Jump to ContentJump to Main Navigation
Show Summary Details
More options …

Clinical Chemistry and Laboratory Medicine (CCLM)

Published in Association with the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM)

Editor-in-Chief: Plebani, Mario

Ed. by Gillery, Philippe / Greaves, Ronda / Lackner, Karl J. / Lippi, Giuseppe / Melichar, Bohuslav / Payne, Deborah A. / Schlattmann, Peter


IMPACT FACTOR 2018: 3.638

CiteScore 2018: 2.44

SCImago Journal Rank (SJR) 2018: 1.191
Source Normalized Impact per Paper (SNIP) 2018: 1.205

Online
ISSN
1437-4331
See all formats and pricing
More options …
Volume 57, Issue 11

Issues

Collection, transport and storage procedures for blood culture specimens in adult patients: recommendations from a board of Italian experts

Francesca De Plato
  • Società Italiana Farmacologia Ospedaliera, Milan, Italy; and Local Health Authority ASL of Teramo, Teramo, Italy
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Carla Fontana
  • Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
  • Microbiology and Virology Laboratory, Polyclinic of Tor Vergata, Rome, Italy
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Giovanni Gherardi
  • Department of Medicine, Laboratory of Clinical Microbiology, University Campus Biomedico, Rome 00128, Italy
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Gaetano Pierpaolo Privitera
  • Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
  • University Hygiene and Epidemiology Complex Operative Unit and Clinical Risk Functional Area Coordinator, University Hospital Pisana, Pisa, Italy
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Vincenzo Puro / Roberto Rigoli
  • Department of Clinical Pathology, Local Health and Social Care Facility, No. 2, Marca Trevigiana, Treviso, Italy
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Bruno Viaggi / Pierluigi Viale
  • Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2019-07-26 | DOI: https://doi.org/10.1515/cclm-2018-1146

Abstract

Bloodstream infections (BSIs) remain a potentially life-threatening condition. The gold standard for the diagnosis of BSI is still blood cultures (BCs), and the diagnostic yield depends on clinical and technical factors that have an impact on collection and transportation. Hence, monitoring of the entire pre-analytical process from blood collection to transportation to the microbiology laboratory is critical. To optimize the clinical impact of the diagnostic and therapeutic procedures, a multidisciplinary approach and univocal protocols are mandatory. A board of specialists discussed the available evidence on the pre-analytical process and produced the present document to guide physicians and nurses on the ideal execution of BC: (1) timing and preparation for blood collection; (2) skin antisepsis; (3) blood volume; (4) sampling method and safety; (5) medium to be used; (6) time to BC transportation; and (7) quality assurance and quality management.

Keywords: blood culture collection; blood cultures; bloodstream infections; storage; transport

Introduction

Bloodstream infection (BSI) is a potentially life-threatening condition with a case fatality rate of 30%–40% and increasing incidence and severity [1], [2]. The rapid and accurate diagnosis of bacteremia and fungemia allows prompt administration of targeted antibiotic therapy (within 24–48 h), with positive effects on the clinical outcomes, reducing mortality and costs, and limiting the development of antimicrobial resistance [3].

The diagnosis of BSI relies on the detection of pathogens, bacteria or fungi in blood cultures (BCs), still considered as the gold standard to identify pathogens and assess their susceptibility profile. The appropriate collection and quick transportation of BCs strongly influence the diagnostic yield. Moreover, safety during BC sampling needs to be tackled using the correct procedures by engaging specialized and well-trained staff [4], [5], [6].

The aim of this article is to provide a practical guide for physicians and nurses on the optimal execution of BC, as recommended by a board of specialists after in-depth discussion of the available evidence in this field. The document contains practical recommendations on the clinical and technical operational procedures of the entire BC pre-analytical process: (1) timing and preparation for blood collection; (2) skin antisepsis; (3) blood volume; (4) sampling method and staff safety; (5) medium to be used; (6) time to BC transportation; and (7) quality assurance and quality management.

Timing and preparation for blood collection

The most appropriate timing for BC collection is the first aspect that needs to be carefully considered. Unfortunately, only few clinical studies evaluating the timing of BC collection are available. Although all guidelines agree that samples for BC should be collected before antimicrobial treatment, it remains controversial whether they should be drawn at or around the time of a fever spike, as physicians often prescribe. In a multicenter retrospective study evaluating the timing of BC collection in relation to temperature increases in patients with BSI, it was found that the likelihood of diagnosing BSI was not significantly enhanced if BC collection was done when patients experienced temperature spikes [7]. Lamy et al. [8] evaluated several studies and concluded that there is no evidence that clearly identifies any optimal timing for BC collection.

  • Therefore, BC samples should be collected as soon as possible when BSI is suspected and before antibiotic use.

  • BC sampling must be performed by specialized and well-trained staff with specific expertise in the various phases of the procedure. Ideally, dedicated phlebotomy teams should be created [9] and this may also be cost-effective [10], [11], [12]. However, several organizational and economic limitations, along with cultural habits, hamper their implementation in many countries.

  • The entire procedure must be carefully standardized and registered. Every health care facility should define and develop core elements and complete a checklist of items related to the pre-analytical steps. Collection of all BC samples must be clearly documented in the patient’s medical records, indicating the date and time of blood collection, skin preparation, sampling site and strategy used [13].

  • Blood collection should be carefully organized by preparing and checking all devices and materials needed for the draw, including safety butterfly sets and personal protective equipment as needed.

  • To reduce the risk of BC contamination at the time of blood collection, hand hygiene must be carefully performed using a hydroalcoholic preparation, and disposable gloves of the correct size must be worn [14]. Wearing disposable gloves is not an alternative to hand hygiene, which must be carried out again after removing the gloves [15]. The use of sterile gloves is not strictly necessary, although it could be considered depending on the institution’s contamination rate [16]. Even after good hand hygiene and wearing gloves, the vein must not be re-palpated after skin antisepsis and before puncture [17].

