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Bacteremia: Blood cultures and other diagnostic tools

Author: Gary V Doern, MD
Section Editor: Denis Spelman, MBBS, FRACP, FRCPA, MPH
Deputy Editor: Elinor L Baron, MD, DTMH

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2020. | This topic last updated: May 23, 2019.

INTRODUCTION

Blood is one of the most important specimens received by the microbiology laboratory for culture, and
culture of blood is a sensitive method for detection of bacteremia or fungemia. Issues related to
indications, techniques, and interpretation for blood cultures will be reviewed here. Issues related to
specimen transport and Gram stain interpretation are discussed in detail separately. (See
"Microbiology specimen collection and transport" and "Approach to Gram stain and culture results in
the microbiology laboratory".)

INDICATIONS TO EVALUATE FOR BACTEREMIA

Blood cultures should be obtained (prior to initiation of antimicrobial therapy) for any patient in whom
there is suspicion of bacteremia or fungemia, including hospitalized patients and selected outpatients
with fever and leukocytosis or leukopenia [1]. However, bacteremia may be present in the setting of
normothermia and/or a normal white blood cell count [2,3]. Circumstances in which blood cultures are
especially important include known or suspected sepsis, meningitis, osteomyelitis, arthritis,
endocarditis, peritonitis, pneumonia, and fever of unknown origin.

Indications for follow-up blood cultures are discussed below. (See 'Follow-up blood cultures' below.)

BLOOD CULTURES
Collection method — In general, adult patients with bacteremia are likely to have low quantities of
bacteria in the blood, even in the setting of sepsis. In addition, bacteremia in adults is generally
intermittent. For this reason, multiple blood cultures, each containing large volumes of blood, are
required to detect bacteremia. Prior to initiation of antimicrobial therapy, at least two sets of blood
cultures taken from separate venipuncture sites should be obtained [4]. The technique, number of
cultures, and volume of blood are more important factors for detection of bacteremia than timing of
culture collection; these are discussed further in the following sections.

Technique — Careful technique is critical to avoid contamination of the blood culture media by
normal skin flora during the process of collection. This is important because normal bacterial skin
flora can also cause systemic disease, such as infective endocarditis, and in some circumstances,
blood culture contamination can make it difficult to distinguish between false-positive results and true
infection. Measures to reduce contamination include effective disinfection of the venipuncture site and
avoiding blood culture collection through existing intravenous lines [5-9].

A tourniquet should be applied and the vein palpated before disinfection of the venipuncture site.
Thereafter, the venipuncture site should be cleansed with 70 percent alcohol followed by 2 percent
tincture of iodine or chlorhexidine [5-8,10,11]. The disinfectant should be allowed to dry before blood
is drawn. If further palpation of the vein is necessary after skin preparation, a sterile glove should be
worn [12].

Lower contamination rates have been observed with iodine tincture and chlorhexidine than with
povidone-iodine [5-7]. In a randomized trial including more than 3800 blood cultures, contamination
rates were lower with iodine tincture than with povidone-iodine (2.4 versus 3.8 percent) [5]. In another
randomized trial including more than 2000 blood cultures, contamination rates were lower with
chlorhexidine than with povidone-iodine (1.4 versus 3.4 percent) [7].

Alcohol should be used to disinfect the septa of culture bottles after removing their caps. Ideally, the
aerobic bottle should be inoculated first. Blood should be collected directly into culture bottles during
the venipuncture procedure, rather than into tubes sent to the laboratory for subsequent transfer into
the culture bottles. For circumstances in which blood has been collected with a syringe and needle
and transferred into blood culture bottles, the needle should not be changed between bottles.

Blood cultures should not be drawn through an intravenous catheter at the time of catheter insertion.
In one study including more than 4100 blood cultures from children with suspected bacteremia, the
false-positive rate was higher for specimens obtained at the time of catheter insertion than for
specimens obtained from a separate site (9.1 versus 2.8 percent) [13].

Drawing blood for cultures through an indwelling intravascular catheter should be avoided whenever
possible, since ports are frequently colonized with skin flora, thereby increasing the likelihood of a
false-positive blood culture. If blood cultures are drawn from an intravenous line, a second specimen
should be drawn from a peripheral venipuncture site. In one center, implementation of an institutional
policy discouraging collection of blood for culture from indwelling vascular catheters was associated
with a reduction in blood culture contamination rates from 1.6 to 0.5 percent [14]. In addition,
venipuncture blood cultures were collected only by trained phlebotomists or members of the hospital’s
intravenous team following receipt of specific training in the use of proper aseptic technique for
drawing blood cultures.

For circumstances in which intravascular catheter-related infection is suspected, the approach to

blood culture collection and diagnostic criteria are discussed in detail separately. (See "Intravascular
non-hemodialysis catheter-related infection: Clinical manifestations and diagnosis", section on 'Blood
cultures'.)

Arterial blood cultures provide the same yield as venous blood cultures.

