Professional Documents
Culture Documents
Dr. John R. Warren Department of Pathology Northwestern University Feinberg School of Medicine June 2007
1In
order of decreasing probability of being a contaminant; % of blood isolates considered etiological in parentheses (Weinstein et al., 1997) 2Excluding Streptococcus pneumoniae
(%) of blood culture isolates from patients with indicated neutrophil count. Only differences statistically significant (p<.05) by 2 are included (Weinstein et al., 1997).
(%) of blood culture isolates from hypotensive and normotensive patients (Weinstein et al., 1977). 2p<.05 (2). Significant differences not observed with individual organisms, nor for unimicrobial bacteremia and fungemia.
no. of episodes = 843 (Weinstein et al., 1997) in which source confirmed by culture and/or clinical evidence 2Bowel and peritoneum, biliary tract, intra-abdominal abscess 3Skin, bone and joint, surgical wound, and other
in parentheses indicate bacteremic episodes for each organism. Weinstein et al., 1997 2(%)=% of the indicated source for the organism
Respiratory=19 (40%) GU=9 (19%) Respiratory=3 (25%) IV=5 (24%) Peritoneal=2 (10%) GU=4 (33%)
in parentheses indicate bacteremic or fungemic episodes for each organism. Weinstein et al., 1997 2(%)=% of the indicated source for the organism
No. (%) deaths/ No. episodes1 Hypotensive Normotensive 5/18 (28%) 14/141 (10%) 4/13 (31%) 10/103 (10%) 12/23 (52%) 19/104 (18%) 3/6 (50%) 5/42 (12%) 5/7 (71%) 14/46 (30%) 35/96 (36%) 85/668 (13%) 10/16 (63%) 17/63 (27%)
differences statistically significant (p<.05) by 2 are included (Weinstein et al., 1997). No significant differences in mortality were observed for coagulase-negative staphylococci, S. pneumoniae, other streptococci, Enterococcus, other gramnegative non-fermenters, and anaerobic bacteria.
Skin antisepsis
Preparation of skin with an agent bactericidal for surface bacterial commensals Commensals (especially coagulase-negative staphylococci) residing deep within sebaceous glands evade the bactericidal action of skin preparation agents Preparation agents include povidone-iodine (skin contact killing time of 1.5-2 min), tincture of iodine (contact killing time of 0.5 min), and recently chlorhexidine (ChloraPrep) (NMH: application to skin venepuncture site for 30 sec by back and forth friction scrub, followed by 30 sec drying time) Blood culture contamination rate reflects effectiveness of antisepsis with lowest rates obtained by laboratory phlebotomy teams
Volume of blood
Bloodstream infections frequently caused by relative few organisms in a given volume of blood (<1- 10 colony forming units/mL of blood) Sensitivity of blood cultures thus directly proportional to the volume of blood cultured Optimal volume for adults: 20-30 mL of blood per culture set Blood volumes >30 mL do not enhance the sensitivity of blood cultures for adults and contribute to nosocomial anemia Optimal volume for children (birth-15 y): 4 to 4.5% of patients total blood volume (Kellogg et al., JCM 38:2181-2185, 2000)
1Cockerill,
III et al., Clin Inf Dis 38:1724-1730, 2004. 2Pathogen recovery without endocarditis (n=763); 1st + bottle indicated for patients with 1 or more, 2 or more, 3 or more, and 4 or more (up to 6) collected. 3Consecutive blood culture drawn; 1 culture (n=118), 2 cultures (n=482), 3 cultures (n=62), 4 cultures (n=98), 5 cultures (n=0), and 6 cultures (n=3) drawn for the indicated number of patients.
1Cockerill,
III et al., Clin Inf Dis 38:1724-1730, 2004 2Pathogen recovery with endocarditis (n=40) and consecutive blood cultures (1-6) over 24 hours. 1st+ bottle indicated for patients with 1, 2, 3, or 4 or more bottles (up to 6) collected.
