Clinical laboratory comparison of a slide blood culture system with a conventional broth system

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.

Prospective evaluation of a semiquantitative dip slide method compared with quantitative bacterial cultures of BAL fluid

BACKGROUND

Quantitative bacteriologic workup of BAL fluid (BALF) has evolved as a sensitive and specific technique for the diagnosis of bacterial pneumonia. Conventional quantitative cultures are expensive, time-consuming, and often unavailable on a 24-h basis. Therefore, we evaluated a dip slide method for the semiquantitative measurement of bacterial cultures in BALF specimens and compared the results with those from conventional quantitative cultures.

METHODS

Fifty BALF specimens from 45 patients with suspected pulmonary infection were examined prospectively with both methods. We compared the microbiologic results of conventional quantitative cultures with those of the dip slide method that is commercially available for blood cultures. Cost-effectiveness analysis of both methods was performed.

RESULTS

In 37 BALF specimens, 64 bacterial strains were detected with both techniques. The dip slide method and conventional cultures showed a high correlation with respect to the colony counts of the individual organisms per milliliter BALF (r=0.935; p= 0.0001) and the sum of colony counts in individual patients (r=0.947; p=0.0001). Although five strains were not detected by the dip slide technique, the diagnostic accuracy was not influenced. In 13 BALF samples, there was no growth of bacteria with both techniques. While the diagnostic yield of both methods was similar, the dip slide technique was 44 to 66% less expensive than conventional cultures.

CONCLUSIONS

The examination of BALF with a clip slide method is highly comparable to conventional quantitative culture techniques, less expensive, and can be used independently of a specialized microbiology laboratory on a 24-h basis.

Continuous-monitoring blood culture screening system improves the detection of bacteremia in neutropenic patients

One reason for the underdiagnosis of bacteremia as an etiology of fever in neutropenic patients might lie in inefficient blood culture techniques. This possibility was investigated in a retrospective study by comparing the efficacies of a manual and an automated blood culture system used to detect bacteremia in such patients. All neutropenic fever episodes accompanying all 93 intensive chemotherapy cycles of 26 consecutive patients with acute myelogenous leukemia (AML) enrolled in Finnish Leukemia Group AML 86 trial and treated in Oulu University Hospital over 3 1/2 years were analyzed. The chemotherapy protocol and the supportive care of the patients remained the same during the whole period. In 1990-91 the blood cultures were made manually and in 1992-93 with an automated continuous-monitoring culture screening system. Evaluable febrile episodes numbered 53 during 1990-91 and 73 during 1992-93. There was a statistically significant increase (p < 0.05) of culture-positive episodes, from 21% to 40%, when the continuous-monitoring system was adopted. The new method proved to be better than the manual one in detecting bacteremia of neutropenic patients.

Diagnosing bacteremia at a Danish hospital using one early large blood volume for culture

The objective of the study was to evaluate the yield of a blood culture based on inoculating 40 ml of blood drawn from 1 venipuncture. During a 3-year period (1990-1992) 1351 (19.3%) of 6994 blood culture sets were positive. The increased yield of true bacteremic events using 40 ml instead of 30 ml of blood per blood culture was estimated to be 4.2%. Contaminants were isolated in 5% of the blood culture sets, with coagulase negative staphylococci being the most frequently isolated contaminants (3.2%, 1.3% of the culture bottles). In most of cases, contaminants were only isolated in 1 or 2 of the 4 bottles of the set. Furthermore, a positive correlation was observed between the number of positive culture bottles and the recovery of a clinically-significant microorganism. Neither the frequency nor the interpretations of positive blood culture events with microorganisms of questionable significance were major obstacles. In conclusion, the spectrum and yield of microorganisms drawing 40 ml of blood from one venipuncture into 4 culture bottles was satisfactory. The method bears obvious advantages from a clinical point of view, since usually only 1 venipuncture is needed before institution of antibiotic treatment.

Evaluation and comparison of different blood culture techniques for bacteriological isolation of Salmonella typhi and Brucella abortus

An experimental study was carried out to evaluate and compare various noncommercial methods of blood culture for the isolation of Salmonella typhi and Brucella abortus from fresh human blood samples that had been artificially inoculated with 1 to 50 microorganisms per ml of blood. The methods compared included the Ruiz-Castañeda blood culture, broth blood culture, leukocyte lysis and direct plating on agar (WBL-P), leukocyte lysis and filtration, Ficoll-Hypaque centrifugation and filtration, Ficoll-Hypaque centrifugation, and Ficoll-Hypaque centrifugation and leukocyte lysis methods. Results with the WBL-P technique showed that S. typhi was isolated in 18 h, and its recovery rate was 36.6% (calculated from the number of CFU recovered per milliliter versus the number inoculated). B. abortus was isolated in 48 h by the same technique, and its recovery rate was 48.8%. The isolation times for the other blood culture techniques were between 36 and 44 h for S. typhi and 66 h for B. abortus. The techniques which relied on filtering systems for the recovery of S. typhi and B. abortus performed poorly. The WBL-P technique for the isolation of S. typhi and B. abortus is faster than the other methods tested.