Number of cultures — The optimal number of blood cultures that should be obtained varies with
the clinical condition, suspicion for underlying infection (eg, the pretest probability), and the urgency
of the need for treatment [15-17]. In addition, the number of cultures obtained depends on the volume
of blood drawn for each culture set. A set consists of one aerobic bottle and one anaerobic bottle.

In pediatric patients, it may be advisable to inoculate two aerobic bottles rather than one aerobic and
one anaerobic bottle, since anaerobic bacteria are far less common than aerobes as causes of
bacteremia in children. Furthermore, in children, it may not be possible to obtain sufficient blood
specimen to inoculate more than a single blood culture bottle; in such case, the all of the blood should
be inoculated into an aerobic bottle.

In adults, one blood culture set is rarely advisable or sufficient. A positive single culture result may not
be interpretable unless an unequivocal pathogen is isolated. If a possible contaminant is reported on
a single culture, additional culture data are needed, and in the interim, unnecessary antimicrobial
therapy or unnecessary testing may be pursued.

Moreover, a single blood culture lacks sensitivity as well as precludes the ability to distinguish
contaminants from true bacteremia with bacteria that are common contaminants such as coagulase-
negative staphylococci and diphtheroids [18]. In studies evaluating yield for four or more blood
cultures, the cumulative yield of true pathogens increased with the number of cultures collected (first,
73 to 80 percent; second, 80 to 89 percent; third, 95 to 98 percent; and fourth, 99 to 100 percent)
[15,17].

A total of two blood culture sets is usually adequate when a continuous bacteremia is suspected and
the pretest probability of bacteremia is high (as in patients with suspected infective endocarditis who
have not received prior antimicrobial therapy). (See "Clinical manifestations and evaluation of adults
with suspected left-sided native valve endocarditis", section on 'Blood cultures'.)

A total of three blood culture sets is appropriate for circumstances in which bacteremia due to a
pathogen not likely to be a contaminant is anticipated (as in intra-abdominal sepsis or pneumonia)
and when the pretest probability of bacteremia is low to moderate. The first two blood cultures,
obtained with separate venipunctures, can be obtained in sequence. The third blood culture should
be obtained four to six hours later.

A total of four blood culture sets is reasonable when the pretest probability of bacteremia is high and
the anticipated pathogen is likely to be a common contaminant, such coagulase-negative
staphylococci. Clinical examples include prosthetic valve endocarditis or endovascular infections due
to infected devices, such as pacemakers or grafts. As many as four blood culture sets may also be
necessary to diagnose endocarditis in patients who have received antimicrobial therapy in the
preceding two weeks.

Additional blood cultures are rarely useful in patients who have been evaluated by the above criteria
unless there has been a significant change in the patient's condition or a new focus of infection is
suspected. Furthermore, the likelihood of obtaining a false-positive test (ie, a positive blood culture
due to a contaminant) increases as more blood cultures are obtained.

Volume of blood — The optimal volume for each blood culture in adults is 20 mL (10 mL
introduced into an aerobic bottle and 10 mL introduced into an anaerobic bottle); the appropriate
volumes for children are summarized in the table (table 1) [19-24].

The blood culture yield depends on the volume of blood cultured [19,25,26]. One study comparing
829 matched pairs of standard volume (mean 8.7 mL) and low volume (mean 2.7 mL) blood cultures
demonstrated that bottles inoculated with at least 5 mL of blood had a significantly higher detection
rate for bacteremia than bottles inoculated with less than 5 mL (92 versus 69 percent) [26]. The
authors estimated that the yield of blood cultures in adults increases approximately 3 percent per mL
of blood cultured.

Timing — Fever at the time of blood culture collection is neither sensitive nor specific for the
presence of bacteremia. In a retrospective study evaluating the timing of blood culture collection in
relation to temperature elevations in over 1400 patients with bacteremia and fungemia, no
relationship was observed between timing of specimen collection and likelihood of a positive blood
culture [27].

Blood cultures should be obtained prior to initiation of antibiotic therapy.

Culture media — Special culture media may be helpful in the following settings:
 ● Use of blood culture bottles containing media with resins, lytic agents, or other neutralizing
substances may be useful for documenting bacteremia in patients receiving antimicrobial therapy
at the time blood cultures are obtained.

● Filamentous and dimorphic fungi, especially Histoplasma capsulatum, are best detected from
blood with the centrifugation-lysis (Isolator) system, which is also useful in the detection of
Mycobacterium avium and Mycobacterium tuberculosis.

● Special broth media (BACTEC) are also available for the detection of mycobacteria species.

Duration of incubation — Most clinically significant bacteremias are detected within 48 hours with
use of instrument-based continuous monitoring blood culture systems. Detection of fungemia may
require 24 to 48 hours of additional incubation [28]. Both common and fastidious pathogens (such as
members of the HACEK group) may be detected within five days of incubation with modern
automated blood culture detection systems; Cutibacterium spp may require more time for recovery
[29,30]. (See "Invasive Cutibacterium (formerly Propionibacterium) infections", section on
'Microbiology and pathogenesis'.)