  • As a general rule, peripheral venipuncture is the method of choice for BC collection. A suitable peripheral venous site must be identified before skin antisepsis.

In the absence of a suitable peripheral venous site, an arterial blood site can be considered a valid alternative, because arterial blood has been shown to perform similar to venous blood in terms of contamination and sensitivity [18]. Sampling through pre-existing intravenous catheters, port-a-cath or central venous catheters increases the risk of contamination [18], [19], [20], [21], and the microbiological results have to be interpreted cautiously. However, there are clinical situations in which access to a peripheral vein may be difficult; this may be particularly evident in critically ill and often edematous patients in the intensive care unit (ICU), for whom peripheral phlebotomy is challenging [22], [23], [24].

Although discouraged, this method can be accepted when venous catheter sampling is performed from a freshly placed cannula [17]. One exception is the diagnosis of central line-associated BSI; most current guidelines recommend simultaneous sampling of two BC sets, one collected from the catheter and the other through a, possibly contralateral, venipuncture to be able to estimate the differential time to positive BC or different microbial load [25], [26], [27].

Skin antisepsis

Antisepsis of the skin must be performed rigorously at the time of peripheral venous sampling to avoid specimen contamination and consequent alteration of the test results.

A BC contamination rate of 3% is generally considered the maximum acceptable value [28]. The microbiology laboratory of every health care facility should analyze the data on contamination of BCs at set time intervals (e.g. every 6 months) and discuss them with the clinical team if necessary.

  • As indicated by a multidisciplinary team review of best practices for BC collection, skin antisepsis must be performed using 2% chlorhexidine in 70% isopropyl alcohol [21], preferably using disposable devices registered as a medicine. The pre-selected site should be disinfected by scrubbing an area of skin 6–7 cm in diameter for 30 s and then waiting about 30 s for the antiseptic to dry. Cleaning the skin treated with chlorhexidine after blood withdrawal is not necessary.

If the patient is allergic to chlorhexidine, alcoholic povidone-iodine can be used for 120 s [21].

When blood collection through a venous, peripheral or a central catheter is unavoidable, great attention must also be paid to disinfect the connection between the catheter and the drawing set (i.e. the needleless connector or the injection port) using a specific product for the appropriate time: 2% chlorhexidine in 70% isopropyl alcohol for a minimum of 30 s and allowed to dry before using the system [14].

The use of sterile disposable devices seems to have various advantages in terms of standardization, exact dosage, sterility, mechanical action and effectiveness [29].

  • The stopper of each BC bottle is not sterile and must be disinfected before inoculation. A specific antiseptic can be used to disinfect the stopper, similar to that used for the skin (2% chlorhexidine in 70% isopropyl alcohol) or 70% isopropyl alcohol alone.

Blood volume

An adequate volume of blood is the most important parameter for the detection of microorganisms in the bloodstream of patients with suspected BSI, because the bacterial and fungal load in most BSIs is very low [8], [30], [31], [32], [33].

  • Recommendations for complete BC sampling suggest at least two sets, corresponding to 30–40 mL in total [24], subdivided into four BC bottles, two for aerobic and two for anaerobic organisms; the aerobic bottle should be filled first. BC should take priority in the case of several specimens from the same venipuncture [26], [28], [34], [35], [36], [37], [38], [39], [40].

  • Recently, a retrospective study of 4000 BSI episodes demonstrated that without a third BC set, 7.9% of BSIs would have been missed, although in 33.9% of the missed episodes, the same organism recovered in the third BC was isolated in other clinical specimens (i.e. urine) for an actual rate of approximately 5% [39].

  • The practice of a “solitary BC” (only two bottles or one set), although still common, is not acceptable and should be actively discouraged [8], [28], [35].

  • BC bottles should be inoculated with 8–10 mL of blood (according to the manufacturer’s instructions). When BC bottles are underfilled (i.e. less than 5 mL of blood per bottle), false-negative results or delays in microbial growth may occur [8], [22]. When BC bottles are overfilled (>10 mL), they are at increased risk of being flagged as false-positive mainly as a result of high production of background CO2 by the white blood cells [41], [42].

The correct filling of BC bottles should be monitored through visual inspection, either at the patient’s bedside or on arrival at the microbiology laboratory before BC incubation [8], [43]. Weighing the BC bottle when delivered to the laboratory is an alternative strategy [8]. Indeed, some BC system manufacturers have developed automated systems to estimate the level in the bottle at the time of loading [44].

  • It has been reported that one aerobic bottle plus one anaerobic bottle yield more pathogens than two aerobic bottles, confirming that an anaerobic bottle should be included in each BC set [45].

An adequate volume of blood can be obtained either by increasing the number of venipunctures (“multi-sampling strategy”) or by collecting an adequate volume through one single venipuncture (“single-sampling strategy”), with comparable performance and similar sensitivity for a given blood volume inoculated [8]. The multi-sampling strategy is the standard approach recommended for decades, based on the execution of at least two separate BC sets within a short period (generally 10–12 min apart). The single-sampling strategy, introduced more recently, is based on the total volume of blood collected from one single draw and inoculating the requested BC bottles (four to six in total) at the same time [8], [46], [47]. Both approaches have advantages and limitations. In particular, the single-sampling strategy has important advantages: it allows a sufficient volume of blood to be collected from a single sample with simultaneous filling of at least four bottles; reducing the contamination rate by limiting the number of blood draws; reducing the workload and therefore the risk of occupational exposure to pathogens; reducing the rate of solitary BCs; and enabling early initiation of empirical antibiotic treatment without waiting for subsequent BC sampling [8], [21], [23], [38], [46], [48], [49], [50], [51].

In a multi-sampling strategy, a positive result depends on the number of positive BC samples found when a culture yields a common contaminant such as coagulase-negative staphylococci. In this case, the result is clinically significant only if there are at least two positive BCs [8]. With the single-sampling strategy, the rules for the interpretation of positive BC results are different, and the probability of having a clinically significant result increases with the number of positive bottles [8].