Comparison of detection speed and yield in BACTEC NR-860 and Roche BCB blood culture systems

Detection speed and yield were compared between BACTEC NR-860 and Roche BCB blood culture systems. From a total of 1,550 paired blood cultures inoculated with the same volume of blood, 161 (10.4%) grew 180 organisms from 140 adult patients. Sixty-six percent of the isolates were clinically significant. The BACTEC system detected more clinically significant isolates than the BCB system, 91% vs 76% (p < 0.01), especially Enterobacteriaceae. In 39 paired blood cultures, 42 significant organisms were detected at different times in the two systems. The vast majority (93%) were detected first (on average 1 day faster) by the BACTEC system (p < 0.05), especially Escherichia coli and streptococci. Generally, detection times were shorter in the BACTEC system. Three fourths (76%) of all significant organisms were detected within the first incubation day as compared to less than half (42%) in the BCB system (p < 0.001). Generally, the agitated aerobic resin medium BACTEC 26 Plus had the fastest detection and highest yield in our study. The contamination rate, below 2% in both systems, was acceptable. The BACTEC NR-860 system with resin-containing media proved to be a reliable, sensitive and fast blood culture system, which deserves further investigation.

Critical assessment of blood culture techniques: analysis of recovery of obligate and facultative anaerobes, strict aerobic bacteria, and fungi in aerobic and anaerobic blood culture bottles

Recent reports have documented a decrease in anaerobic bacteremias and have questioned the need for routine anaerobic blood cultures. At the same time, we and others have noted an increase in fungal bloodstream infections. In this two-part study, we first compared recoveries of obligate anaerobic bacteria with those of fungi over a 13-year period and then examined the recoveries of all bacteria and fungi in aerobic and anaerobic blood culture bottles during a 12-month period. During the 13-year period, the number of patients with anaerobic bacteremia remained relatively constant (average, 39 patients per year), while the incidence of fungemia steadily increased, from 12 patients in 1978 to 117 patients in 1990. Of the 1,090 anaerobic isolates, 55.1 and 90.2% were recovered in aerobic and anaerobic bottles, respectively, compared with 98.6 and 37.0% of the 2,582 fungi. During the 12-month period of evaluation, 2,980 bacteria and fungi were recovered in cultures collected from 1,555 patients. Overall, 21.1% more organisms were recovered in aerobic bottles than in anaerobic bottles, including significantly more Staphylococcus species; gram-positive aerobic bacilli; Escherichia, Enterobacter, Pseudomonas, Xanthomonas, and Acinetobacter species; miscellaneous gram-negative bacilli; and yeasts. Only anaerobic gram-negative bacilli and non-spore-forming gram-positive bacilli were isolated more commonly in anaerobic bottles. These data support the concepts that bacteremia caused by obligate anaerobic bacteria is decreasing relative to sepsis caused by other bacteria and fungi and that the routine use of unvented anaerobic blood culture bottles reduces the recovery of common aerobic bloodstream pathogens.

Evaluation of the pediatric Septi-Chek blood culture system

The pediatric Septi-Chek blood culture system is a biphasic system that uses a 20-ml bottle of brain-heart infusion broth. We compared this system with a supplemented peptone broth tube (Vacutainer) for the recovery of aerobic organisms from blood cultures obtained from patients in a pediatric hospital. Blood specimens for culture were drawn into transport tubes containing sodium polyanetholsulfonate (SPS), and equal volumes were allocated into a Septi-Chek bottle and a Vacutainer tube which was vented for the first day of incubation. A total of 4828 blood culture sets was included, from which 243 probable pathogens were recovered, including 211 in the Septi-Chek system and 204 from the Vacutainer Tube. There were no significant differences in the recovery of individual pathogens. The mean time to initial detection of pathogens was comparable in the two systems, but the mean time to growth on solid media for pathogens recovered in both systems was shorter with Septi-Chek (37.2 hr compared with 45.5 hr, p less than 0.001). The pediatric Septi-Chek system is comparable with a vented Vacutainer tube for the recovery of aerobic pathogens, and its use facilitates the early identification and susceptibility testing of bloodstream pathogens.

Comparison of Roche blood culture bottle with an in-house conventional blood culture system

A comparison was made of the in-use performance of an in-house broth blood culture in a general hospital during 8 mths in 1988 with that of a commercial biphasic culture (BCB system, Roche Products Pty Ltd, Sydney) for the corresponding period in 1989. The clinical services and the number of blood samples tested were comparable. The yields of organisms after 48 hrs incubation were similar in both systems. Staphylococcus aureus showed up 3 times as often after 24 hrs incubation in the conventional system as in the BCB system. Agitation of the BCB facilitated macroscopic detection of growth in the initial 24 hrs incubation.

