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Blood Cultures - Fiji Islands
- 1. Navua Hospital CME: Blood Cultures Jeremy Paris Navua Hospital Trainee Intern Semester I 2019
- 2. Background • BC ordered en mass daily. • Important investigation: guides diagnosis, prognosis, therapy • Contamination: confusion, overtreatment, abx resistance, misspent resources (trickle down effects?)
- 3. Navua Hospital Microbiology samples • Total samples- 943 • Total PBC- 134 • Total ABC- 206 • Total BC- 350 • All processed in Suva • Samples • Results • Transportation • Storage • Dispatch book
- 7. Indications • Suspicion of bacteremia, mostly outpatients with fever and leukocytosis or leukopenia. • Normal WCC does not rule out bacteremia. • Known or suspected sepsis, meningitis, osteomyelitis, arthritis, endocarditis, peritonitis, pneumonia, and fever of unknown origin.
- 8. Method • Adults: low quantities of bacteria in blood, intermittent. • Thus: Large volumes and multiple required. • Prior to abx • Separate venepuncture sites (recommendation - usually 4 bottles at a time)
- 9. Collection Technique • Avoid skin flora contamination: Aseptic technique Cleaning: Betadine O/S ? Conflicting evidence Iodine tincture + chlorhexidine better than povidone-iodine (Cont.Rate 2.4% vs 3.8%) [4] Another study: Chlorhexidine (1.4%) vs povidone-iodine (3.3%) [5] Recommendation: Chlorhexidine gluconate 2% followed by 70% isopropyl alcohol Allow to dry at least 30sec Clean tops of BC bottles with alcohol just prior to collection
- 10. • Volume of Blood to be collected? • Direct relationship b/w volume of blood obtained and yield of blood culture set. • Timing: no relationship observed between timing of specimen collection (in relation to fever) and likelihood of a positive blood culture. [7] • * Typhoid: relatively few bacteria per mL of blood are detected. Need large sample. (30-90%) [3]
- 11. • Each milliliter missed decreases the sensitivity by 3% [8] • Swirl bottles - do not shake. Label etc Note: Contamination rates of less than 3 percent are desirable; higher rates should be investigated and corrected with educational efforts. Pacific data predicting a standard?
- 12. Consequences of sub-optimal processes • Patients: Delay in diagnosis/treatment, incorrect treatment, prolonged/ insufficient treatment = poor outcomes • Navua: Stress, frustration, reputation • MOH: Financial strain etc etc
- 13. Eg: Jan 2019 Contaminants = 122 x $65.40 = $7,978.80
- 14. So how do we improve our practice?
- 15. Take Home Message - ABCDE A - Aseptic technique. B - The more Blood the better. C - Utilize antiseptic agents available – make due but maintain salient steps in Collection. D - Proper handling, storage and timely transportation to Divisional hospital E - Re-Evaluation
- 16. Vinaka
- 17. References • [1] Devi, L. (2019) Statistics November 2018-January 2019. [Powerpoint Slides]. • [2] Effiom, V. (2016) Indication and Collection of Blood Culture. [Powerpoint Slides]. • [3] Getahun, A. (2017) Food and Waterborne Diseases Part 2. [Powerpoint Slides]. • [4] Little JR, Murray PR, Traynor PS, Spitznagel E. A randomized trial of povidone-iodine compared with iodine tincture for venipuncture site disinfection: effects on rates of blood culture contamination. Am J Med. 1999;107(2):119-25. • [5] Mimoz O, Karim A, Mercat A, et al. Chlorhexidine compared with povidone-iodine as skin preparation before blood culture. A randomized, controlled trial. Ann Intern Med. 1999;131(11):834-7. • [6] Ministry of Health Fiji. (2012) Public Hospitals And Dispensaries Act (CAP. 110) : Public Hospitals and Dispensaries (Amendment) Regulations 2012 • [7] Riedel S, Bourbeau P, Swartz B, et al. Timing of specimen collection for blood cultures from febrile patients with bacteremia. J Clin Microbiol. 2008;46(4):1381-5. • [8] Van ingen J, Hilt N, Bosboom R. Education of phlebotomy teams improves blood volume in blood culture bottles. J Clin Microbiol. 2013;51(3):1020-1
Editor's Notes
- esp for sepsis, meningitis, osteomyelitis, arthritis, endocarditis, peritonitis, pneumonia, and fever of unknown origin.
- $22,400 worth of BC sent in 12 month period.
- Chlorhexidine: At physiologic pH, chlorhexidine salts dissociate and release the positively charged chlorhexidine cation. The bactericidal effect is a result of the binding of this cationic molecule to negatively charged bacterial cell walls. At low concentrations of chlorhexidine, this results in a bacteriostatic effect; at high concentrations, membrane disruption results in cell death.
- Roughly $95k a year