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Best Practices in Blood Cultures: Effective QA. Michael Mitchell, MD, F(CAP) Department of Hospital Laboratories, UMass Memorial Medical Center Worcester, MA. Introduction and Overview. Review issues related to bacteremia and fungemia Review general principles of QA monitors

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Best practices in blood cultures effective qa

Best Practices in Blood Cultures: Effective QA

Michael Mitchell, MD, F(CAP)

Department of Hospital Laboratories,

UMass Memorial Medical Center

Worcester, MA

Introduction and overview

Introduction and Overview

  • Review issues related to bacteremia and fungemia

  • Review general principles of QA monitors

  • QA monitors for routine blood cultures

  • Data analysis

  • Responses and interventions

Bacteremia and fungemia

Bacteremia and Fungemia

Significant bacteremia

Significant Bacteremia

  • Bugs in > Bugs out

    • Endovascular vs. extra-vascular infection

    • Bacteremia may be continuous or intermittent

  • “Organism load” (cfu/mL) is low

Clinical implications

Clinical Implications

  • Bacteremic infections are increasing

  • Bacteremic infection result in high morbidity and mortality

  • Isolates are more likely to be resistant

  • Bacteremic infection may cause metastatic, localized complications

Risk factors

Risk Factors

  • Pathogen virulence factors

  • Host underlying medical conditions

  • Nosocomial factors

Impact of true positive cultures

Impact of True Positive Cultures

  • Provides therapeutic and prognostic insight

  • Informs a general approach to care

    • Antimicrobials

    • Critical care interventions

    • Investigation of sources

Impact of true positive cultures1

Impact of True Positive Cultures

  • Provides a pathogen for further testing

    • Another indicator of prognosis

    • Susceptibility testing

    • Testing for specific virulence factor

    • Stocked organisms

Impact of contaminated cultures

Impact of Contaminated Cultures

  • Costs to Patient

    • Additional testing

    • Unneeded antimicrobial therapy

    • Additional LOS

    • Complications of the above!

Impact of contaminated cultures1

Impact of Contaminated Cultures

  • Costs to the Institution

    • $10 to $40 thousand dollars per episode of care!

    • Patient safety and satisfaction

    • Public Reporting

Quality assurance general issues

Quality assurance: general issues

Quality monitors

Quality Monitors


    • Analytical

    • Pre-analytical

    • Post-analytical


What is monitored and reported will improve

What is Monitored and ReportedWill Improve…

Effective qa programs

Effective QA Programs

  • Harmonize Lab’s and Institution’s QA activities

  • Choose Indicators that reflect quality

  • Choose Indicators for a assessment of all aspects of analytical process

  • Engage stakeholders

Effective qa monitor data

Effective QA Monitor Data

  • Measurable, reliable and objective

  • Collection must be achievable

  • Interpretable and informative

  • Allow for relevant stratification

  • Actionable

Developing effective monitors

Developing Effective Monitors

  • Define critical elements in process

  • Determine informative data

  • Determine how data will be analyzed

  • Determine potential “interventions”

  • Collectable over time; analyze effects of interventions

  • Determine “Life Cycle”?

Microbiologists and hospital qa

Microbiologists and Hospital QA

  • Access to patient-specific and cumulative data

  • Comfortable with computer databases and analytical tools

  • Insight into pre-, post- and analytical aspects of quality

  • Experience working in multi-disciplinary teams

  • Use of Standards is standard

Choose indicators wisely

Choose indicators wisely

Objective data

Easily captured

Informative analysis (insight into problems)

Subject to intervention

Don’t choose too many!