In general, the single-sampling strategy seems to be preferable in some types of patients, such as those in the ICU and emergency department. Conversely, the multi-sampling strategy is required to diagnose infective endocarditis, for which the number of positive samples on three separate venipunctures over 24 h is part of the modified Duke Criteria [52].

Sampling method and safety

Needlestick injuries represent a significant proportion of the work-related accidents recorded in hospitals; therefore, equipment and techniques for BC sampling must guarantee the operator’s safety [4], [5]. In accordance with international recommendations and the European Directive 2010/32/EU [6], devices must be adopted that guarantee the safety of the patient and the health operator: a sampling set with a butterfly needle equipped with a safety mechanism and an adapter for the collection of multiple blood specimens directly into the vials. The use of the same syringe to draw blood and then to inoculate the bottles must be avoided. The practice of capping sharp objects has been banned by the Directive 2010/32/EU. At the end of blood withdrawal, the safety mechanism should be activated and the sampling set disposed of in the appropriate container for sharp waste.

Medium to be used

In addition to the recommendation to always use both aerobic and anaerobic bottles, it remains optional to use a third bottle specifically for fungal detection and bottles with special media (i.e. enriched with substances that improve microbial recovery by absorbing antimicrobial agents present in the blood or that lyse the white blood cells releasing the microorganisms).

In patients with candidemia, the sensitivity for detecting Candida growth varies depending on the species, the system and the type of vials used [53]; sensitivity rates are lower in patients with neutropenia and those undergoing antifungal treatment [54]. The quantitative burden of Candida is very low in most cases; more than 50% of Candida BCs have ≤1 CFU/mL [33]. Similar to bacteria, a BC collection of four to six bottles is recommended, and, following these recommendations, a sensitivity of approximately 50%–75% has been reported to detect Candida in BCs.

Most clinical laboratories do not routinely use mycosis media for all BCs because most cases of candidemia can be successfully diagnosed using aerobic blood vials [55], [56], [57]; the exception is some Candida spp., such as C. glabrata, which is particularly prone to growing more frequently or more quickly in anaerobic vials [54], [56], [58], [59]. Therefore, for some Candida spp. and depending on the system and type of bottles used, mycosis bottles need to be included [54], [60]. Yeasts other than Candida in BCs have been increasingly reported as emerging and rare pathogens in up to 5% of patients with fungemia, and lysis/centrifugation methods are more suitable for detecting these rare yeast pathogens in BCs with higher efficacy [54].

  • Although BCs must be collected before starting antibiotic treatment, in some situations this is not possible, especially in those cases where symptoms of bacteremia persist due to inappropriate antimicrobial treatment [37].

  • The superior neutralizing capacity of resin-based media has been demonstrated, although different resins may affect the performance of neutralization [61], [62].

A valid alternative to the use of media containing resins is the dilution of blood in broth at ratios greater than 1:5, which increases microbial recovery, probably by diluting antimicrobial agents and natural inhibitory factors in the blood to subinhibitory concentrations [63].

Time to BC transportation

The transport time of inoculated BC bottles to the laboratory and their incubation in continuous monitoring systems is a critical factor, and any delay beyond the maximum limit can postpone or hamper microbial growth [64], [65].

  • The inoculated BC bottles must be sent as soon as possible to the microbiology laboratory.

  • A time of 2 h between sample collection and incubation in a BC system can be considered optimal [24], [28]. The maximum acceptable limit is 4 h; beyond this time, a delay might negatively affect the positive BC rate and the time to prompt and effective antimicrobial therapy [64], [66], [67], [68], [69]. Although the optimal time to transportation should be <2 h, even a threshold of 4 h may be difficult to achieve in many situations [67], [70].

To follow these recommendations, health care facilities must implement adequate organization to make rapid delivery of BC bottles to a microbiology unit possible. Therefore, it is not acceptable to accumulate the BC samples inoculated throughout the day and send them together to the laboratory. Inoculated BC bottles, if not delivered to the laboratory immediately, must be stored at room temperature, avoiding temperatures higher than 30 °C or refrigerated conditions [24].

  • In health care organizations where immediate transport of BCs to the laboratory for incubation in BC continuous monitoring systems cannot be guaranteed, and in those institutions where the microbiology service is not active 24 h per day, 7 days per week, the use of satellite BC instruments for incubation in specific settings, such as emergency departments and the ICU, has been suggested to allow significant improvements in terms of time and quality of the results [71]. However, the level of evidence remains limited, and further studies are needed to assess costs and benefits associated with such an organization.

Good practices for execution of BC are presented in Table 1.

Table 1:

Good practice for the execution of blood cultures.

Quality assurance and quality management

Quality control of the pre-analytical phase should be monitored regularly by critical key performance indicators; several have been proposed and are in use [70]. The first step is to clearly communicate to the clinician and all the staff involved uniform and standardized guidelines for correct BC collection. Indicators allow different parts of the pre-analytical phase of BCs to be monitored. Monitoring the total volume of blood collected using systematic internal programs is a strong quality assurance requirement [8], [22], [24], [44], [70], [71], [72], [73]; the proportion of solitary BCs, which should be as low as possible (<10%), should be monitored.

False-positive and false-negative results are also essential indicators of analytical processes [8], [69], [70]. Moreover, the contamination rate should be assessed and should be less than 3% [21], [24], [74], [75], [76], [77], [78]. Although no definitive criteria are available, distinguishing contaminated BCs from those that are true-positive cultures is possible primarily by identifying the organism responsible for bacteremia and the number of positive BC samples or bottles with the same bacterial species. Moreover, clinical and laboratory information, the possible infection source, and assessment of the time to positivity may represent additional markers useful in clinical settings to discriminate between contamination and true-positive BCs [24], [74]. Contamination rates can be diminished by revised procedures and techniques, such as skin antisepsis, optimum sampling site and a single-sampling strategy [8], [24]. Monitoring the percentage of bottles collected via an indwelling intravascular access device instead of venipuncture BC collection and those obtained percutaneously is also important [77].

