Cumitech 1C: Blood Cultures IV

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To overcome this delay, various methods for rapid bacterial identification have been proposed. As well as bacterial identification, MALDI-TOF mass spectroscopy can detect strains carrying resistant genes such as those coding for carbapenemases, 2 contributing to the proper choice of antibiotics right from the beginning. These rapid pathogen identification systems have been proven to be cost-effective and associated with better clinical outcomes.

On the other hand, I feel that the importance of the proper management or handling of blood culture samples is considerably less recognized. If blood cultures are not submitted to clinical laboratories, the steps necessary to implement rapid bacterial identification systems are not initiated. At Okayama University Hospital, the clinical laboratory does not receive blood culture bottles during off-hours such as during the night and holidays. The incubation of blood samples begins on the following morning for samples collected overnight, and at the beginning of the week for samples collected on weekends.

For example, an incubation of blood samples obtained on Saturday is started on Monday, resulting in about a two-day delay before results are obtained. Delayed inoculations correspond to longer periods until results are reported. Thus, diagnosis of severe infections is often protracted at our facility.

Furthermore, the positive detection rate may decrease if the incubation of culture bottles is delayed by more than 24 h. With a sense of urgency, I have advised the Department of Clinical Laboratory and the Department of Infectious Diseases to reconsider the current examination system. However, my suggestions have unfortunately been rejected. Okayama University Hospital is a tertiary medical facility with more than admission beds including two intensive care units and an advanced emergency medical service center.

More than 10, operations per year are performed at the hospital, including organ transplantations. Many inpatients receive anticancer agents or immunosuppressive therapy.

Cumitech #1C Blood Cultures IV

Thus, many patients are immunocompromised and vulnerable to infections. For such a patient population, delays in diagnosis can lead to poor prognosis.

I argue that the present system for blood culture examination, i. If the number of clinical laboratory technicians is insufficient, hospital administrators should increase hiring accordingly. Clinicians should demand that blood culture samples are promptly incubated, even during off-hours, to improve patient prognosis.

How are blood culture examinations handled at other clinical hospitals? The importance of rapid diagnosis is becoming increasingly emphasized in this modern world of highly advanced medical technology, particularly in the field of infectious diseases. I hope our medical facility will respond to such demands and expectations. Thus, the available data suggest that iodine tincture and chlorhexidine products are likely to be equivalent and that both may reduce contamination rates to a greater degree than products containing povidone-iodine preparations.

Chlorhexidine preparations have the advantage of being both colorless and less irritating to skin, so that their use may allow one to abandon the additional step necessary with iodine preparations of removing the iodophor using a final alcohol scrub after the venipuncture is completed.

Both iodophors and chlorhexidine may have toxicity for neonates; further studies are needed One study found skin preparation for catheter insertion using 0. Until further studies are available, it is important to wash the area with alcohol when these disinfectants are used on the skin of neonates.

Some institutions substitute two separate alcohol cleansings, allowing the alcohol to dry thoroughly after each use, for the more active disinfectants if neonates are known to be sensitive to the other agents. If aqueous iodophors are used after the alcohol step, they are applied in increasing concentric circles from the actual venipuncture spot because the disinfectant takes so long to act to dry that viable contaminants might be reintroduced to the area that had been prepared if the swab is allowed to recontact the initial site.

There are no data supporting applying alcoholic disinfectants in an outward concentric circle, but vigorous friction is important. If palpation of the vein is necessary after skin disinfection, the gloved finger should be cleansed with the antiseptic agent and allowed to dry before touching the site.

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Some commercial preparations incorporate alcohol and disinfectant into a sponge to allow a one-step process. Methods of Obtaining Blood for Culture Venipuncture remains the technique of choice for obtaining blood for culture 6, Arterial blood cultures are not associated with higher diagnostic yields than venous blood cultures and are not recommended Blood cultures obtained from indwelling intravascular access devices are associated with greater contamination rates than are blood cultures obtained by venipuncture 17, 31, Although physicians and nurses may think they are saving patients the pain of an extra needle stick when blood cultures are obtained from catheters as opposed to venipuncture, they may actually be doing their patients and the health care system a disservice if contaminants are grown, resulting in the need for even more blood cultures and costly additional diagnostic studies or the immediate institution of long-term intravenous antibiotic therapy.

Blood obtained through an indwelling line is twice as likely to yield a contaminant than blood obtained through a properly prepared skin site So although blood occasionally may need to be obtained from intravenous lines and similar access devices, a culture of blood from such a device should be paired with another culture of blood obtained by venipuncture to assist in interpretation in the event of a positive result.

This technique was used to reduce potential contamination in case any skin microorganisms might be present on the first needle following the venipuncture. With increased concern about the risk of HIV transmission to health care workers associated with needle-stick injuries, the two-needle technique was abandoned when several studies showed that contamination rates were not significantly increased when a single needle was used for both venipuncture and inoculation of blood culture vials 61, 73, Although a subsequent meta-analysis demonstrated somewhat higher contamination rates with the single-needle method 3.

Blood may also be inoculated directly to evacuated culture vials containing broth media through a transfer set or a double-ended needle, or into an evacuated blood collection tube containing sodium polyanetholsulfonate SPS used for transfer to the laboratory where the specimen is then inoculated to culture vials.