Specific qa monitors for blood cultures

Specific QA monitors for blood cultures



  • CLSI document M-47A: Principles and Procedures for Blood Cultures; Approved Guideline

  • Cumitech 1C Blood Cultures IV

  • Various publications (See Reference pages below)

  • Local process analysis—Ishikawa diagram

M 47a quality components

M-47A Quality Components

  • Pre-Analytical

    • Patient Evaluation

    • Test Selection and Ordering

    • Sample Collection and Inoculation

    • Sample Transport

    • Sample Receipt and Initial Processing

M 47a quality components1

M-47A Quality Components

  • Analytical

    • Platforms and procedures for detection

    • Identification of Isolates

    • Susceptibility testing protocols

    • Verification of results

    • Interpretation of results

M 47a quality components2

M-47A Quality Components

  • Post-Analytical

    • Reporting

    • Record Management

    • Consultation

Ummmc quality monitors

UMMMC Quality Monitors

  • True Positive and Contamination Rates

  • Single Bottle Cultures

  • Single Culture Evaluations

  • Clinically Uninformative Cultures

  • Stratification by Location

  • Harmonize with CR-BSI Activities

Ummmc blood culture qa initiative

UMMMC Blood Culture QA Initiative

  • Laboratory

    • Microbiology, Information Services, Phlebotomy, Quality Management

  • Critical Care Operations

  • Infection Control

  • Patient Safety/Quality Management

Npr report

NPR Report

  • Lab#

  • MR#

  • Patient name

  • Date and time of collection

  • Location of collection

  • Requesting MD

  • Culture results

Activities related to blood culture quality

Activities Related to Blood Culture Quality

Review External Benchmarks

Provide Educational Resources

On-site visits to Units

Stress critical aspects for Quality

Quarterly monitoring and reporting



Avoid collection through lines.

Sterilize of each “barrier” crossed

Collection of multiple independent cultures; Avoid excessive cultures

Recognize of probable contaminants

Skin decontamination

Skin Decontamination

M47 discusses several methods for effective skin decontamination:

  • Tincture of iodine or chlorhexidine gluconate

  • 30 second abrasive scrub

Specificity number of cultures per evaluation

Specificity: Number of Cultures per Evaluation

The risk of a patient having a contaminated blood culture increases arithmetically with the number of cultures obtained.

The cost of contaminated blood culture is high

The Cost of Contaminated Blood Culture is High

Increased LOS

Increased antibiotic treatment

Increased numbers of laboratory tests

Complications of above

Sensitivity volume of blood inoculated

Sensitivity: Volume of blood inoculated

You have to get bugs in the broth to get a positive blood culture!

Typical bacteremia 1 cfu/mL + log10.

Linear increased detection as inoculum increases.



How do we get volume?

Volume of blood per bottle

Number of bottles per culture

Number of cultures per evaluation

Culture timing

Culture Timing

Back-to-back cultures may be collected.

Wait 48 to 72 hours before repeating evaluation with additional blood cultures.

Consider other sources of infection or diagnostic techniques.

Prior probability of bacteremia or fungemia

Prior Probability of Bacteremia or Fungemia

CLSI Recommendation: For patients with low prior probability of bacteremia or fungemia, surveillance cultures or extensive test of cure assessments are not recommended.

Evaluation recommendation

Evaluation Recommendation

  • Each blood culture:

    • Collect 20 mL by venipuncture for each culture

    • Inoculate 10mL of blood each into an aerobic and an anaerobic bottle

  • Immediately collect a second, independent blood culture

If you think about doing a blood culture do two

If you think about doing a blood culture,DO TWO

Inoculum volume for adults

Inoculum Volume for Adults

Data analysis

Data analysis

Paper is sooo last milenium

Paper is sooo Last Milenium

  • Reports

    • Relevant Fields

    • Unformated text file

    • Importable into data management program

Blood culture qa data

Blood Culture QA Data

Lab #

Patient Name

Patient MR#

Patient Age

Collection Date

Collection Time

Collection Location

Submitting MD

Aerobic Bottle Result

Anaerobic Bottle Result

Interpretation (TP, FP)

Interpretation of positive cultures

Interpretation of Positive Cultures

  • Species isolated

  • Other co-isolated organisms

  • Isolation of the organism from other independent blood cultures or infected sites

Blood culture pairs

Blood Culture Pairs

Label bottles so that those from a single collection can be accurately paired

Never submit bottles from different collections as a single culture

Questionable positive

Questionable Positive

Best practices in blood cultures effective qa











How have we done

How Have We Done?

Performance over time

Performance Over Time

Performance over time1

Performance Over Time

Responses and interventions

Responses and interventions

Assess seal cracks

If a monitor exceeds threshold:

Is it real?

Is it sustained?