The time to transportation to the laboratory is another important key indicator. Because earlier detection is achieved if the transport time is minimized, it has been proposed that the proportion of BCs submitted with a delay should be monitored [76]. Although the critical limit that should not be exceeded has not yet been defined, it is advisable to have the shortest time delay possible [70].

A list of recommendations and comments on the correct procedures and techniques for BC collection are given in Table 2.

Table 2:

Recommendations for the correct procedures and techniques for collecting blood cultures.

Discussion and conclusions

To ensure rapid and accurate BC results, it is mandatory to adequately select, collect and transport the specimens, a process that includes several steps from sample withdrawal to incubation [8], [24], [48], [69], [78], [79], [80].

The process involves various health personnel, who must operate in agreement with good clinical practice within a multidisciplinary team. In addition to the doctors and nurses engaged in the diagnostic process, the hospital pharmacist with infectious disease training plays an important role, because he/she is responsible for the procurement, proper preservation and, together with the other personnel involved, the choice of pharmaceutical products required for correct BC practice, which undeniably have an impact on the validity of the test [69], [81], [82], [83], [84], [85].

Despite the existence of some national and international reviews on the correct procedures and techniques for the pre-analytical phase, adopting the current recommendations is a critical issue in many cases [8], [24], [28], [70]. In many hospital wards, the execution of BCs is insufficient in numerical terms and often incorrect, especially within emergency departments where limited time and the large number of patients requiring critical care often result in incorrect procedures [74]. Although most cases of BSI come from the community, making the involvement of emergency departments essential, shortcomings of a cultural (often there is a delay in transferring the patient to the department after initiating empirical antibiotic treatment) and organizational nature (lack of microbiology laboratories open 24 h a day or lack of satellite incubators that enable sampling to be performed at any time) make the execution of BC tests suboptimal.

Hence, organizational and cultural operative interventions must be planned and implemented in clinical practice. In particular, with regard to cultural and educational aspects, certain potentially effective actions are advisable:

  1. Dissemination of protocols and their application: for the first time, this document brings together the operative procedures that constitute the BC test;

  2. Interventions on communication and training of medical and nursing personnel (drawing up and disseminating authoritative documents, courses, but also practical training at the patient’s bedside, bringing together all the various professional figures involved: doctor, nurses, microbiologist and others);

  3. The formation, within the hospital, of a BC team comprising nurses, clinical microbiologists and infectious disease experts, who have expertise in sampling and, as a second step, the establishment and review of the treatments involving other professional figures (intensive care experts, clinicians, hospital pharmacists, etc.).

To translate these actions into practice, it is vital to increase awareness among Health Management and Scientific Societies that have the task of organizing training courses and educational initiatives, as well as providing the theoretical and organizational framework required for optimal clinical practice [86]. The medico-legal and health cost aspects associated with the accuracy and reliability of BC tests should also be underlined. The incorrect execution of a BC can, for example, lead to legal disputes and claims for compensation. Moreover, a false-positive result, with the consequent increase in antibiotic treatments and hospital stays, can translate into higher health costs, but also in a pointless and damaging selective pressure on which antimicrobial resistance emergencies are based. Finally, extending awareness of the problem of BSI is to be hoped for beyond the health care field, among institutions, the media and the general population. It is known that 80% of septic events arise in communities [87]; increasing awareness and educating people to recognize the initial symptoms will reduce fatal outcomes due to late interventions.

BSI is a global concern that needs to be adequately considered and tackled with a multidisciplinary approach. Although other recommendations have been released for the correct management of the pre-analytical phase, including venous blood sampling and sample transportation, BC specimens require more detailed and specific guidelines [88], [89], [90].

To guarantee the clinical effectiveness of BC and the best possible patient outcome, it is paramount that the involvement of the various professionals is based on constant communication and strict adherence to shared procedures. These aspects of communication and adherence to univocal protocols are currently the main issues that must be addressed to optimize the clinical impact of the diagnostic and therapeutic procedures. Only in this way will it be possible to reduce the rate of morbidity and mortality that BSIs still cause worldwide.

Acknowledgments

Editorial assistance was provided by Edra S.p.A. V.P.’s work is supported by the Italian Ministry of Health, Ricerca Corrente, Linea 1 Progetto 3.

References

  • 1.

    Laupland KB, Gregson DB, Zygun DA, Doig CJ, Mortis G, Church DL. Severe bloodstream infections: a population-based assessment. Crit Care Med 2004;32:992–7. CrossrefPubMedGoogle Scholar

  • 2.

    Bearman GM, Wenzel RP. Bacteremias: a leading cause of death. Arch Med Res 2005;36:646–59. PubMedCrossrefGoogle Scholar

  • 3.

    Pliakos EE, Andreatos N, Shehadeh F, Ziakas PD, Mylonakis E. The cost-effectiveness of rapid diagnostic testing for the diagnosis of bloodstream infections with or without antimicrobial stewardship. Clin Microbiol Rev 2018;31:e00095–17. Google Scholar

  • 4.

    Di Bari V, De Carli G, Puro V, Gruppo Collaborativo dello Studio Italiano sul Rischio Occupazionale da HIV e Altri Patogeni a Trasmissione Ematica (SIROH). [Prevention of accidental needle sticks before the Directive 2010/32/EU in a sample of Italian hospitals]. Med Lav 2015;106:186–205. Google Scholar

  • 5.

    Green-McKenzie J, McCarthy RB, Shofer FS. Characterisation of occupational blood and body fluid exposures beyond the Needlestick Safety and Prevention Act. J Infect Prev 2016;17:226–32. CrossrefPubMedGoogle Scholar

  • 6.

    Council Directive 2010/32/EU of 10 May 2010 implementing the Framework Agreement on prevention from sharp injuries in the hospital and healthcare sector concluded by HOSPEEM and EPSU. Official Journal of the European Union 2010;134:66–72. Google Scholar

  • 7.

