Blood Culture

Blood culture
A Positive Blood Culture Clinically Important Organism

Failure of host defenses to contain an
infection at its primary focus
Failure of the physician to effectively

eradicate, drain, excise, or otherwise remove that focus of infection
Indicator of disseminated infection

associated with poor prognosis
Clinical manifestation
Bacteremia or Fungemia
That simply identify the presence of bacteria or fungi respectively in the blood
Sepsis
The presence of clinical symptoms of infection in the presence of positive blood culture
Septicemia
Serious clinical syndrome associated with evidence of acute infection and organ failure related to release of mediators like cytokines into the circulation Septicemia may or may not be associated with positive blood culture
3
Clinical Patterns of Bacteremia and Fungemia

Transient bacteremia lasting minutes to hours, is most common occur after the manipulation of infected tissue surgical procedure involve contaminated or colonized mucosal surfaces onset of acute bacterial infection
Clinical Patterns of Bacteremia and Fungemia

Intermittent bacteremia occur, clear then recurs in the same patient due to the same microorganism Associated with under drained closed space infections Continuous bacteremia infective endocarditis occur early in the course of brucelosis and typhoid fever
Risk Factors for Bacteremia and Fungemia

There is increased risk at the extremes of age; premature infants are especially at risk for bacteremia Some of illnesses: hemotologic/nonhematologic malignancies Diabetes mellitus renal failure requiring dialysis hepatic cirrhosis immune deficiency syndromes
Mortality rates and Risk Factors Associated with Bacteremia

Condition Age of patient < 20 21-40 41-50 >50 Source of infection IV catheter Genitourinary Foley catheter Surgical wound Abscess Respiratory infection M ortality(%) Related risk of death 1.0 2.33 3.06 3.55 1.00 1.35 3.38 3.88 4.65 4.73
7
13.8 32.8 42.9 49.8 1.1 14.9 37.8 42.9 51.2 52.3

Condition Predisposing Condition Surgery Trauma Diabetes mellitus corticosteroids Renal failure Neoplasm cirrhosis Mortality(%) Related risk of death 0.78 1.37 1.43 1.59 1.79 2.01 3.40
8
16.3 27.3 30.0 33.3 37.5 42.1 71.5

condition Type of O rganism Nonfermenters Enterobactericaea E.coli Kle.pneum oniae Gram-positive cocci Strept. neumoniae Enterococci Unimicrobial bacteremia Polymicrobial bacteremia Fungi M ortality(% ) Related risk of death 6.84 3.36 4.52 3.08 2.08 4.28 5.96
27.7 35.5 48.0 32.7 22.0 45.5 37.7 63.0 67.7
The 10 major pathogens causing bacteremia and fungemia in adults from 1975 to 1977 and 1992 to 1993
Microorganism 1975-1977 1992-1993
E. coli S. aureus S. pneumoniae K. pneumoniae P. aeruginosa B. fragilis Enterococcus spp. S. pyogenes C. albicans P. mirabilis
S. aureus E. coli
CNS
K. pneumoniae Enterococcus spp. P. aeruginosa S. pneumoniae

Viridans groups streptococci
C. albicans E. cloacae
Major Pathogens Causing Nosocomial Bloodstream Infections, 1981-1998

Pathogen Rank % of isolates 1981-6 1987-92 (899) 1.0 5.2 18.7 2.7 11.6 8.0 6.1 10.0 5.9 8.7 (1655) 9.2 9.3 9.7 8.5 6.6 8.6 8.8 9.4 7.7 6.2 1993-8 (5209) 16.4 11.5 8.7 7.9 7.7 7.3 7.2 7.2 6.8 6.3 1 2 3 4 5 6 7 8 9 10
CoNS
Candida spp. S. aureus E. coli K. pneumoniae Enterobacter spp. Acinetobacter spp. P. aeruginosa Enterococcus
Other NFGNB
Blood Culture Collection Guidelines

Number of Cultures
Adult patients Two or three blood cultures per septic episode >95% detection ensuring adequate volumes of blood distinguish between clinically important and contaminant More than three blood cultures do not help distinguish between clinically important and contaminant expensive
Larry et al. 1997. Clin. Microbiol.Rev.

Set (Aerobic/Anaerobic, Two-Bottles) Number
Acute sepsis Endocarditis, acute 2-3 sets, separate sites, within 10 min 3 sets, separate sites, over 1-2 h if negative at 24h,3 more sets FUO 2-3 sets, separate sites, 1h apart; if negative at 24h, 3 more sets
Manual of Clinical Microbiology 2000
Endocarditis, subacute 3 sets, separate sites, 15min apart;

Disinfection
Culture Bottle 70% isopropyl alcohol to rubber stoppers and wait 1 min Venipuncture site 70% alcohol Swab concentrically with iodine preparation Allow iodine to dry Do not palpate vein Collect blood Remove iodine with alcohol

Blood Volume
Higher volume most productive Aerobic/anaerobic two-bottle set Adult: 10-20 ml/set Infant: 1-10 ml/set

Timing of Cultures
Soon after fever spike No difference in drawn simultaneously and serially

over a 24-h period
Li et al. 1994. J. Clin. Microbiol.