2004
Incubation conditions
Without EC With EC 1d 2,052 (76.5) 144 (77.8) 2d 393 (91.2) 26 (91.9) 3d 123 (95.8) 8 (96.2) 4d 61 (98.1) 1 (96.8) 5d 35 (99.4) 2 (97.8) 6d 14 (99.9) 4 (100) 7d 3 (100) ------------1Positivity of blood cultures for pathogens by incubation day (BACTEC 9240), EC=endocarditis 2Cockerill, III et al., Clin Inf Dis 38:1724-1730, 2004
Isolator (Wampole)
Isolator tube contains a blood cell lysing solution consisting of saponin and a fluorocarbon cushion that captures organisms during centrifugation Following centrifugation supernatants are discarded, and pellets resuspended for inoculation to solid medium appropriate for type of culture being performed (sheep blood, chocolate, MAC, CNA, BCYE, IMA, Middlebrook agar) Highly versatile and sensitive (except for anaerobic bacteria), but labor intensive for routine work Excellent system for isolation from blood of Mycobacterium avium or M. tuberculosis complex, dimorphic fungi, Bartonella, Legionella, and other fastidious pathogens
BacT/ALERT (bioMrieux)
The first continuous-monitoring blood culture system (CMBCS), introduced in early 1990s Broth bottles monitored continuously (every 10-15 min) for growth in self-contained modular units and bottles require no manipulation until flagged as positive for growth Growth monitored by a colorimetric CO2 sensor at the base of each bottle Computer algorithms interpret CO2 production as microbial growth when arbitrary thresholds exceeded, minimal linear increases of CO2 occur, or there is change in the rate of CO2 production
Characteristics of CMBCSs
Microbial growth detected 1-2 days earlier than with manual systems (total incubation time of 5 days) Provides 24/7 service with prompt reporting of Grams stain results for positive blood cultures Decreases laboratory workload
CNS Algorithm
Single blood culture + for CNS, no other blood cultures collected +/- 48 hr: Evaluation of patient for sepsis Single blood culture + for CNS, additional blood cultures collected +/- 48 hr negative for CNS: No ID or susceptibility unless physician request Single blood culture + for CNS, additional blood cultures collected +/- 48 hr positive for CNS: Evaluation of patient for sepsis Richter et al. JCM 40:2437-2444, 2002.
CNS Algorithm
If 2 or more blood cultures submitted and only one + for CNS, reported as likely contaminant (no species ID, no susceptibility) If 1 of 1 blood culture submitted and is positive for CNS, reported as of indeterminate significant and physician advised to contact laboratory if ID and susceptibility needed If 2 or more blood cultures submitted + for CNS, ID and susceptibility determined; if both isolates same species, ID and susceptibility reported; if different species, reported only as CNS without species and susceptibility Weinstein JCM 41:2275-2278, 2003.
References
Weinstein et al. The clinical significance of positive blood cultures in the 1990s: A prospective comprehensive evaluation of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults. Clin Inf Dis 24:584-602, 1997. Munson et al. Detection and treatment of bloodstream infection: Laboratory reporting and antimicrobial management. J Clin Micro 41:495-497, 2003. Jaimes et al. Predicting bacteremia at the bedside. Clin Inf Dis 38:357-362, 2004. Mohr et al. Manual and automated systems for detection and identification of microoranisms. Manual of Clinical Microbiology, Volume 1:185-191, 2003. Reimer et al. Update on detection of bacteremia and fungemia. Clin Micro Rev 10:444-465. Weinstein. Current blood culture methods and systems: Clinical concepts, technology, and interpretation of results. Clin Inf Dis 23:4046, 1996. Dunne et al. Blood Cultures III. Cumitech 1B, 1997.
References
Kellogg et al. Frequency of low-level bacteremia in children from birth to fifteen years of age. J Clin Micro 38:2181-2185. Cockerill III et al. Optimal testing parameters for blood cultures. Clin Inf Dis 38:1724-1730. Weinstein et al. Remarks concerning testing parameters for blood cultures. Clin Inf Dis 40:202, 2005. Cockerill III. Reply to Weinstein and Reller. Clin Inf Dis 40:202-203, 2005. Richter et al. Minimizing the workup of blood culture contaminants: Implementation and evaluation of a laboratory-based algorithm. J Clin Micro 40:2437-2444, 2002. Weinstein. Blood culture contamination: Persisting problems and partial progress. J Clin Micro 41:2275-2278, 2003. Mirrett et al. Relevance of the number of positive bottles in determining clinical significance of coagulase-negative staphylococci in blood cultures. J Clin Micro 39:3279-3281. Bates et al. Contaminant blood cultures and resource utilization. J Am Med Assoc 265:365-369, 1991.