    Riedel S, Bourbeau P, Swartz B, Brecher S, Carroll KC, Stamper PD, et al. Timing of specimen collection for blood cultures from febrile patients with bacteremia. J Clin Microbiol 2008;46:1381–5. CrossrefPubMedGoogle Scholar

  • 8.

    Lamy B, Dargère S, Arendrup MC, Parienti J-J, Tattevin P. How to optimize the use of blood cultures for the diagnosis of bloodstream infections? A state-of-the art. Front Microbiol 2016;7:697. Google Scholar

  • 9.

    Foggiato GF, Tuon FF, Becker G, Dos Santos AH, Pereira BR, de Souza GL, et al. Reduction of blood culture contamination rates after implementation of a phlebotomist team. Am J Infect Control 2017;45:698–9. PubMedGoogle Scholar

  • 10.

    Gander RM, Byrd L, Decrescenzo M, Hirany S, Bowen M, Baugman J. Impact of blood cultures drawn by phlebotomy on contamination rates and health care costs in a hospital emergency department. J Clin Microbiol 2009;47:1021–4. CrossrefGoogle Scholar

  • 11.

    Weinbaum FI, Lavie S, Danek M, Sixsmith D, Heinrich GF, Mills SS. Doing it right the first time: quality improvement and the contaminant blood culture. J Clin Microbiol 1997;35:563–5. PubMedGoogle Scholar

  • 12.

    Washer LL, Chenoweth C, Kim H-W, Rogers MA, Malani AN, Riddell J, et al. Blood culture contamination: a randomized trial evaluating the comparative effectiveness of 3 skin antiseptic interventions. Infect Control Hosp Epidemiol 2013;34:15–21. PubMedCrossrefGoogle Scholar

  • 13.

    National Health System, Department of Health. Taking blood cultures, a summary of best practice. Available at: http://webarchive.nationalarchives.gov.uk/20120118171812/http://hcai.dh.gov.uk/files/2011/03/Document_Blood_culture_FINAL_100826.pdf. Accessed: 20 Jan 2018. 

  • 14.

    Al-Hamad A, Al-Ibrahim M, Alhajhouj E, Al-Alshaikh Jaffer W, Altowaileb J, Alfaraj H. Nurses’ competency in drawing blood cultures and educational intervention to reduce the contamination rate. J Infect Public Health 2016;9:66–74. PubMedCrossrefGoogle Scholar

  • 15.

    Rupp ME, Cavalieri RJ, Marolf C, Lyden E. Reduction in blood culture contamination through use of initial specimen diversion device. Clin Microbiol Infect 2017;61:201–5. Google Scholar

  • 16.

    Kim NH, Kim M, Lee S, Yun NR, Kim KH, Park SW, et al. Effect of routine sterile gloving on contamination rates in blood culture: a cluster randomized trial. Ann Intern Med 2011;154:145–51. PubMedCrossrefGoogle Scholar

  • 17.

    Bentley J, Thakore S, Muir L, Baird A, Lee J. A change of culture: reducing blood culture contamination rates in an Emergency Department. Br Med J Qual Improv Rep 2016;5:u206760.w2754. CrossrefGoogle Scholar

  • 18.

    Stohl S, Benenson S, Sviri S, Avidan A, Block C, Sprung CL, et al. Blood cultures at central line insertion in the intensive care unit: comparison with peripheral venipuncture. J Clin Microbiol 2011;49:2398–403. CrossrefPubMedGoogle Scholar

  • 19.

    Levin PD, Moss J, Stohl S, Fried E, Cohen MJ, Sprung CL, et al. Use of the nonwire central line hub to reduce blood culture contamination. Chest 2013;143:640–5. PubMedCrossrefGoogle Scholar

  • 20.

    Dawson S. Blood culture contaminants. J Hosp Infect 2014;87: 1–10. PubMedCrossrefGoogle Scholar

  • 21.

    Garcia RA, Spitzer ED, Beaudry J, Beck C, Diblasi R, Gilleeny-Blabac M, et al. Multidisciplinary team review of best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremias, reducing contamination, and eliminating false-positive central line-associated bloodstream infections. Am J Infect Control 2015;43:1222–37. PubMedGoogle Scholar

  • 22.

    Mermel LA, Maki DG. Detection of bacteremia in adults: consequences of culturing an inadequate volume of blood. Ann Intern Med 1993;119:270–2. PubMedCrossrefGoogle Scholar

  • 23.

    Vitrat-Hincky V, Francois P, Labarere J, Recule C, Stahl JP, Pavese P. Appropriateness of blood culture testing parameters in routine practice. Results from a cross-sectional study. Eur J Clin Microbiol Infect Dis 2011;30:533–9. PubMedCrossrefGoogle Scholar

  • 24.

    Willems E, Smismans A, Cartuyvels R, Coppens G, Van Vaerenbergh K, Van den Abeele A-M, et al. The preanalytical optimization of blood cultures: a review and the clinical importance of benchmarking in 5 Belgian hospitals. Diagn Microbiol Infect Dis 2012;73:1–8. CrossrefPubMedGoogle Scholar

  • 25.

    Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O’Grady NP, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:1–45. CrossrefGoogle Scholar

  • 26.

    Wilson ML, Mitchell M, Morris AJ, Murray PR, Reimer RG, Reller LB, et al. Principles and procedures for blood cultures; approved guidelines, CLSI document M47-A, 27. Wayne, PA: Clinical and Laboratory Standard Institute; 2007. Google Scholar

  • 27.

    Gruppo di Lavoro Infezioni nel Paziente Critico. Infezioni nel torrente circolatorio 2014. Available at: http://www.amcli.it/wpcontent/uploads/2015/09/PDinfezionieltorrentecircolatorioFONTANA2014.pdf. Accessed: 20 Jan 2019. 

  • 28.

