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A Lecture at the APIC Central Illinois IP Conference, Bloomington, IL November 17, 2017 Robert Garcia, BS, MT(ASCP), FAPIC, CIC Infection Control Preventionist
A Lecture at the APIC Central Illinois IP Conference,
Bloomington, IL
November 17, 2017
Robert Garcia, BS, MT(ASCP), FAPIC, CIC
Infection Control Preventionist
Lecture Objectives Provide evidence on the potential impact of specimen
contamination on CLABSIs and CAUTIs
Describe guideline recommendations and study findings that provide insight on blood and urine culture collection
Provide a checklist of best practices in blood and urine culture collection
Review Article on Blood Culture Collection and Handling
A Multidisciplinary Team Review of Best Practices for 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 (CLABSI)
R. Garcia, E. Spitzer, J. Beaudry, C. Beck, R. DiBlasi, M. Gilleeney-Blabac,
C. Haugaard, S. Heuschneider, B. Kranz, K. McLean, K. Morales, S. Owens,
M. Paciella, E. TorregrossaReviewed by L. Hadaway, T. Murphy, F. Singh, D. Roberts
American Journal of Infection Control and Epidemiology, Dec 2015
Reasons for Optimizing Blood Culture Collection & Handling
Identifying true pathogens
Avoidance of blood culture contamination
Avoiding false positive CLABSIs
Need for Maximizing True Pathogens Septicemia is the 11th leading cause of death in the U.S. accounting for
more than 38,000 lives per year
Sepsis is currently the most expensive hospital condition ($20.29 billion) among inpatients
….has accounted for a 32 percent increase in hospitalizations in recent years
…and is the leading cause of admission to a hospital for adults aged 45 to 84 years after an Emergency Department (ED) visit
Guidelines recommend blood cultures to be obtained within three hours of presentation and prior to administration of antibiotics
CDC, Leading causes of death, US, 2013. available at: http://www.cdc.gov/nchs/data/dvs/LCWK9_2013.pdf
Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. Statistical Brief #160. National
Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011. Available at: http://www.hcup-
us.ahrq.gov/reports/statbriefs/sb160.pdf.
Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. Statistical Brief #161. Trends in
Septicemia Hospitalizations in Selected HCUP States, 2005 1nd 2010. Available at: http://www.hcup-
us.ahrq.gov/reports/statbriefs/sb161.pdf.
Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. Statistical Brief #174. Overview of
Emergency Department Visits in the United States, 2011. Available at: http://www.hcup-
us.ahrq.gov/reports/statbriefs/sb174-Emergency-Department-Visits-Overview.pdf.
Surviving Sepsis Campaign. Updated Bundles in Response to New Evidence. Available at:
http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf
http://www.cdc.gov/nchs/data/dvs/LCWK9_2013.pdfhttp://www.hcup-us.ahrq.gov/reports/statbriefs/sb174-Emergency-Department-Visits-Overview.pdf
Blood Culture Contamination
Contaminated BCs are associated with severe financial and clinical consequences
Landmark study by the College of American Pathologists (CAP) of 497,134 BCs obtained in 640 hospitals reported mean contamination rate of 2.5%
Most U.S. hospitals use a BCC benchmark of ≤3.0% as derived from CAP Q-Tracks Monitor data
BCs are considered contaminated if one or more of the following organisms are found in only one bottle in a series of BC sets (e.g., 1 of 1; 1 of 2, etc.): CoNS, Micrococcus, alpha-hemolytic viridens strep, Propionibacterium
acnes, Corynebacterium sp., Bacillus sp.
Bates DW, Goldman L, Lee TH. Contaminant blood cultures and resource utilization: the true consequences of false-
positive results. JAMA 1991;265(3):365-69.
Schifman RB, Strand CL, Meier FA, Howanitz PJ. Blood culture contamination: a College of American Pathologists Q-
Probes study involving 640 institutions and 497,134 specimens from adult patients. Arch Pathol Lab Med 1998;122:216-
21.
Bekeris LG, Tworek JA, Walsh MK, Valenstein PN. Trends in blood culture contamination: a College of American
Pathologists Q-Tracks Study of 356 institutions. Arch Pathol Lab Med 2005;129:1222-25.
