University Malaya Medical Centre/

University Malaya
RUKUMANI DEVI VELAYUTHAN
Importance of Blood Culture

Increasing incidence of sepsis

18 20 million Cases/ year Worldwide

High attributable mortality of bacteremia

and fungemia
4.5 6.0 million Deaths/ year Worldwide vs

1.8 million Deaths/ year for AIDS

1.7 million Deaths/ year for TB

Worsening problem of antimicrobial resistance

(AMR)
 The resistance of bacteria strains in the
ICU and CCU has gone up by 50% or 60%
causing medicines that were rarely used to
be used to fight these bacteria. These
medicines may have an adverse effect,"

Datuk Dr Christopher Lee

(Hospital Sungai Buloh)
Health Ministry's Department of Medicine
National Head and Consultant for infectious disease
October 4th, 2014
Source: http://www.thesundaily.my/news/1185241
 studies on new superbugs such as
carbapenem-resistant Enterobacteriaceae
(CRE) showed the number of infections
went up from 150 cases in 2013 to 181
cases in 2014, with the number of deaths
increasing from 25% in 2013 to 37% in
2014.

YB DATO SERI DR. HILMI B. HAJI YAHYA

Deputy Health Minister
National level Antibiotics Awareness Week at Kuala Lumpur Hospital
November 17th, 2015
Source: http://www.freemalaysiatoday.com/category/nation/2015/11.
 Definitions for better understanding :
Bacteremia:
Cultivable bacteria in the blood stream (may be transient
eg. After brushing teeth..)

Note: Bacteria isolated from blood maybe the cause of

sepsis, indeterminate as a cause of sepsis, or contaminants.

Breakthrough bacteremia : Bacteremia persists while

patient is receiving antimicrobial therapy.
Note:
1. Due to inappropriate or inadequate antimicrobial therapy.
2. Result of of focus of infection(e.g., an abscess) that has not
been drained.
Definitions for better understanding :
Septicaemia:
Systemic disease associated with presence and
persistence of pathogenic microorganisms or their
toxins in the blood
(Dorlands medical dictionary)

usually a complication of a local infection

(eg: pyelonephritis, peritonitis, cholangitis, pneumonia,
osteomyelitis, abscesses of internal organs)
also a basic feature of generalised infections like enteric fever,
brucellosis.
-usually due to a single organism, but sometimes, can be more
than one organism

Sepsis- Systemic inflammatory response syndrome

(SIRS) plus infection.

Septic shock sepsis with arterial hypotension

despite adequate fluid resuscitation.

Severe sepsis- sepsis associated with organ

dysfunction, hypoperfusion, or hypotension
Definitions for better understanding :

SIRS- Systemic Inflammatory reponse

syndrome:
Physiological state triggered by the innate
immune response.
SIRS present when one or more of this
clinical/lab findings:
( T>38C, or < 36C HR>90/min, RR>20/min or PaCO2<32mmHg,
WBC>12,000/ul or < 4000 cells /ul
General Rule :

CUMITECH Blood Cultures IV, ASM Press 2005 Mylotte and Tayara EJCMID 2000
Before doing the procedure : Ask yourself
Why do blood cultures?

Whats the best way to do it?

a) When to take it ?
b) How much?
c) How to do it :
what precautions?
What does aseptic method really mean?
d) What happens to it?
e) How to interpret results?

Guidelines / reading

Summary / recommendations
Key Parameters for Optimal Results

I. Timing of Blood Cultures

II. Volume of Blood for Culture
III. Number of Blood Cultures
IV. Optimal Combination of Blood Culture Bottles
V. Use the Right Types of Media
I. Timing of Blood Cultures

When should blood cultures be taken?

Timing of Blood Culture
Clinical and Laboratory
Standards Institute
(CLSI) recommends:

Draw blood cultures

as close as possible
to the episode of
chills or fever

Do NOT delay, as
recovery of
microorganisms
diminishes with time
after the fever spike
Timing of Blood Culture
Blood cultures should be obtained simultaneously
or over a short time frame (less than 1 hour)

Indications for drawing blood at INTERVALS:

Suspected infective endocarditis

Other endovascular infections( e.g., cathether
related) infections.
Table: Recommendations for the timing of the blood cultures
in different clinical conditions and syndromes

Cumitech 1C, Blood Cultures IV. 2005

II Blood Volume

Blood volume is the single-most

important factor in optimizing the
sensitivity of blood culture
Blood Volume

What volume of blood is normally collected?