    Baron EJ, Miller JM, Weinstein MP, Richter SS, Gilligan PH, Thomson RB, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)(a). Clin Infect Dis 2013;57:e22–121. CrossrefGoogle Scholar

  • 29.

    Madeo M, Barlow G. Reducing blood-culture contamination rates by the use of a 2% chlorhexidine solution applicator in acute admission units. J Hosp Infect 2008;69:307–9. PubMedCrossrefGoogle Scholar

  • 30.

    Arpi M, Bentzon MW, Jensen J, Frederiksen W. Importance of blood volume cultured in the detection of bacteremia. Eur J Clin Microbiol Infect 1989;8:838–42. CrossrefGoogle Scholar

  • 31.

    Jonsson B, Nyberg A, Henning C. Theoretical aspects of detection of bacteraemia as a function of the volume of blood cultured. APMIS 1993;101:595–601. CrossrefPubMedGoogle Scholar

  • 32.

    Opota O, Croxatto A, Prod’hom G, Greub G. Blood culture-based diagnosis of bacteraemia: state of the art. Clin Microbiol Infect 2015;21:313–22. PubMedCrossrefGoogle Scholar

  • 33.

    Pfeiffer CD, Samsa GP, Schell WA, Reller LB, Perfect JR, Alexander BD. Quantitation of Candida CFU in initial positive blood cultures. J Clin Microbiol 2011;49:2879–83. CrossrefPubMedGoogle Scholar

  • 34.

    Riedel S, Carroll KC. Blood cultures: key elements for best practices and future directions. J Infect Chemother 2010;16:301–16. PubMedCrossrefGoogle Scholar

  • 35.

    Lamy B, Seifert H. Microbial diagnosis: septicemia. In: Cornaglia G, Courcol R, Herrmann JL, Kahlmeter G, Peigue-Lafeuille H, Vila J, editors. European Manual of Clinical Microbiology (SFM/ESCMID), 1st ed. Paris: SFM; 2012:101–10. Google Scholar

  • 36.

    Public Health England. UK Standards for Microbiology Investigations B 37: Investigation of blood cultures (for organisms other than Mycobacterium species). 2014. Available at: https://www.gov.uk/government/collections/standards-for-microbiology-investigations-smi. Accessed: 20 Jan 2019. 

  • 37.

    Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017;43:304–77. CrossrefPubMedGoogle Scholar

  • 38.

    Patel R, Vetter EA, Harmsen WS, Schleck CD, Fadel HJ, Cockerill 3rd FR. Optimized pathogen detection with 30- compared to 20-milliliter blood culture draws. J Clin Microbiol 2011;49:4047–51. CrossrefPubMedGoogle Scholar

  • 39.

    Collazos-Blanco A, Pérez-García F, Sánchez-Carrillo C, de Egea V, Muñoz P, Bouza E. Estimation of missed bloodstream infections without the third blood culture set: a retrospective observational single-centre study. Clin Microbiol Infect 2019;25:469–73. CrossrefGoogle Scholar

  • 40.

    Bartlett JG, Dick J. The controversy regarding routine anaerobic blood cultures. Am J Med 2000;108:505–6. PubMedCrossrefGoogle Scholar

  • 41.

    Wilson ML, Weinstein MP, Reller LB. Automated blood culture systems. Clin Lab Med 1994;14:149–69. PubMedCrossrefGoogle Scholar

  • 42.

    Reimer LG, Wilson ML, Weinstein MP. Update on detection of bacteremia and fungemia. Clin Microbiol Rev 1997;103:444–65. Google Scholar

  • 43.

    van Ingen J, Hilt N, Bosboom R. Education of phlebotomy teams improves blood volume in blood culture bottles. J Clin Microbiol 2013;51:1020–1. CrossrefPubMedGoogle Scholar

  • 44.

    Chang J, Park JS, Park S, Choi B, Yoon NS, Sung H, et al. Impact of monitoring blood volume in the BD BACTEC™ FX blood culture system: virtual volume versus actual volume. Diagn Microbiol Infect Dis 2015;81:89–93. PubMedCrossrefGoogle Scholar

  • 45.

    Grohs P, Mainardi J-L, Podglajen I, Hanras X, Eckert C, Buu-Hoï A, et al. Relevance of routine use of the anaerobic blood culture bottle. J Clin Microbiol 2007;45:2711–5. CrossrefPubMedGoogle Scholar

  • 46.

    Li J, Plorde JJ, Carlson LG. Effects of volume and periodicity on blood cultures. J Clin Microbiol 1994;32:2829–31. PubMedGoogle Scholar

  • 47.

    Kirn TJ, Weinstein MP. Update on blood cultures: how to obtain, process, report, and interpret. Clin Microbiol Infect 2013;19:513–20. CrossrefPubMedGoogle Scholar

  • 48.

    Bates DW, Goldman L, Lee TH. Contaminant blood cultures and resource utilization. The true consequences of false-positive results. J Am Med Assoc 1991;265:365–9. CrossrefGoogle Scholar

  • 49.

    Lamy B, Roy P, Carret G, Flandrois JP, Delignette-Muller ML. What is the relevance of obtaining multiple blood samples for culture? A comprehensive model to optimize the strategy for diagnosing bacteremia. Clin Infect Dis 2002;35:842–50. PubMedCrossrefGoogle Scholar

  • 50.

    Arendrup M, Jensen IP, Justesen T. Diagnosing bacteremia at a Danish hospital using one early large blood volume for culture. Scand J Infect Dis 1996;28:609–14. CrossrefGoogle Scholar

  • 51.

    Dargère S, Parienti JJ, Roupie E, Gancel PE, Wiel E, Smaiti N, et al. Unique blood culture for diagnosis of bloodstream infections in emergency departments: a prospective multicenter study. Clin Microbiol Infect 2014;20:O920–7. PubMedCrossrefGoogle Scholar

  • 52.

    Li JS, Sexton DJ, Mick N, Nettles R, Fowler Jr VG, Ryan T, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000;30:633–8. CrossrefGoogle Scholar

  • 53.