Nonvalue of terminal aerobic subculture of unvented Roche Columbia broth blood culture bottles

This study evaluated the need for a terminal aerobic blind subculture of unvented Roche Columbia broth. Only 2 of 2,871 bottles subcultured grew clinically significant organisms that were not also found in another blood culture. We conclude that in our tertiary care institution, blind subcultures of Roche Columbia broths are unwarranted.

Toothbrushing and transient bacteremia in patients undergoing orthodontic treatment

This study was made to determine whether and to what extent bacteremia occurred after toothbrushing in patients undergoing orthodontic treatment with fixed appliances. Twenty patients were selected, all with negative history of heart or hematologic disorders. These patients had not taken antibiotics or had a history of a cold in the previous 30 days. Blood samples of 20 ml were drawn before and 5 minutes after brushing. The immune status of the patients was tested by measurement of isohemagglutins and immunoglobulin levels. Blood samples were incubated in paired culture bottles containing trypticase soy broth (TSB) with an agar paddle and Columbia broth. All samples taken before brushing were negative for bacteria. Five of the 20 patients (25% of the sample) had positive blood tests after brushing. Both anaerobic and aerobic bacteria were identified from the blood samples. Those patients who were found to have a bacteremia did not display poor oral hygiene.

Controlled evaluation of BACTEC Plus 26 and Roche Septi-Chek aerobic blood culture bottles

Blood culture bottles that accept up to 10 ml of blood have recently been introduced for the BACTEC nonradiometric blood culture system. The new formulation, designated BACTEC Plus, contains 25 ml of tryptic soy broth, 0.05% sodium polyanetholesulfonate, and mixed resins. In a collaborative study conducted at three university hospitals, we evaluated the BACTEC Plus 26 (BP26) aerobic bottle and the Roche Septi-Chek aerobic bottle with its agar slide paddle in 5,293 paired blood cultures. Significantly more microorganisms (P less than 0.001), especially Staphylococcus aureus (P less than 0.001), Staphylococcus epidermidis (P less than 0.01), enterococci (P less than 0.005), and members of the family Enterobacteriaceae (P less than 0.005), were detected by the BP26 bottle. When both bottles detected growth, BP26 did so earlier (P less than 0.001). In particular, S. epidermidis (P less than 0.001), streptococci (P less than 0.005), enterococci (P less than 0.05), and members of the family Enterobacteriaceae (P less than 0.001) were detected earlier by the BP26 bottle. We conclude that the BP26 bottle provides a yield and speed of detection of microorganisms superior to those of the Roche Septi-Chek aerobic blood culture bottle.

Clinical comparison of the recoveries of bloodstream pathogens in Septi-Chek brain heart infusion broth with saponin, Septi-Chek tryptic soy broth, and the isolator lysis-centrifugation system

The recoveries of microorganisms in the Septi-Chek biphasic tryptic soy broth (TSB) and Isolator blood culturing systems were compared with the recovery in Septi-Chek biphasic brain heart infusion broth supplemented with the lytic agent saponin (L-BHIB; Roche Diagnostics, Division of Hoffmann-La Roche Inc.). A total of 5,096 TSB-L-BHIB blood culture sets and 1,778 Isolator-L-BHIB sets were evaluated. There were 435 pathogenic organisms recovered in 413 (8.1%) of the TSB-L-BHIB cultures, with 348 organisms in the TSB bottles and 370 in the L-BHIB bottles (P less than 0.05). Significantly more yeast isolates were recovered in the L-BHIB system (P less than 0.01). Terminal subculture of the L-BHIB system was required to detect 13 clinically significant organisms. Significantly more organisms were recovered in the L-BHIB bottles than with the Isolator system (P less than 0.001), including Torulopsis glabrata, coagulase-negative staphylococci, and Pseudomonas species. The time required for detection of all major groups of organisms was the same in both comparisons. However, detection of microbial growth in the L-BHIB bottles required macroscopic inspection of the attached agar slide unit and the use of terminal subcultures after 7 days of incubation. The primary advantage of the biphasic L-BHIB system when compared with either the biphasic TSB system or the Isolator system was improved recovery of fungi.