What volume of blood should be collected?

Compliance with Blood Volumes Collected for Blood
Cultures between Physicians and Phlebotomists
Eun-ha Koh, Sunjoo Kim, Dong-hyun Lee, Seong Chun Kim
Ann Clin Microbiol Vol.16, No.2, June,2013

Blood Volume Compliance

Evaluation of the Blood Volume Effect on the Diagnosis
of Bacteremia in Automated Blood Culture Systems
Hsiu-Hsien Lin, Yen-Fang Liu, Ni Tien, Cheng-Mao Ho, Ling-Nu Hsu, Jang-Jih Lu

Blood Volume Effect

Pediatrics

Towards-Better-Lives

Cumitech 1C, Blood Cultures IV. 2005

 Adults
20 to 30 ml per culture
(i.e., per venipuncture)

Aerobic & Anaerobic bottles

Optimal blood volume:
10 mL/ bottle

Towards-Better-Lives

CLSI M47-A- Principles and Procedures for Blood Culture-Approved

Guidelines
Infants & Young Children
No more than 1% of patients
total blood volume (TBV)

Towards-Better-Lives

CLSI M47-A- Principles and Procedures for Blood Culture-Approved

Guidelines
 b) How much to ta ke?

ADULT bottle:
Optimum: 8-10 ml in each bottle
Paediatric bottle:
Optimum: 1-3 ml in each
bottle (range 0.5-5ml)
Babies: calculate volume
that can be taken
More or less really matters!
How many blood culture sets
should be drawn?
Number of Blood Cultures
CLSI recommends 2-3 sets
evaluation (adult sepsis patient) for initial

Single blood cultures are not acceptable

for adults
inadequate volume
difficult to interpret

1 set 2 sets 3 sets

Number of Blood Cultures
More than 2 sets of blood cultures are to be
collected for sepsis patient diagnosis.

Infectious Disease Society of America (IDSA), Surviving

sepsis Campaign International Guidelines ( March 2008).
Lee at. al. 2007

61.4% 78.2% 93.1%

RECOVERY RECOVERY RECOVERY
Do we need to Repeat blood culture
Blood cultures are Not be repeated for 2 to 5 days,
because the blood does not become sterile
immediately following the start of antimicrobial
therapy.

Surveillance blood cultures only for early detection

of sepsis in certain population
e.g Intensive care, undergoing transplantation or
with vascular catheters.

Blood culture obtained for the prediction of septic

episode are of limited value Not to be performed
routinely.
- No values in patient management and Cost issues.

CLSI M47-A- Principles and Procedures for Blood Culture-Approved

Guidelines
Follow up Blood cultures
Follow up blood cultures for clearing of pathogens in
blood NOT routinely recommended.
However 2 exceptions are :
1.Infective endocarditis for documenting clearing of
bacteremia and to assess and guide therapy.

2. Patient with Staphylococcus aureus bacteremia

where positive follow up blood cultures drawn at 48
to 96 hours were the strongest predictors of
complicated S.aureus bacteremia.

CLSI M47-A- Principles and Procedures for Blood Culture-Approved

Guidelines
IV. Optimal Combination of Blood
Culture Bottles
Aerobic vs. Anaerobic Media

How common are anaerobes?

What grows in anaerobic bottles?
What are the advantages of using 2 different culture
media?
 Anaerobic Blood Culture Media

Recovery of obligate & facultative anaerobic

bacteria from blood
Obligate anaerobes: 0.4 4% positive growth1
High mortality rate: 50%2,3

Some examples of facultatively anaerobic bacteria stap, strep and Ecoli

1. Ortiz E, Sande MA. Routine use of anaerobic blood cultures: are they still
indicated? Am J Med 2000 Apr 15; 108(6):445-7.
2. Pottumarthy S, Morris AJ. Assessment of the yield of anaerobic blood
cultures. Pathology 1997 Nov; 29(4):415-7.
3. Iwata K, Takahashi M. Is anaerobic blood culture necessary? If so, who
needs it? Am J Med Sci 2008 Jul; 336(1):58-63.
 The Value of Anaerobic Blood Cultures