    Horvath LL, George BJ, Murray CK, Harrison LS, Hospenthal DR. Direct comparison of the BACTEC 9240 and BacT/ALERT 3D automated blood culture systems for candida growth detection. J Clin Microbiol 2004;42:115–8. PubMedCrossrefGoogle Scholar

  • 54.

    Cuenca-Estrella M, Verweij PE, Arendrup MC, Arikan-Akdagli S, Bille J, Donnelly JP, et al. ESCMID guideline for the diagnosis and management of Candida diseases 2012: diagnostic procedures. Clin Microbiol Infect 2012;18(Suppl 7):9–18. PubMedGoogle Scholar

  • 55.

    George BJ, Horvath LL, Hospenthal DR. Effect of inoculum size on detection of Candida growth by the BACTEC 9240 automated blood culture system using aerobic and anaerobic media. J Clin Microbiol 2005;43:433–5. PubMedCrossrefGoogle Scholar

  • 56.

    Köck R, Eissing LC, Boschin MG, Ellger B, Horn D, Idelevich EA, et al. Evaluation of Bactec mycosis IC/F and Plus aerobic/F blood culture bottles for detection of Candida in the presence of antifungal agents. J Clin Microbiol 2013;51:3683–7. CrossrefPubMedGoogle Scholar

  • 57.

    Altun O, Almuhayawi M, Lüthje P, Taha R, Ullberg M, Özenci V. Controlled evaluation of the new BacT/Alert Virtuo blood culture system for detection and time to detection of bacteria and yeasts. J Clin Microbiol 2016;54:1148–51. CrossrefPubMedGoogle Scholar

  • 58.

    Lai CC, Wang CY, Liu WL, Huang YT, Hsueh PR. Time to positivity of blood cultures of different Candida species causing fungaemia. J Med Microbiol 2012;61:701–4. PubMedCrossrefGoogle Scholar

  • 59.

    Cobos-Trigueros N, Kaasch AJ, Soriano A, Torres JL, Vergara A, Morata L, et al. Time to positivity and detection of growth in anaerobic blood culture vials predict the presence of Candida glabrata in candidemia: a two-center European cohort study. J Clin Microbiol 2014;52:3082–4. CrossrefPubMedGoogle Scholar

  • 60.

    Gokbolat E, Oz Y, Metintas S. Evaluation of three different bottles in BACTEC 9240 automated blood culture system and direct identification of Candida species to shorten the turnaround time of blood culture. J Med Microbiol 2017;66:470–6. PubMedCrossrefGoogle Scholar

  • 61.

    Flayhart D, Borek AP, Wakefield T, Dick J, Carroll KC. Comparison of BACTEC PLUS blood culture media to BacT/Alert FA blood culture media for detection of bacterial pathogens in samples containing therapeutic levels of antibiotics. J Clin Microbiol 2007;45:816–21. CrossrefPubMedGoogle Scholar

  • 62.

    Mitteregger D, Barousch W, Nehr M, Kundi M, Zeitlinger M, Makristathis A, et al. Neutralization of antimicrobial substances in new BacT/Alert FA and FN Plus blood culture bottles. J Clin Microbiol 2013;51:1534–40. PubMedCrossrefGoogle Scholar

  • 63.

    Reimer LG, Wilson ML, Weinstein MP. Update on detection of bacteremia and fungemia. Clin Microbiol Rev 1997;103:444–65. Google Scholar

  • 64.

    Rönnberg C, Mildh M, Ullberg M, Özenci V. Transport time for blood culture bottles: underlying factors and its consequences. Diagn Microbiol Infect Dis 2013;76:286–90. PubMedCrossrefGoogle Scholar

  • 65.

    Van den Poel B, Klak A, Desmet S, Verhaegen J. How small modifications in laboratory workflow of blood cultures can have a significant impact on time to results. Eur J Clin Microbiol Infect Dis 2018;37:1753–60. CrossrefPubMedGoogle Scholar

  • 66.

    Seegmüller I, Eschenbach U, Kamereck K, Miethke T. Sensitivity of the BacT/ALERT FA-medium for detection of Pseudomonas aeruginosa in pre-incubated blood cultures and its temperature-dependence. J Med Microbiol 2004;53:869–74. PubMedCrossrefGoogle Scholar

  • 67.

    Morton B, Nagaraja S, Collins A, Pennington SH, Blakey JD. A retrospective evaluation of critical care blood culture yield-do support services contribute to the “weekend effect”? PLoS One 2015;10:e0141361. CrossrefPubMedGoogle Scholar

  • 68.

    Kerremans JJ, van der Bij AK, Goessens W, Verbrugh HA, Vos MC. Immediate incubation of blood cultures outside routine laboratory hours of operation accelerates antibiotic switching. J Clin Microbiol 2009;47:3520–3. CrossrefPubMedGoogle Scholar

  • 69.

    Venturelli C, Righi E, Borsari L, Aggazzotti G, Busani S, Mussini C, et al. Impact of pre-analytical time on the recovery of pathogens from blood cultures: results from a large retrospective survey. PLoS One 2017;12:e0169466. CrossrefPubMedGoogle Scholar

  • 70.

    Lamy B, Ferroni A, Henning C, Cattoen C, Laudat P. How to: accreditation of blood cultures’ proceedings. A clinical microbiology approach for adding value to patient care. Clin Microbiol Infect 2018;24:956–63. CrossrefPubMedGoogle Scholar

  • 71.

    Rocchetti A, Rapallo F, Bottino P, Mastrazzo A. Implementation of satellite blood-culture system in an emergency department: impact of time-to results in sepsis detection. Microbiol Med 2016;31:5859. Google Scholar

  • 72.

    Schifman RB, Bachner P, Howanitz PJ. Blood culture quality improvement: a college of American Pathologists Q-probes study involving 909 institutions and 289572 blood culture sets. Arch Pathol Lab Med 1996;120:999–1002. PubMedGoogle Scholar

  • 73.