Comparison of the lysis-centrifugation and agitated biphasic blood culture systems for detection of fungemia

Although the detection of fungemia has been improved by the use of vented or biphasic blood culture bottles, the best recovery and earliest detection have been reported in the Isolator lysis-centrifugation system. It was recently demonstrated that improved detection of both bacteria and fungi was accomplished by mechanically agitating blood culture bottles for the first 24 h of incubation. In this study the detection of fungemia by use of the Isolator system was compared with that of an agitated biphasic system. A total of 182 fungi were isolated from blood specimens inoculated into both culture systems. No difference in the overall recovery of fungi or individual species of yeasts was observed between the two systems. However, all seven isolates of Histoplasma capsulatum were recovered in the Isolator system only. The time required to detect fungemia with each of the two systems was also compared. No statistically significant difference was observed. From the data collected during this 18-month study, it can be concluded that the overall recovery and time of detection of yeasts are equivalent in the lysis-centrifugation system and the agitated biphasic blood culture system. The lysis-centrifugation system is still superior for the detection of filamentous fungi such as H. capsulatum.

A comparison of oxoid signal with nonradiometric BACTEC NR-660 for detection of bacteremia

The Oxoid Signal (Oxoid U.S.A. Inc., Columbia, Maryland) system was compared with the nonradiometric BACTEC NR-660 (Johnston Laboratories, Towson, Maryland) system for detection of bacteria in 2714 blood cultures. The volume of blood collected into 20 ml blood-collection tubes containing sodium polyanetholsulfonate (SPS) (Becton Dickinson, Vacutainer Systems, Rutherford, New Jersey) ranged from 10 to 20 ml with an average of 15 ml. Subsequently, equal volumes of blood were inoculated into each system. A total of 250 organisms was isolated (9.6%), of which 149 (5.5%) were considered significant while 111 isolates from 98 cultures (3.6%) were contaminants. Of the significant isolates 32.9% were aerobic Gram-negative rods, 53.0% aerobic Gram-positive cocci, 5.4% anaerobes, 7.4% yeasts, and two isolates of Neisseria meningitidis. Ninety-five isolates were recovered in both systems, 29 by Bactec only and 25 by Signal only. Of the isolates recovered there were no significant differences in detection between the two systems with the exception of anaerobes (p less than 0.005). The median detection times for many of the most commonly isolated organisms--Enterobacteriaceae, streptococci, and Staphylococcus aureus--were very similar in both systems, ranging from 14 to 21 hours. With the remaining organisms recovered, the median times in hours for BAC-TEC and Signal, respectively, were 31 and 47 for Staphylococcus epidermidis, 48 and 60 for Bacteroides, 39 and 168 for yeast, and 16.5 and 168 for N. meningitidis. Oxoid Signal compares favorably with the BACTEC system. Its main advantages are: (1) it requires no instrumentation; (2) it is characterized by ease of detection; and (3) it uses a single-bottle system.(ABSTRACT TRUNCATED AT 250 WORDS)

Controlled comparison of a new Becton Dickinson agar slant blood culture system with Roche Septi-Chek for the detection of bacteremia and fungemia

Two commercially available agar slide blood culture systems, Septi-Chek (Roche Diagnostics, Div. Hoffmann-La Roche Inc., Nutley, N.J.) and VACUTAINER agar slant (Becton Dickinson [BD] Vacutainer Systems, Rutherford, N.J.), were compared in 5,628 paired blood cultures from adult patients. The systems were inoculated with equal volumes (5 ml) of blood. There was no statistically significant difference between the two systems in the overall recovery of clinically important microorganisms; however, significantly more Escherichia coli (P less than 0.05) organisms were detected in the Septi-Chek system. Concurrently, significantly more contaminants (P less than 0.001) also were present in Septi-Chek bottles. When microorganisms grew in both systems, there was no significant difference in the time to recovery of important organisms, except that anaerobes were detected more quickly in the BD system. This study suggests that the BD VACUTAINER agar slant is an acceptable alternative to the Septi-Chek system for routine blood cultures.

Detection of bloodstream infections in children

A critical responsibility of the clinical microbiology laboratory serving clinicians who care for infected children is accurate and timely detection of bacteremia. Blood culture protocols which are suitable for processing adult specimens are not necessarily the first choice for processing pediatric specimens. In this review, the following aspects of detection of bacteremia in children are covered: obtaining blood culture specimens from children, including skin disinfection, specimen volume and timing of specimen collection; the array of blood culture methods available, focusing upon conventional, radiometric, infrared spectroscopic and manometric broth cultures, as well as biphasic agar/broth and lysis direct plating techniques: the strengths and weaknesses of the various methods; and recommendations to laboratories for selection of a blood culture method based upon the laboratory's staffing level.