12 years surveillance of anaerobic BSI

at Mayo Clinic

Increase in anaerobic bacteremia:

1993-1996 53 cases/year
1997-2000 75 cases/year
2001-2004 91 cases/year

An overall increase of 74%

Reasons for increase in anaerobic bacteremia:

Complex, advanced disease
Immunocompromised patients
Elderly patients

Lassmann et al, CID 2007

 Optimal Combination of Blood Culture Bottles

JCM, Dec. 2011, p.4047-4051

Optimal Combination of Blood Culture Bottles
IV. Use the Right Types of
Media
 BACTEC Blood Culture Media

BACTEC Plus Aerobic/F BACTEC Plus Anaerobic/F

Use: Use:
Recovery of aerobic bacteria, Recovery of obligate &
yeasts & fungi from blood. facultative anaerobic bacteria
Recommended incubation from blood.
protocol: Recommended incubation
5 days protocol:
Advantage: 5 days
Contains resins for antibiotic Advantage:
neutralization Contains resins for antibiotic
Optimal blood volume: neutralization
10 mL/ bottle Optimal blood volume:
10 mL/ bottle
 BACTEC Blood Culture Media
BACTEC Peds Plus /F
Use:
Recovery of aerobic
microorganisms (mainly bacteria &
yeast) from pediatric
Recommended incubation protocol:
5 days
Advantages:
~ Contains resins for antibiotic
neutralization
~ Contain lower SPS (anticoagulant)
concentration.
Optimal blood volume:
1-3 mL/ bottle
BACTEC Myco /F Lytic
Use:
~ Nonselective culture medium
~ Recovery of mycobacteria from
blood and yeast & fungi from blood
& sterile body fluids
Recommended incubation protocol:
- Yeast: 7 days
- Fungi: 30 days
- Mycobacteria: 42 days
Optimal blood volume:
3-5 mL/ bottle
 BACTEC Blood Culture Media

BACTEC Lytic/10 Anaerobic/F

Use:
Recovery of obligate & facultative anaerobic bacteria from blood.
Recommended incubation protocol:
5 days
Advantage:
Pre-reduced enriched Soybean-Casein Digest broth with CO2
and N2. It is formulated with lytic agents to lyse blood
cells and release intracellular microorganism to facilitate
early pathogen detection
Optimal blood volume:
10 mL/ bottle
 Use the Right Types of Media

Resin Media
Effective and fast antibiotic neutralization
Proven best recovery and shortest time to detection

The strong cationic exchange resins bind ionically to

positively charged antimicrobials like aminoglycosides.

The polymeric adsorbent resins are capable of binding to

the hydrophobic regions of virtually any antimicrobial agent .
2 unique resin beads:

How Resins Work?

Not all Resins are created equally!

Value of Resins
Study findings suggest using sensitive and rapid-to-detect blood culture
media to aid in the diagnosis of sepsis may improve patient care and
outcomes.

Zadroga et al., CID, March 15, 2013

Blood Culture Collection Procedure
VIDEO Demo

I. Skin Antisepsis
II. Catheter or Venipuncture Site?
III. BACTEC Bottles Preparation
IV. Order of Draw
V. Transporting and Handling
 I Skin disinfection before taking blood culture
Iodine tincture, and chlorhexidine gluconate (CHG) are superior
to povidone-iodine preparations as skin disinfectants for blood
culture

(But iodine preparations may be associated with allergic reactions

and need to be wiped off with 70% alcohol after the procedure).

Iodine tincture and CHG require about 30 seconds for antiseptic effect
compared with 1.52 minutes for povidone iodine

May cleanse the site first with 70% alcohol, followed by the main
disinfectant

Mandell also mentions under chapter on sepsis, severe sepsis and septic
shock that 2% chlorhexidine in 70% alcohol was superior to 10% aqueous
povidone iodine for preventing culture contamination in a trial done.)

**Chlorhexidine gluconate is not recommended for use in infants

less than 2 months of age, however it is the recommended skin
disinfectant for older infants, children and adults.