Performance Improvement
Define & Measure (Surveillance): NHSN CLABSI Definitions, 2016
Laboratory-Confirmed Bloodstream Infection (LCBI) –Must meet one of the following criteria:
LCBI 1 Patient has a recognized pathogen cultured from one or more blood cultures AND organism cultured from blood is not related to an infection at another site.
LCBI 2 Patient has at least one of the following signs or symptoms: fever (>38.0oC), chills, or hypotension AND organism cultured from blood is not related to an infection at another site (See Appendix 1 Secondary BSI Guide) AND the same common commensal (i.e., diphtheroids [Corynebacterium spp. not C. diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., and Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions.
LCBI 3 Patient ≤ 1 year of age has at least one of the following signs or symptoms: fever (>38.0oC), hypothermia (
COMMUNICATION
BETWEEN PROVIDERSEDUCATION
STAFF BEHAVIOR
& PRACTICE
CLABSI
POICY & PROCEDUREDOCUMENTATIONPRODUCTS &
DEVICES
BSI surveillance rounds
Communicate monitoring findings
to appropriate staff
Review CR-BSI data with staff
Consideration for alternative
devices
Insertion & maintenance
of catheters & lines
Aseptic vs. Sterile
Techniques used
during insertion &
maintenance
Attire worn
during
procedure
Site of Insertion
Indications for insertion
Replacement and
Relocation of device
Replacement of dressing
Maintenance of log/book
to track patients
Nursing / Physician chart
documentation
Dating of dressings
Dating insertion site
Dressings
Catheters (coatings)
Skin antiseptic
Risk by site of insertion
Guidewire changes
Replacement of administration sets
Hang time for parenteral fluids
Knowledge of definition
of CR-BSI
Attire during insertion
System Analysis
Catheter culturing technique
Dressing Kit
Experience of
Person Inserting
Application, care &
maintenance of dressings
CVC insertion observation
Dressing observation
R. Garcia, 2002
Prevention by Use of Bundles: The 100,000 Lives Campaign
Institute for Healthcare Improvement initiative to reduce healthcare errors and infections
Implemented January 2005 Addresses specific healthcare-acquired infections
CVC-associated BSI “Central line bundle”
Hand hygiene Maximal sterile barriers upon insertion Chlorhexidine skin antisepsis Optimal catheter site selection Daily review of line necessity with prompt removal of
unnecessary lines
http://ihi.org/IHI/Programs/Campaign/Campaign.htm
Blood Culture Collection & Handling
Surveillance
System Analysis
Preventive Initiatives
BCC Effect on CLABSIs LCBI 1: so called NHSN “recognized pathogens” such as S. aureus
or Enterococcus have been identified as contaminants (6.4% and 16.1% respectively) in major study; when a “pathogen” is not related to an infection at another site, as occurs when a contaminant is identified, then the event is a CLABSI
LCBI 2: clinical situations, e.g., patient’s venous condition, limited CVAD lumen access, clinician’s workload may restrict “ideal” blood draws from separate sites or at different times.
There exists no “gold standard” for determining true infection vs. contamination of BCs….this limitation may impact the variability in identifying reportable CLABIs
Freeman JT, et al. Blood culture contamination with Enterococci and skin organisms: implications for surveillance definitions
of primary blood stream infections. Am J Infect Control 2011;39:436-48.
Steinberg JP, et al. Distribution of pathogens in central line-associated bloodstream infections among patients with or
without neutropenia following chemotherapy: evidence for a proposed modification to the current surveillance definition.
Infect Control Hosp Epidemiol 2013;34:171-75.
Backman LA, et al. Validation of the surveillance and reporting of central line-associated bloodstream infection data to a
state health department. Am J Infect Control 2010;38:832-38.
BC Organisms: Pathogens or Contaminants?Organism Probability That the Organism Is a True Pathogen
Gram positive aerobic bacteria
Staphylococcus aureus High
Coagulase-negative staphylococci Low/intermediate
Enterococcus spp. Intermediate/high
Viridens group streptococci Intermediate
Beta-hemolytic streptococci High
Streptococcus pneumoniae High
Bacillus spp. Low
Corynebacterium spp. Low
Gram-negative aerobic bacteria
Eschericia coli High
Klebsiella pneumoniae High
Enterobacter cloacae High
Pseudomonas aeruginosa High
Acinetobacter baumanii Intermediate/high
Anaerobic bacteria
Clostridium spp. Intermediate
Propionbacterium spp. Low
Bacteroides fargilis group High
Yeast
Candida spp. High
E. Spitzer MD, PhD. Infectious
Diseases. In: Laboratory Medicine:
The Diagnosis of Disease in the
Clinical Laboratory. Second Edition,
McGraw Hill Education.