Comparative evaluation of the oxoid signal and Roche Septi-Chek blood culture systems

The Oxoid Signal blood culture system (Oxoid USA, Inc., Columbia, Md.) was compared with the Roche Septi-Chek system (Roche Diagnostics, Div. Hoffmann-La Roche Inc., Nutley, N.J.), with the latter consisting of a tryptic soy broth (R-TSB) bottle with an attached agar slide unit and a Columbia broth bottle. A total of 5,034 cultures with equal volumes of blood in each bottle were processed. Overall, more organisms were recovered in the R-TSB bottle than in the Signal bottle, with significantly more aerobic organisms (Pseudomonas spp., Acinetobacter spp., and yeasts) recovered in the R-TSB bottles and anaerobes and viridans group streptococci recovered in Signal bottles. Approximately equivalent numbers of organisms were recovered in the Signal and Columbia broth bottles. The times of detection were essentially identical with the three blood culture broth systems. During the study, 30.6% of the Signal bottles had a positive indicator of growth, of which 1,103 (71.7%) were false-positive cultures. Additionally, nonviable organisms resembling streptococci were observed in 13.7% of the Signal bottles that were Gram stained and in unioculated blood culture bottles. With appropriate modifications of the preparation of the media, the latter problem can be eliminated.

Effect of blood culture media on the in vitro recovery of Mycoplasma hominis

Despite the prevalence of Mycoplasma hominis few cases of septicaemia due to this organism have been reported. The ability of various blood culture media to sustain the growth of an inoculum of M. hominis was therefore studied. Of the media tested, an 'in-house' Hartley's digest broth with 0.1% glucose was the most efficient. The investigation also demonstrated that growth of M. hominis is adversely affected by the concentration of liquoid (sodium polyanetholsulphonate) present in blood culture media.

Comparison of a biphasic system and a non-radiometric system for blood culture

The performance of a biphasic system for blood culture and a non-radiometric system using infrared spectroscopy was compared using 2,000 blood samples. The biphasic system detected bacteria or fungi in 237 blood cultures in 114 patients, while the non-radiometric system detected these microorganisms in only 186 blood cultures in 91 patients (p less than or equal to 0.05). The speed with which the bacteria were detected and the rate of contamination were similar in the two systems. The capacity to detect different genera and species was similar except in the case of Brucella spp., which the biphasic system detected in 28 blood cultures but the non-radiometric system in only 12 (p less than or equal to 0.05).

Blood-culture techniques. A survey in Australasian laboratories

The blood-culture methods of participants in the Microbiology Quality Assurance Programme were surveyed in late 1983; 183 participants from Australasia and S.E. Asia completed a questionnaire, the results of which are discussed. The choice of skin disinfectants varied widely. Conventional broth media were used by 85 participants; one or more diphasic bottles by 56; Roche Septi-Chek was used by 25; and BACTEC by 17. Only 80% of respondents reported the use of sodium polyanethol sulfonate. Contamination rates ranged from 0 to greater than 10%. Cultures were kept for as little as five days or as long as three weeks and were examined by inspection and/or Gram stain and/or subculture at widely varying intervals. While a great diversity of methods was used, in most cases these were adequate. The workload involved in some of the more laborious routines was considerable. It would be desirable to evaluate the cost-effectiveness of many blood culture practices.

Effect of agitation and frequent subculturing on recovery of aerobic and facultative pathogens by Roche Septi-Chek and BACTEC blood culture systems

The positivity rate and time to recovery of pathogens were compared in Roche Septi-Chek (RSC-TSB) and BACTEC radiometric systems on 3,539 paired blood cultures. Both systems were steadily agitated, with frequent subculturing or processing of the RSC-TSB agar slides and BACTEC bottles, respectively, during the first 24 h of incubation. The RSC-TSB system recovered 249 pathogens (7.0% positivity rate), compared with 234 (6.6% positivity rate) isolates recovered from BACTEC. For the most common isolates, Staphylococcus aureus and the Enterobacteriaceae, the median time to detection was 15.8 h for BACTEC and 18.6 h for the RSC-TSB system. No statistically significant difference was observed in recovery of organisms from the two systems, except for S. aureus (P less than 0.05). In the RSC-TSB system, 42% of S. aureus, 58% of the Enterobacteriaceae, and 45% of Pseudomonas aeruginosa isolates had sufficient growth on the agar slant to allow performance of rapid standardized identification and susceptibility studies. In comparison with other studies using static incubation, it appears that agitation and frequent subculturing of the RSC-TSB system during the first 24 h of incubation decreased the time to detection for the majority of significant blood culture isolates.