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If the latter method is used, SPS is the preferred anticoagulant, since citrate, heparin, EDTA, and oxalate may be toxic for some bacteria. However, SPS is also toxic to some bacteria, such as Neisseria meningitidis If a direct inoculation method is used, collection bottles or tubes must be held below the level of the venipuncture needle to minimize the risk of reflux. In general, use of intermediate collection tubes is discouraged, since i SPS present in collection tubes will be added to that present in blood culture bottles, thereby increasing the final concentration of SPS in the blood-broth mixture; ii the extra step of transferring blood to ultimate bottles, tubes, or plates provides additional opportunity for contamination; iii transferring blood increases the risk of exposure of laboratory personnel to blood-borne pathogens; and iv use of collection tubes instead of direct inoculation into vials containing media may compromise cultures that are delayed or require transport to a distant laboratory.

Use of direct-draw methods does not allow the amount of backpressure to be controlled as is the case when a needle and syringe method is used; the arbitrary vacuum may result in collapse of veins and inability to obtain the correct volume of blood from some patients, such as the frail elderly or those on long-term chemotherapy. In addition, the vacuum present within culture vials may not be precise, and the volume of blood obtained may not be optimal.

After the appropriate volume of blood is obtained and inoculated to culture vials, the mixture should be gently agitated or the vials inverted to prevent clotting. If the vein is missed initially, a new needle or 8 Baron et al. As with all specimens submitted to the laboratory, blood culture vials should be labeled with the appropriate identification information and accompanied by an electronic or written requisition showing date and time of collection, the identification of the person collecting the specimen, and any other information required by institutional policy.

All bottles or tubes are labeled with two unique patient identifiers, such as name and birthdate or name and Social Security number. The specific site of collection which vein, which arm, etc. Denoting individual lumens has no additional value, and there is no literature to support the clinical relevance of results from an individual lumen. One method of obtaining this information is to supply test codes for order entry that represent specific sites. If the volume in any bottle is less than the total amount desired, the actual volume of blood injected into the bottle should be documented on information accompanying the bottle to the laboratory.

The volume of blood in collection tubes can be measured when the blood is transferred into blood culture broth. Transport to the Laboratory and Handling and Moving within the Laboratory 1. Blood should be transported as quickly as possible to the laboratory, preferably within 2 h, and should be placed into the incubator as quickly as possible. Although most modern blood culture instruments will detect growth at any stage, delay beyond 2 h in incubating cultures usually results in delay in detection of positives.

Those with positive color changes can be managed immediately. Those samples not received within these time frames must be stained and subcultured and incubated manually off-line.

Blood for culture should never be refrigerated or allowed to cool. Blood collected in tubes should remain at room temperature until it is injected into culture bottles. Because of their relatively small headspace and thin walls, tubes could be stressed by gas formation from growing organisms enough that they may explode if they are incubated. Safety for transport. Blood culture bottles should be carried in some sort of container that will protect them from dropping and from knocking against each other.

Technical Improvements in Culturing Blood

Carrying tubes or bottles in the hands is dangerous and should not be done, even for short distances within the laboratory. If tubes or bottles must travel through a pneumatic tube system, they should be checked in advance for ability to withstand the harshest conditions of transport. Many people feel that if the container is intact after being dropped to the floor from a 4foot height, it will be strong enough for transport in a pneumatic tube. There are no published studies on container strength.

Cumitech #1c Blood Cultures IV:

Bottle Examination, Processing Protocols, and Rejection Criteria Staff who receive blood cultures in the laboratory should check the bottles and requisitions carefully to detect a number of problems or errors, listed here. Depending on laboratory and hospital guidelines, specimens with improper labeling may need to be rejected. Bottles with no labels are usually rejected at all times. Patient identification data on the culture bottles and requisition must match, and mismatched specimens may have to be rejected, depending on laboratory policy.

Miscellaneous Media now available in shatter-resistant, plastic bottles that retain transparency and thermal resistance of glass. Bottles do not require venting and contain a liquid emulsion CO2 sensor and larger headspace with performance equal to traditional glass bottles. Controller module has touch-activated panel for text-free random loading and unloading of samples. Bar code scanner recognizes bottle type and patient accession data.

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FAN media formulations contain activated charcoal particles for nonspecific removal of toxic inhibitors of bacterial growth. This system detects CO2 production directly in the headspace of the bottle through the use of infrared laser spectroscopy. The system LCD screen provides one-touch access to bottle information and allows new bottles to be scanned and loaded into any available culture station. Visual and audible alerts with remote alarm capability or 6 3, Once every 12 min for stirred bottles; once every 24 min for stationary bottles Vortexing with a magnetic stir bar at 3, rpm 5 ml maximum ml bottle or 10 ml maximum ml bottle , 0.

Bottles must be checked for leaking or blood on the outside of the bottle. All blood products should be handled with gloves to avoid skin contact with blood. The collecting person should be notified immediately by telephone of the potential for causing risk to laboratory workers, and a note should be placed on the report stating that the sample was received contaminated, e. In some rare instances, bottles may crack before use or in transit to the laboratory.

Sepsis Diagnosis: The Path Forward - Clinical Lab Products

If the crack does not destroy the integrity of the bottle, i. Specimens submitted in wrong containers or tubes, such as a purple-top EDTA Vacutainer tube, cannot be processed as blood cultures. Notify the physician or collector immediately that the specimen is being rejected and explain the proper method.

Request resubmission of a sample using correct protocols. Blood cultures submitted in expired tubes or bottles should be processed, but the collecting site should be notified immediately to discard all expired bottles and obtain current supplies.