High – 90% to 100%
Intermediate - >10% to
Are we preventing the preventable?
Major Guidelines Addressing BCs Clinical and laboratory Standards Institute (CLSI). Principles and Procedures for Blood Cultures:
Approved Guideline. CLSI document M47-A. Vol. 46. No. 31. Wayne, PA: Clinical and Laboratory Standards Institute, 2007
Centers for Disease Control and Prevention. Assessment of Best Practices for Standardized Quality Assurance Activities in Pathology and Laboratory Medicine. Available at: http://wwwn.cdc.gov/cliac/pdf/Addenda/cliac0907/AddendumF.pdf.
Emergency Nurses Association. Clinical Practice Guideline: Prevention of Blood Culture Contamination. December 2012. Available at: http://www.guideline.gov/content.aspx?id=47353.
National Health Service, Department of Health, United Kingdom. Taking blood cultures: a summary of best practice. Available at: http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/files/2011/03/Document_Blood_culture_FINAL_100826.pdf.
Cherson C. Blood Cultures. In: Kulich PA, Taylor DL, editors. The Infection Preventionist’s Guide to the Laboratory. Washington, D.C.: Association for Professionals in Infection Control and Epidemiology and the American Society of Microbiology; 2012. . p. 35-43.
Infusion Nurses Society. Infusion Nursing Standards of Practice. J Inf Nurs (Supp.) Jan/Feb 2011;Vol 34, No. 1S. p. S1-S110.
http://www.guideline.gov/content.aspx?id=47353http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/files/2011/03/Document_Blood_culture_FINAL_100826.pdf
Optimizing Blood Culture Collection: Elements in the Process
Clinical Indications for BCs Obtain BCs for specific clinical conditions:
Patients with… fever (≥38°C) hypothermia (≤36°C) leukocytosis an absolute granulocytopenia …or combination of these markers
Sepsis Meningitis Suspected catheter-related bacteremia Infectious endocarditis Arthritis Osteomyelitis Fever of unknown origin
Willems E, Smismans A, Cartuyvels R, Coppens G, van Vaerenbergh K, van den Abeele, et al. The preanalytical optimization of blood cultures:
a review and the clinical importance of benchmarking in 5 Belgian hospitals. Diag Microbiol Infect Dis 2012;73:1-8.
Universal Decolonization Large study, 74 adult ICUs, 43 hospitals
Strategy of using intranasal mupirocin and daily chlorhexidine gluconate using impregnated cloths was most effective
45% reduction in BCC rate
Three other studies showed 58.1%, 41.3%, and 53.0% BCC rate reduction , respectively
•Septimus EJ, Hayden MK, Kleinman K, Avery TR, Moody J, Weinstein RA, et al. Does chlorhexidine bathing in adult
intensive care units reduce blood culture contamination? A pragmatic cluster-randomized trial. Infect Control Hosp
Epidemiol 2014;35:S17-S22.
•Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing
to reduce catheter-associated bloodstream infections in medical intensive care patients. Arch Intern Med
2007;167:2073-79.
•Popovich KJ, Hota B, Hayes R, Weinstein RA, hayden MK. Effectiveness of routine patient cleansing with
chlorhexidine gluconate for infection prevention in the medical intensive care unit. Infection Cont Hosp Epidemiol
2009;30:959-63.
•Hayden MK, Lin MY, Lolans K, Weiner S, Blom D, Moore NM, et al. Prevention of colonization and infection by
Klebsiella pneumonia carbepenemase-producing Enterobacteriaceae in Long-term acute-care hospitals. Clin Infect Dis
2015;1-9. Available at: http://cid.oxfordjournals.org/content/early/2015/01/26/cid.ciu1173.long. Accessed 2/1/15.
http://cid.oxfordjournals.org/content/early/2015/01/26/cid.ciu1173.long. Accessed 2/1/15
Venipuncture vs. Central Line Draw
“Blood for BCs should be drawn via peripheral venipuncture unless clearly
necessary”--Centers for Disease Control and Prevention. Assessment of Best Practices for Standardized Quality Assurance Activities
in Pathology and Laboratory Medicine. Available at: http://wwwn.cdc.gov/cliac/pdf/Addenda/cliac0907/AddendumF.pdf.