Rubber septum of blood culture bottle may be wiped with 70%

isopropyl alcohol, then dry

If not enough , fill aerobic bottle first

Reference: From CLSI. Principles and Procedures for Blood cultures; Approved Guideline. CLSI document M47A. Clinical and Laboratory Standards
Institute, 2007
 Catheter or Venipuncture Site?

Catheter-drawn cultures are more likely to

be contaminated. Direct venipuncture
cultures are recommended
Everts, et. al. JCM 2001;39:3393

Whenever possible, blood for culture should

be drawn via a peripheral venipuncture

Catheter-Related Bloodstream Infections

(CRBSI)
draw from both a vein and the catheter

** interpretation need expert advice..

 Blood Culture Collection
BACTEC Bottles Preparation
Before:
Check expiry date
Mark desired fill level
Remove flip-off cap & wipe with alcohol swab

8 10 mL

initial vol.
Blood Culture Collection
Skin Preparation
Cleanse the
venipuncture
site in circular
motion with
70% alcohol

Air dry and

do not touch
the site after
cleansing
*NOTE:
Blood culture contamination rate
should not exceed 3%
 Sequence of drawing:

Blood Culture Collection

Safety-Lok Blood Collection Set

Blood Culture Collection
SAFETY
BD Vacutainer Safety-Lok blood collection set

reducing risk of contaminations & needle-stick

injuries of health care workers
Blood Culture Collection
BACTEC Bottles Preparation

After:
Label bottles
Do not cover up barcode label
 Transporting & Handling
Timing
send to the lab as quickly as possible, within 2
hours

Temperature
transport at room temperature
****Do not freeze or refrigerate or incubate at 37oC

Safety for transport

carry out in container that will protect them from
dropping and from knocking against each other
Factors Responsible for Negative
Blood Cultures
Too low blood volume collected
a frequent issue

Many patients (28-63%) on antibiotics

an increasingly important issue
 BACTEC Instruments
BACTEC FX
BACTEC 9000 series

BACTEC 9240

BACTEC 9120 BACTEC 9050

BACTEC FX 40

Towards-Better-Lives
Interior compartment..
CO2 production in bottle by growing bacteria
will be detected by automated blood culture
system machine, and it flags positive
Blood culture Gram stain + subculture
will then be performed
From laboratory will be telephoned to
the doctor
Gram stain appearance Possibilities
Gram positive cocci In clusters: Staphylococcus
aureus,
coagulase negative
Staphylococcus,
Micrococcus spp.,
In chains: Streptococcus
agalactiae, etc.
Gram positive rods Bacillus species,
Corynebacterium spp.,
Listeria spp.
Branching: Nocardia spp.,
Actinomyces spp.
Gram negative bacilli E. coli, Klebsiella,
Enterobacter, Proteus,
Pseudomonas, etc. etc.
Gram negative cocci Neisseria species
Gram negative diplococci:
Neisseria meningitidis,
Neisseria gonorrhoeae,
 Blood Cultures: Summary
Blood cultures are critical for the successful
documentation of the cause of sepsis and effective
treatment

Successful blood cultures are determined by

collection of the proper volume of blood
Blood fill per bottle
2 bottles per culture and 2 to 3 cultures per day

Successful blood cultures are determined by

selection of the appropriate media
Use of resin media for inactivation of antibiotics
improves overall detection and time to detection
of bloodstream pathogens
Anaerobic media improves recovery of strict and
facultative anaerobes

Successful blood cultures are determined

Performing the correct procedure following
Aseptic techniques
Next time when you taking blood culture Check List in your mind

Best time? - during chill or fever

Optimal volume?
- Adult : 10mL/ bottle
- Pediatric: 1-3mL/ bottle
Sets?
- 2 sets (Left & Right arms)

Optimal combination?
Sequence?/Procedure

Catheter ?
x NO
Venipuncture
References:
Guidelines for the collection, processing, and interpretation of
blood cultures are needed so that laboratories and providers (
thats YOU) use optimal laboratory methods for
recovering specific pathogens, interpret the results
correctly, and help control healthcare costs.

NO CONTAMINATION PLEASE!