Does it stratify by location or time?

Change in patient population?

Change in any aspect of process?

Assess/Seal Cracks



  • Assess for “breaks” in process

  • Re-education, general or site-focused

  • Stress: “Take time to do it right!”

  • Establish phlebotomy teams

  • Create barriers against poor quality practices



  • QA activities related to blood cultures are critical for patient outcome and cost-effective care

  • Objective, actionable monitors are part of the laboratory’s QA activities

  • A committed multi-disciplinary team is involved

  • Significant improvements have been achieved, but challenges continue

Thank you

Thank You!

  • Contact Information

    Michael J. Mitchell, MD, FCAP

    Director, Microbiology Services

    Department of Hospital Laboratories

    UMass Memorial Medical Center

    365 Plantation Street, Room 279

    Worcester, MA 01605

    Phone: 774-442-9630



  • Baron EJ, et al. Cumitech 1C: Blood Cultures IV. 2005.

  • Cockerill FR, et al. Optimal Testing Parameters for Blood Cultures. 2004. Clin Infect Dis 38: 1724-30.

  • Connell TG, et al. How Reliable Is a Negative Blood Culture Result? Volume of Blood Submitted for Culture in Routine Practice in a Children’s Hospital. 2007. Pediatrics 119: 891-6.

  • Dwivedi S, et al. Discarding the Initial Aliquot of Blood Does Not Reduce Contamination Rates in Intravenous-Catheter-Drawn Blood Cultures. 2009. JCM 47: 2950-1.

  • Everts RJ, et al. Contamination of Catheter-Drawn Blood Cultures. 2001. JCM 39: 3393-94.

References 2

References 2

  • Gander RM, et al. Impact of Blood Cultures Drawn by Phlebotomy on Contamination Rates and Health Care Costs in a Hospital Emergency Department. 2009. JCM 47: 1021-24.

  • Hall KK and JA Lyman. Updated Review of Blood Culture Contamination. 2006. ClinMicrobiol Rev 19: 788-802.

  • Ilstrup DM and JA Washington 2d. The importance of volume of blood cultured in the detection of bacteremia and fungemia. 1983. DiagnMicrobiol Infect Dis. 1: 107-10.

  • Levin PD, et al. Routine Surveillance Blood Cultures: Their Place in the Management of Critically Ill Patients. 1997. J Infect 35: 125-8.

References 3

References 3

  • Mermel LA and DG Maki. Detection of Bacteremia in Adults: Consequences of Culturing an Inadequate Volume of Blood. 1993. Ann Intern Med 119: 270-272.

  • Mirrett S, et al. Relevance of the Number of Positive Bottles in Determining Clinical Significance of Coagulase-Negative Staphylococci in Blood Cultures. 2001. JCM 39: 3279-81.

  • Nielsen J, et al. Poor Value of Surveillance Cultures of Prediction of Septicaemia Caused by Coagulase-negative Staphylococci in Patients Undergoing Haemodialysis with Central Venous Catheters. 1998. Scand J Infect Dis 30: 569-72.

  • Patel R, et al. Optimized Pathogen Detection with 30- Compared to 20-Milliliter Blood Culture Draws. 2011. JCM 49: 4047-4051.

References 4

References 4

  • Seifert H. The Clinical Importance of Microbiological Findings in the Diagnosis and Management of Bloodstream Infections. 2009. Clin Infect Dis 48: S238-45.

  • Weinbaum FI, et al. Doing It Right the First Time: Quality Improvement and the Contaminant Blood Culture. 1997. JCM 35: 563-65.

  • Weinstein MP, et al. The Clinical Significance of Positive Blood Cultures in the 1990s… 1997. Clin Infect Dis 24: 584-602.

  • Wilson ML, et al. CLSI document M47-A Principles and Procedures for Blood Cultures; Approved Guideline. 2007.

References 5

References 5

  • Yokoe DS, et al. Simplified Surveillance for Nosocomial Bloodstream Infections. 1998. Infect Control Hosp Epidem 19: 657-60.

  • Zwang O and RK Albert. Analysis of Strategies to Improve Cost Effectiveness of Blood Cultures. 2006. J Hosp Med 1: 272-6.

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