Collection Procedure
Not drawn from indwelling vascular catheters Culture bottle disinfected with alcohol swab Collected by venipuncture of peripheral veins Iodine should not be used to disinfect bottle Iodine or iodophore should be used in patients and wait for
1-3 min
Regarding
skin
preparation
with
iodine for venipuncture; bacteria are killed by drying, not by drowning.

Frank Koontz, Ph.D. University of Iowa Hospitals Iowa City, Iowa
A schematic overview of the Microbiology Laboratory

e in am Ex ain St
D/ I
ul tu
ST A
re
Specimen
Pr re elim po in rt ar Ph on y
Report
er ep or t
Blood Culture Methods

Manual Conventional broth Biphasic Lysis-centrifugation Automated BACTEC 460, 660,730, 860 BacT/Alert BACTEC 9000 series Difco ESP bioMerieux Vital Bio Argos
Principles of Laboratory Detection

Volume of blood Culture
Adult patient
The most important variable <1-10 CFU/ml Increasing 1 ml, increasing microbial recovery up to 3%
Children or infant
100-1000 CFU/ml Increasing volume, increasing yield Mermel & Maki 1993. Ann. Innter. Med.
Principles of Laboratory Detection

Ratio of Blood to Broth
Blood: broth (1:5 1:10) Diluting antimicrobial agents Diluting natural inhibitory factors Prevent clotting
Huang et al. 1998. Eur.J..Clin..Microbiol. Infect. Dis.
Pitfalls about Blood Cultures

Prolonged incubation (2-4 weeks)
Brucella, Bartonella Subacute bacterial endocarditis, FUO Faint gram-negative bacteria
Campylobacter, Helicobacter, Legionella, Brucella, Bartonella
Catheter-Drawn Blood
Continues to increase
Patients: little discomfort Physicians Ease of drawing blood Keeping catheter in place and treating with antibiotics
without removal of the catheter Identifying catheter-related septicemia: higher CFU from catheter-drawn vs. peripheral blood
Laboratory: NOT recommended
Management of Bacteremia
Essential Aspects
Early clinical recognition of sepsis Rapid laboratory detection of the causative organisms Prompt initiation of appropriate antimicrobial therapy
Notification and Reporting of Positive Blood Cultures

Gram-stained Morphotype
Preliminary Results Bacterial Genus and Direct AST Definitive Results Bacterial Species and Indirect AST
Positive Blood Culture Bottles

Gram-Stained Morphotypes
Gram positive versus Gram negative Bacilli, cocci, coccobacilli, curved bacilli, and others Differentiation among
Staphylococci, pneumococci, enterococci, other
streptococci
Enterobacteriaceae, NFGNB, Acinetobacter spp. Others (Campylobacter, Helicobacter spp. etc.) C. glabrata, other Candida spp, and Molds
Communications between clinicians and microbiologists
Positive Blood Cultures

Preliminary Results Presumptive bacterial ID Direct AST results
General panel Specific panel
Definitive Results Definitive bacterial ID Indirect AST results

Specific panel
Difference between general and specific panels

Blood Culture

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Blood culture

A Positive Blood Culture Clinically Important Organism

Failure of the physician to effectively

Indicator of disseminated infection

Clinical Patterns of Bacteremia and Fungemia

Clinical Patterns of Bacteremia and Fungemia

Risk Factors for Bacteremia and Fungemia

Mortality rates and Risk Factors Associated with Bacteremia

Mortality rates and Risk Factors Associated with Bacteremia

16.3 27.3 30.0 33.3 37.5 42.1 71.5

Mortality rates and Risk Factors Associated with Bacteremia

27.7 35.5 48.0 32.7 22.0 45.5 37.7 63.0 67.7

K. pneumoniae Enterococcus spp. P. aeruginosa S. pneumoniae

Major Pathogens Causing Nosocomial Bloodstream Infections, 1981-1998

Blood Culture Collection Guidelines

Larry et al. 1997. Clin. Microbiol.Rev.

Blood Culture Collection Guidelines

Endocarditis, subacute 3 sets, separate sites, 15min apart;

Blood Culture Collection Guidelines

Blood Culture Collection Guidelines

Blood Culture Collection Guidelines

Soon after fever spike No difference in drawn simultaneously and serially

Li et al. 1994. J. Clin. Microbiol.

Blood Culture Collection Guidelines

iodine for venipuncture; bacteria are killed by drying, not by drowning.

A schematic overview of the Microbiology Laboratory

Blood Culture Methods

Principles of Laboratory Detection

Principles of Laboratory Detection

Huang et al. 1998. Eur.J..Clin..Microbiol. Infect. Dis.

Pitfalls about Blood Cultures

Laboratory: NOT recommended

Notification and Reporting of Positive Blood Cultures

Positive Blood Culture Bottles

Communications between clinicians and microbiologists

Positive Blood Cultures

Definitive Results Definitive bacterial ID Indirect AST results

Difference between general and specific panels

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