Improvement of positive blood culture detection by agitation

To evaluate the advantages of agitation in reducing the detection time and increasing the recovery rate of positive blood cultures, 1,000 three-bottle sets of tryptic soy broth on adult inpatients were analyzed. Two bottles were transiently vented, one of which was agitated (250 rpm) for 7-19 hr at 35 degrees C. The other vented bottle and the anaerobic bottle were incubated stationary at 35 degrees C. Smears and subcultures were performed 7-19 hr after collection on both agitated and nonagitated vented bottles. Subcultures were done on all bottles at 72 hr and smears were performed on the anaerobic bottle. There were 137 of 1000 (13.7%) positive cultures from 90 patients. The agitated bottle detected 112 of 137 (81.8%) positive cultures, was the first or only means of detection in 57 of 137 cultures (41.6%), and was the only positive bottle in 30 of 137 (21.9%) cultures. The nonagitated vented bottle detected 89 of 137 (65.0%) of positive cultures and was the only means of detection in 13 of 137 (9.5%), but was never the first means of detection. The anaerobic bottle detected 76 of 137 (55.5%) of positive cultures, was the first or only means of detection in 11 of 137 (8.0%), and was the first means of detection in one of 137 (0.7%) cultures. When both the agitated and nonagitated bottle were positive, the agitated bottle was positive on the average 35 hr earlier. We conclude that agitation of the vented bottle in a conventional blood culture system significantly decreases the detection time of positive blood cultures and increases the number of positive blood cultures detected.

Performance characteristics of a commercially prepared biphasic blood culture bottle

A biphasic blood culture bottle (BiPB: GIBCO Laboratories, North Andover, Mass.) with an architectural design that physically separates the agar slant from the broth was compared with a conventional vented monophasic bottle (MPB-A) for use in the routine culture of blood. Both bottles contained tryptic soy broth. Tryptic soy agar was used for the BiPB slant. A third unvented bottle (MPB-N) with Columbia broth was included as part of the blood culture set. Of 3,537 sets collected, 444 were positive; 57 of these 444 sets were positive by virtue of an exclusively positive anaerobic bottle. Both BiPB and MPB-A were positive in 235 of the remaining 387 positive sets. A total of 521 isolates was recovered during the study. Of these isolates, 252 were recovered in both the BiPB and the MPB-A from the same set; 105 isolates grew in the BIPB but not in MPB-A, 95 isolates grew only in the MPB-A but not in BiPB, and 69 grew exclusively in the MPB-N. The BiPB allowed more rapid recovery of Candida spp., J-K diphtheroids, Pseudomonas spp. Making BiPB subcultures was easy enough to permit both early and daily subculture, which provided isolated colonies sooner than could be done by using the MPB-A. Isolated colonies and, therefore, identification and susceptibility results were available at least 1 day earlier for the BiPB isolates in approximately 50% of instances when both the BiPB and the MPB-A were positive. Staphylococcus epidermidis and streptococci were recovered more frequently in the BiPB, while gram-positive anaerobes were detected at a significantly (P less than 0.025) more frequent rate in the MPB-A than in the BiPB. Either bottle, however, should be used in conjunction with an anaerobic bottle for optimal recovery of anaerobic bacteria.

Controlled evaluation of the agar-slide and radiometric blood culture systems for the detection of bacteremia and fungemia

A commercially available agar-slide blood culture bottle (Septi-Chek; Roche Diagnostics, Div. Hoffman-La Roche, Inc., Nutley, N.J.) was compared with the radiometric blood culture system (BACTEC; Johnston Laboratories, Inc., Towson, Md.) in 8,544 paired blood cultures from adult patients. The systems were inoculated with equal volumes (10 ml) of blood. Overall, there was no statistically significant difference between the two systems in the recovery of clinically important microorganisms, but significantly more members of the family Enterobacteriaceae other than Escherichia coli were detected by the agar-slide system (P less than 0.005). The agar-slide system detected more fungi, and the BACTEC detected more anaerobic bacteria; however, small numbers of recovered organisms precluded statistical significance. When microorganisms grew in both systems, their presence was detected one or more days earlier in the BACTEC (P less than 0.001). More contaminants grew in the agar-slide system (P less than 0.001). Both systems performed well, and either system should provide high yield and prompt detection of positive blood cultures in patients with bacteremia and fungemia if used in an optimal way as recommended by the respective manufacturers.

A note on the use of 3-section plates for the estimation of the numbers of bacteria and to obtain isolated colonies in 1 day

By streaking with an open loop and then swabbing a 4-5 cm2 area on 3-section agar plates, it is possible to obtain isolated colonies and to estimate bacterial densities from 100 to 10(7)/ml on the swabbed area.

Comparison of a biphasic medium plus routine early subculture with a slide blood culture system

The accuracy of a biphasic medium plus routine early subculture on chocolate agar was compared with that of a slide blood culture system for detecting facultatively anaerobic bacteria in blood cultures. Over a three month period 2,745 pairs of blood cultures were examined. Bacteremia was diagnosed in 91 patients. Twelve cases would have been missed by using the slide blood culture system alone, in contrast to only three by the biphasic medium alone. The two techniques detected the same amount of contaminant bacteria. Although the slide blood culture system required less time in general, the biphasic medium proved more accurate for isolating Staphylococcus aureus (p = 0.005) and detected gram-positive bacteria more rapidly (p = 0.002).

