood culture contamination in the acute setting. Reductions in the proportion of contaminated blood cultures have the potential to save money, unrequired treatment (particularly antimicrobials) and hospital bed days.

SYSTEMATIC REVIEW REGISTRATION

In accordance with guidelines outlined in the PRISMA-P methodology, this protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on December 8, 2017, and last updated on January 4, 2018 (registration number CRD42017081650).