Snyder SR, Favoretto AM, Baetz RA, Derzon JH, Madison BM, Mass D, et al. Effectiveness of practices to reduce
blood culture contamination: a Laboratory Medicine Best Practices systematic review and meta-analysis. Clin Biochem
2012;45:999-1011.
Venipuncture Procedure
When CRBSI is Suspected Non-neutropenic adults: Draw 2 sets of BCs, one from the line and one
peripheral
Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O’Grady NP. 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.
Adult patient with fever and neutropenia: Draw at least two sets, with a set collected from simultaneously from each lumen of an existing catheter, and a peripheral vein site
Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, et al. Clinical Practice Guidelines for the use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America. Clin Infect Dis 2011;52:56-93.
Needleless Connectors & Hubs
“…the NC should be changed in the following circumstances…prior to drawing a sample for BC from the VAD,…”
No studies published examining BCC rates when drawing directly from an IV hub or new NC
Infusion Nurses Society. Infusion Nursing Standards of Practice. J Inf Nurs (Supp.) Jan/Feb 2016;Vol 39, No. 1S. p. S1-
S110.
Pre-Packaged Kits
Snyder SR, Favoretto AM, Baetz RA, Derzon JH, Madison BM, Mass D, et al. Effectiveness of practices to reduce blood
culture contamination: a Laboratory Medicine Best Practices systematic review and meta-analysis. Clin Biochem
2012;45:999-1011.
Sterile Gloves Sterile Gloves: 6-month, cluster randomized trial, 17
medical units, interns drawing BCs via venipuncture, Korea
Use of sterile gloves reduced BCC by 50%
Kim NH, Kim H, Lee S, Kim K-H, Park SW, Kim HB, et al. Effect of routine sterile gloving on contamination rates in blood cultures. An
Intern Med 2011;154:145-51.
Masks: No EvidenceNormal flora of oral cavity
Actinobacillus
Actinomyces
Fusobacterium
Haemophilus
Lactobacillus
Micrococcus
Mycoplasma
Propionibacerium
Streptococcus viridens grp
NHSN reported CLABSI pathogens (top eight)
1. Coag. Negative Staph.
2. S. aureus
3. E. faecalis
4. Candida other than albicans
5. Klebsiella
6. E. faecium
7. C. albicans
8. Enterobacter spp.
Brooks K. Chapter five: Common Commensals and Other Normal
Flora. In: Brooks K, editor. Ready Reference for Microbes. Washington,
D.C.: Association for Professionals in Infection Control and
Epidemiology; 2012. P. 87-95.
Sivert DM, Ricks P, Edwards JR, Schneider A, Patel J, Srinivasan
A, et al. Antimicrobial-resistant pathogens associated with
healthcare-associated infections: summary of data reported to the
National Healthcare Safety Network at the Centers for Disease
Control and Prevention, 2009-2010. Infect Control Hosp Epiddemiol
2013;34:1-14.
Antisepsis of Skin Systematic review of RCTs: Alcoholic chlorhexidene
gluconate solutions are associated with lower rates of BCC
Calderia D, David C, Sampaio C. Skin antiseptics in venous puncture-site disinfection for prevention of blood culture
contamination: systematic review with meta-analysis. J Hosp Infect 2011;77:223-32.
Central Line Procedure
BC Bottles: Disinfection The septa of BC bottles are
not sterile
“…the rubber septum on the BC bottle should be disinfected with 70% alcohol and allowed to dry”1
Do not use iodine products
1. Clinical and Laboratory Standards Institute (CLSI). Principles and Procedures for Blood Cultures: Approved
Guideline. CLSI document M47-A. Vol. 46. No. 31. Wayne, PA: Clinical and Laboratory Standards Institute, 2007.