    Novis DA, Dale JC, Schifman RB, Ruby SG, Walsh MK. Solitary blood cultures: a College of American Pathologists Q-probes study of 132,778 blood culture sets in 333 small hospitals. Arch Pathol Lab Med 2001;125:1290–4. PubMedGoogle Scholar

  • 74.

    Hall KK, Lyman JA. Updated review of blood culture contamination. Clin Microbiol Rev 2006;19:788–802. PubMedCrossrefGoogle Scholar

  • 75.

    Baron EJ, Weinstein MP, Dunne WM, Yagupsky P, Welch DF, Wilson DM. Blood cultures IV. Cumitech cumulative techniques and procedures in clinical microbiology 1C. Washington DC: ASM Press, 2005:1–16, 23–5. Google Scholar

  • 76.

    Clinical Laboratory Standards Institute (CLSI). Principles and procedures for blood cultures. CLSI document M47-A. Wayne, PA: CLSI, 2007:1–53. Google Scholar

  • 77.

    Isenberg HD. Clinical microbiology procedures handbook. In: York MK, Henry M, Gilligan P, editors. Section 3.4.1 Aerobic bacteriology, blood cultures, general detection and interpretation. Washington, DC: American Society of Microbiology Press, 2010. Google Scholar

  • 78.

    Siméon S, Moing VL, Tubiana S, Duval X, Fournier D, Lavigne J-P, et al. Time to blood culture positivity: an independent predictor of infective endocarditis and mortality in patients with Staphylococcus aureus bacteraemia. Clin Microbiol Infect 2019;25:481–8. PubMedCrossrefGoogle Scholar

  • 79.

    M47A: Principles and procedures for blood cultures. Clinical & Laboratory Standards Institute. Available at: https://clsi.org/standards/products/microbiology/documents/m47/. Accessed: 3 Sep 2018. 

  • 80.

    Buchler T, Pavlik T, Melichar B, Bortlicek Z, Usiakova Z, Dusek L, et al. Bevacizumab with 5-fluorouracil, leucovorin, and oxaliplatin versus bevacizumab with capecitabine and oxaliplatin for metastatic colorectal carcinoma: results of a large registry-based cohort analysis. BMC Cancer 2014;14:323. PubMedCrossrefGoogle Scholar

  • 81.

    Nucera G, Esposito A, Tagliani N, Baticos CJ, Marino P. Physicians’ and nurses’ knowledge and attitudes in management of sepsis: an Italian study. J Health Soc Sci 2018;3:13–26. Google Scholar

  • 82.

    Arena F, Argentieri M, Bernaschi P, Fortina G, Kroumova V, Manso E, et al. Real life turnaround time of blood cultures in the clinical microbiology laboratory: results of the first Italian survey, May 2015. Microbiol Med 2016;31:6127. Google Scholar

  • 83.

    Edmiston CE, Garcia R, Barnden M, DeBaun B, Johnson HB. Rapid diagnostics for bloodstream infections: a primer for infection preventionists. Am J Infect Control 2018;46:1060–8. CrossrefPubMedGoogle Scholar

  • 84.

    Rello J, van Engelen TS, Alp E, Calandra T, Cattoir V, Kern WV, et al. Towards precision medicine in sepsis: a position paper from the European Society of Clinical Microbiology and Infectious Diseases. Clin Microbiol Infect 2018;24:1264–72. PubMedCrossrefGoogle Scholar

  • 85.

    Garcia RA, Spitzer ED, Kranz B, Barnes S. A national survey of interventions and practices in the prevention of blood culture contamination and associated adverse health care events. Am J Infect Control 2018;46:571–6. PubMedCrossrefGoogle Scholar

  • 86.

    Dargère S, Cormier H, Verdon R. Contaminants in blood cultures: importance, implications, interpretation and prevention. Clin Microbiol Infect 2018;24:964–9. CrossrefPubMedGoogle Scholar

  • 87.

    CDC. Think sepsis. Time matters. Centers for Disease Control and Prevention 2016. Available at: https://www.cdc.gov/vitalsigns/sepsis/index.html. Accessed: 28 May 2018. 

  • 88.

    Lippi G, Chance JJ, Church S, Dazzi P, Fontana R, Giavarina D, et al. Preanalytical quality improvement: from dream to reality. Clin Chem Lab Med 2011;49:1113–26. PubMedGoogle Scholar

  • 89.

    Simundic AM, Bölenius K, Cadamuro J, Church S, Cornes MP, van Dongen-Lases EC, et al. Working Group for Preanalytical Phase (WG-PRE) of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) and Latin American Working Group for Preanalytical Phase (WG-PRE-LATAM) of the Latin America Confederation of Clinical Biochemistry (COLABIOCLI). Joint EFLM-COLABIOCLI recommendation for venous blood sampling. Clin Chem Lab Med 2018;56:2015–38. Google Scholar

  • 90.

    Zaninotto M, Tasinato A, Vecchiato G, Legnaro A, Pinato A, Plebani M. Performance specifications in extra-analytical phase of laboratory testing: sample handling and transportation. Clin Biochem 2017;50:574–8. CrossrefPubMedGoogle Scholar

About the article

Corresponding author: Vincenzo Puro, MD, National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome 00149, Italy, Phone: +39 0655170902


Received: 2018-10-24

Accepted: 2019-06-24

Published Online: 2019-07-26

Published in Print: 2019-10-25


Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: This work was supported by an unconditional contribution from Becton Dickinson.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


Citation Information: Clinical Chemistry and Laboratory Medicine (CCLM), Volume 57, Issue 11, Pages 1680–1689, ISSN (Online) 1437-4331, ISSN (Print) 1434-6621, DOI: https://doi.org/10.1515/cclm-2018-1146.

Export Citation

©2019 Walter de Gruyter GmbH, Berlin/Boston.Get Permission

Comments (0)

Please log in or register to comment.
Log in