Clinical comparison of an agar slide blood culture bottle with tryptic soy broth and a conventional blood culture bottle with supplemented peptone broth

The Roche Septi-Chek biphasic blood culture system with tryptic soy broth was compared with a conventional blood culture bottle with supplemented peptone broth in 6,956 paired blood cultures from adult patients. Both systems were inoculated with equal volumes of blood (5 ml) and incubated aerobically (vented) for 2 weeks. More clinically important bacteria and fungi, including Staphylococcus aureus, S. epidermidis, Escherichia coli and other Enterobacteriaceae, Pseudomonas aeruginosa, and Candida albicans and C. tropicalis were recovered from the biphasic system (P less than 0.001). In contrast, more clinically important anaerobic bacteria (P less than 0.001) and Gardnerella vaginalis (P less than 0.05) were recovered in conventional supplemented peptone broth. Staphylococci (P less than 0.01), Enterobacteriaceae other than E. coli (P less than 0.05), and fungi (P less than 0.001) were detected 1 or more days earlier in the biphasic system, whereas streptococci (P less than 0.001) were detected earlier in the conventional bottle. The overall superiority of the agar slide blood culture system compared with conventional blood culture bottles was confirmed by this evaluation. For optimal detection of anaerobic bacteremia, however, the agar slide bottle should be paired with an anaerobic bottle.

Determination of the optimum incubation period of blood culture broths for the detection of clinically significant septicemia

The value of incubating blood culture broths for more than 7 days was analyzed. A total of 20,155 blood cultures, consisting of a vented Roche tryptic soy broth (R-TSB) bottle and an unvented Difco thiol broth bottle, was processed; 2,509 organisms were recovered in the R-TSB bottles, and 1,865 organisms in the thiol bottles. Only 32 organisms isolated in the R-TSB bottles and 10 organisms isolated in the thiol bottles were detected after incubation for more than 7 days; 15 of the 32 isolates in the R-TSB bottles and all 10 of the isolates in the thiol bottles were either recovered in other blood cultures or were not considered to be clinically significant. Thus, incubation of the R-TSB bottles and unvented thiol bottles for more than 7 days is unnecessary for the detection of most clinically significant septicemias.

Controlled evaluation of Trypticase soy broth in agar slide and conventional blood culture systems

A commercially available biphasic blood culture system that utilizes an attachable agar slide paddle and Trypticase soy broth (BBL Microbiology Systems, Cockeysville, Md.) was compared with a conventional Trypticase soy broth blood culture bottle in 6,867 paired blood cultures from adult patients. Both systems were inoculated with equal volumes of blood (5 ml) and incubated aerobically (vented) for 2 weeks. More clinically important bacteria and fungi, including Staphylococcus epidermidis, streptococci, Escherichia coli, Klebsiella spp., other Enterobacteriaceae, and Pseudomonas aeruginosa, were recovered from the biphasic system (P less than 0.001). In contrast, more anaerobic bacteria of importance were recovered in the conventional bottle (P less than 0.01). Staphylococci (P less than 0.001), gram-negative facultative and aerobic bacteria (P less than 0.001), and fungi (P less than 0.001) were detected 1 or more days earlier in the biphasic system, whereas pneumococci (P less than 0.05) were detected earlier in the conventional bottle. Of 603 clinically important microorganisms that grew in the biphasic system, 601 (99.7%) were detected by day 7 of incubation, but only 403 of 490 microorganisms (82.2%) were detected by day 7 in the conventional bottle. Overall, the biphasic system was superior to the conventional bottle. For optimal detection of anaerobic bacteremia, however, the biphasic system should be used in conjunction with a complementary anaerobic conventional bottle.

Comparison of lysis-centrifugation with a biphasic blood culture medium for the recovery of aerobic and facultatively anaerobic bacteria

The Du Pont Isolator tube and Roche Septi-Chek blood culture bottle employ solid media which facilitate the removal of bacteria from static or cidal substances in blood to increase recovery and decrease detection time. In a comparison of 11,567 blood culture sets, the Isolator tube and vented Roche Septi-Chek bottle were positive for 533 (80%) and 494 (74%) of the aerobic and facultatively anaerobic organisms recovered, respectively. This difference was not significant. A significant difference was found in the overall detection time. The Isolator tube recovered the bacteria ca. 1 day earlier. The earlier detection time was most notable with Staphylococcus aureus, viridans streptococci, and Pseudomonas aeruginosa. Among the 355 bacteremic episodes analyzed by a computer program, the Isolator tube was responsible more often for the first report of bacteremia in a given patient. Both systems performed well for the recovery of aerobic and facultatively anaerobic bacteria, but it is recommended that either be used in combination with an unvented broth-containing bottle.