Discarding Initial Volume Practice of discarding the initial aliquot of blood
before inoculating blood culture bottle
Not addressed in guidelines
Studies indicate that discarding initial aliquot of blood reduces contamination only when drawing via venipuncture not a central line; theory is that bacteria present on skin increases contamination
Winokur EJ, Pai D, Rutledge DN, Vogel K, Al-Majid S, Marshall C, Sheikewitz P. Blood culture accuracy: discards from
central venous catheters in pediatric oncology patients in the emergency department. J Emerg Nurs 2014;40:323-9.
Dwivedi S, Bhalla R, Hoover DR, Weinstein MP. Discarding the initial aliquot of blood does not reduce contamination
rates in intravenous-catheter-drawn blood cultures. J Clin Microbiol 2009;47:2950-51
Patton RG, Schmitt T. Innovation for reducing blood culture contamination: Initial Specimen Diversion Technique. J
Clin Microbiol 2010;48:4501-03.
BC Bottles: Volume of BloodDrawing the correct volume of blood is
the single most important factor in maximizing the yield of true pathogens
When collecting blood for culture, fill each bottle to the “fill” line
Clinical and Laboratory Standards Institute (CLSI). Principles and Procedures for Blood Cultures: Approved Guideline. CLSI
document M47-A. Vol. 46. No. 31. Wayne, PA: Clinical and Laboratory Standards Institute, 2007.
media media
Fill to
hereFill line
here
Aerobic Anaerobic
Recommended Volumes of Blood Adults: 20-30 mL of blood per culture set
Pediatrics (blood culture set may use only 1bottle):
Baron EJ, et al. A Guide to utilization of the Microbiology Laboratory for diagnosis of infectious diseases: 2013
recommendations by the IDSA and ASM. Clin Infect Dis 2013;57:e22-121.
Weight of Patient (kg)
Total Patient Blood
Volume (mL)
Recommended Volume of Blood for Culture (mL)
Total Volume for
Culture (mL)
% of Total Blood
VolumeCulture Set No. 1
Culture Set No. 2
≤1 50–99 2 … 2 4
1.1–2 100–200 2 2 4 4
2.1–12.7 >200 4 2 6 3
12.8–36.3 >800 10 10 20 2.5
>36.3 >2200 20–30 20–30 40–60 1.8–2.7
BC Bottles: Order of Draw
In order to minimize contamination, when collecting blood for multiple laboratory tests during a single procedure, blood for culture should be collected first
Clinical and Laboratory Standards Institute (CLSI).
Principles and Procedures for Blood Cultures: Approved
Guideline. CLSI document M47-A. Vol. 46. No. 31. Wayne,
PA: Clinical and Laboratory Standards Institute, 2007.
BC Bottles: Distribution of Sample
Aerobic bottle: contains broth media that that enhances the growth of bacteria that require oxygen to survive
Anaerobic bottle: contains broth media that enhances growth of bacteria from body sites where oxygen is limited
Majority of organisms grow in aerobic conditions (90% vs. 10%)…..therefore….
…aerobic first …anaerobic second
BC Bottles: Number of Sets Draw two or more sets when possible
Washington
195
Weinstein1983
Cockerill2004
Lee2007
Patel2011
N=80 N=282 N=181 N=687 N=285
# of cultures
Cumulative % positive
1 80 91 67 73 71
2 88 >99 82 90 82
3 99 >99 96 98 92
4 - >99 100 >99 -
Hansen G. Blood cultures and the detection of sepsis. MLO Med Lab Obs, 2013;45:42-3.
BC Bottles: Antibiotic-Absorbing Resin Media
BCs should be obtained prior to starting antibiotics
28-63% of patients are on antibiotics prior to BC collection
Use BC bottles that have antibiotic-absorbing resin media
Riedel S, Carroll KC. Blood cultures: key elements for best
practices and future directions. J Infect Chemother
2010;16:301-16.
BC Bottles: Labeling
BC Bottles: Transport
Transport to lab within 2 hours of collection
Specimens should be held at room temperature but never refrigerated or frozen
Clinical and Laboratory Standards Institute (CLSI). Principles and Procedures for Blood Cultures: Approved Guideline.
CLSI document M47-A. Vol. 46. No. 31. Wayne, PA: Clinical and Laboratory Standards Institute, 2007.
Checklist of BC Process Elements
Thank you!
Robert Garcia, BS, MT(ASCP), CIC
Cell 516.810.3093
mailto:[email protected]