Initial detection of bacteremia by subculture of unvented tryptic soy broth blood culture bottles

Routine subculture of macroscopically negative blood cultures is a traditional blood culture procedure. The need to perform routine early (6-17 hr) and late (48 hr) subculture of unvented blood culture bottles when a simultaneous subculture of the vented bottle is performed has been questioned. Blood cultures in paired vented and unvented tryptic soy broth (TSB) bottles from 4574 patients were examined retrospectively. Subculture of unvented TSB bottles provided initial detection of 412 (5.0%) isolates from 277 (6.1%) patients and was comparable to that of vented TSB bottles for Pseudomonas and all other microorganisms, except for the Enterobacteriaceae (p less than 0.001; vented TSB), Candida (p less than 0.001; vented TSB), and Haemophilus influenzae (p less than 0.01; unvented TSB). Of the H. influenzae isolates, 46% were detected initially by subculture of the unvented TSB bottles; early subculture recovered 67% of these isolates. The value of subculture of unvented TSB bottles is minimized when subculture of the vented TSB bottle is routinely performed; however, routine subculture of the unvented bottle is recommended whenever TSB is used for detection of bacteremia in patients in whom H. influenzae infection is possible.

Comparison of the Roche Septi-Chek blood culture bottle with a brain heart infusion biphasic medium bottle and with a tryptic soy broth bottle

In a comparison of 1,368 positive blood cultures, a vented Roche Septi-Chek (V-RSC) blood culture bottle was superior to an unvented tryptic soy broth-containing bottle (Difco) for the recovery of all aerobic and facultatively anaerobic microorganisms. Anaerobic bacteria were recovered more frequently and earlier in the unvented tryptic soy broth-containing bottle. A separate comparison of 529 positive blood cultures was conducted to examine the performance of the V-RSC bottle with that of a vented brain heart infusion biphasic medium. The V-RSC bottle recovered significantly more isolates of Enterobacteriaceae and of anaerobic bacteria than did the vented brain heart infusion biphasic medium. The V-RSC bottle is a reliable blood culture system for all aerobic and facultatively anaerobic microorganisms. Because of its suboptimal recovery of anaerobic bacteria, it is recommended that the V-RSC bottle be used in combination with an unvented vacuum blood culture bottle.

Recent and innovative methods for detection of bacteremia and fungemia

Advances continue to be made in methods for more reliable or more rapid means of detecting bacteremia and fungemia. The importance of blood sample volume and broth dilution has been established in controlled studies. New technology includes the use of resins that remove antimicrobials from blood samples, detection of radioactivity from organisms given radiolabeled substrate, use of dyes that stain microbial DNA and RNA, use of slides coated with growth media, and lysis-centrifugation for trapping microorganisms. Technology now being considered includes counterimmunoelectrophoresis, head-space gas chromatography, electrical impedance, microcalorimetry, and the use of lasers to detect pH changes and turbidity.

Value of routine aerobic subculturing of unvented blood culture bottles

The value of performing routine aerobic subcultures of both vented and unvented blood culture bottles has not been evaluated critically. We studied 4,954 pairs of blood culture bottles consisting of one vented biphasic tryptic soy broth bottle (Roche Diagnostics) and one unvented Thiol broth bottle (Difco Laboratories). A total of 736 isolates were detected, of which 124 (17%) were in the Thiol broth bottle only. Some 15 isolates were detected only by subculturing the Thiol broth, and 13 of these isolates either were contaminants or were detected in previous positive cultures. Similar results were obtained when the unvented Thiol broth bottle was paired with a vented Difco tryptic soy broth bottle. Analysis of these pairs revealed a total of 360 isolates detected in 2,669 pairs of bottles, of which 83 isolates (23%) were in the Thiol broth bottle only. There were 11 isolates seen only in subcultures of the Thiol broth bottle, and 8 of these were probable contaminants. Thus, routine subculturing of unvented Thiol broth bottles had limited value. These results may differ with the use of other culture media or subculturing procedures. We recommend that each laboratory evaluate critically its experience with aerobic subcultures from unvented bottles.

Comparison of tryptic soy broth with tryptic soy broth supplemented with sucrose in the septi-chek blood culture system

The performance of tryptic soy broth (TSB) was compared with TSB supplemented with 10% sucrose (TSB-S) in the Septi-Chek blood culture system (Roche Diagnostics, Div. Hoffmann-La Roche Inc.). A total of 2,292 sets of blood cultures were evaluated. Although slightly more isolates were recovered in the TSB bottle in comparison with the TSB-S bottle, there was no significant difference between the two medium formulations in the recovery of either gram-positive or gram-negative bacteria. Significantly more isolates of fungi were recovered in the TSB bottles. At least 94% of all isolates were detected by day 3 of incubation in both the TSB and TSB-S bottles. Thus, the addition of sucrose to TSB did not result in greater total recovery or faster recovery of the isolates detected in this study.