Organism identification — Conventional methods for organism identification utilize physical

characteristics and biochemical reactions to establish an organism's metabolic profile, which
subsequently can be compared with an established database of profiles. Most automated systems
rely on indicators including pH changes, enzymatic reactions, indicators of metabolic activity in the
presence of a variety of carbon sources, detection of volatile or nonvolatile acids, and recognition of
visible growth [31].

In addition, rapid diagnostic tools may be used for organism identification. (See 'Rapid diagnostic
tools' below.)

Interpreting positive cultures

Types of bacteremia — There are two clinical patterns of bacteremia: intermittent and continuous:

● Intermittent bacteremia implies that bacteria are present in the blood for periods of time followed
by nonbacteremic periods; this is the most common pattern of bacteremia. It can occur following
manipulation of infected tissues (such as surgical abscess drainage), following instrumentation of
contaminated mucosal surfaces (such as dental procedures, cystoscopy, or sigmoidoscopy), or in
the setting of bacterial infections (such as pneumonia, arthritis, osteomyelitis, soft tissue
infection, and meningitis).

● Continuous bacteremia usually reflects a persistent endovascular infection such as endocarditis

or endarteritis, suppurative thrombophlebitis, an infected aneurysm, or infection of intravascular
 foreign bodies such as vascular grafts. It also occurs in the first two weeks of typhoid fever and
brucellosis; although in these diseases, relatively few bacteria per mL of blood are detected.

There are two major categories of infection associated with bacteremia: extravascular infection and
intravascular infection. Extravascular infections originate outside the bloodstream (such as
pneumonia or urinary tract infection) and enter the vascular supply via the lymphatic system.
Intravascular infections are associated with a primary infectious process within the bloodstream;
examples include infective endocarditis, suppurative thrombophlebitis, vascular graft infections,
mycotic aneurism infections, and endovascular catheter infections.

The efficiency of bacterial clearance depends on the infecting microorganism and the host immune
status. For example, bacterial capsules and other virulence factors may delay clearance by
decreasing opsonization, while the presence of specific antibodies may enhance clearance by
promoting opsonization.

Contamination — Contamination of blood cultures can occur even when precise techniques for
collection and processing are used. Contamination rates of less than 3 percent are desirable; higher
rates should be investigated and corrected with educational efforts [32].

Staphylococcus aureus, Streptococcus pneumoniae, group A streptococci, Enterobacteriaceae,

Haemophilus influenzae, Pseudomonas aeruginosa, Bacteroidaceae, and Candida species are
always important clinical pathogens [33]. Viridans streptococci and enterococci may reflect true
pathogens or contaminants.

Organisms for which it can be difficult to distinguish between clinical significance and contamination
include Cutibacterium (formerly Propionibacterium) acnes, Corynebacterium species, Bacillus
species, and coagulase-negative staphylococci; the likelihood of clinical significance is increased if
the organism is observed in multiple blood cultures obtained from separate venipunctures [4,6,18]. In
addition, the presence of these organisms in the setting of prosthetic heart valves or intravascular
devices should prompt consideration of infective endocarditis.

Contamination should be suspected when bacterial growth first occurs in blood cultures after 72
hours of incubation. Exceptions in which delayed growth of true infection can occur in blood cultures
include certain fastidious organisms (such as Eikenella, some Haemophilus species, Kingella, and
Cardiobacterium) and bacteria that have been suppressed by antimicrobial therapy administered prior
to blood culture collection.

Because of the economic and clinical ramifications of contaminated blood cultures, laboratories
should have algorithms in place for assessing the clinical significance of all positive blood cultures
when contamination is a possibility [32]. Information pertinent to assessing the significance of a blood
culture isolate includes the specific organism(s) recovered from the blood culture(s), the number of
blood cultures obtained, and, among these, the number of positive cultures, the length of time it took
for blood cultures to become positive, the manner in which the blood specimen(s) were obtained, and
the likelihood that an individual patient has bacteremia based on clinical and epidemiologic
assessment.

False-positive results — Rarely, continuous monitoring blood culture instruments signal a

positive culture but no organisms are seen on Gram stain of blood culture broth, direct tests for
microorganisms are negative, and subcultures do not yield an isolate. This is most often an
instrument false positive. This information should, however, be communicated to care providers with
appropriate caveats, and blood cultures should be repeated.

In the setting of pneumococcal bacteremia, the organism may grow in culture (with positive culture
signalled by the instrument) followed by autolysis, resulting in no viable organisms. In such cases, the
organism may be detected by an antigen detection test. (See "Invasive pneumococcal (Streptococcus
pneumoniae) infections and bacteremia", section on 'Diagnosis and laboratory features'.)

Follow-up blood cultures — Follow-up blood cultures within one to two days of initiating
antimicrobial therapy should be obtained in the following circumstances:

● Bacteremia due to S. aureus (see "Clinical approach to Staphylococcus aureus bacteremia in

adults")
● Known or suspected endocarditis (see "Clinical manifestations and evaluation of adults with
suspected left-sided native valve endocarditis")
● Presence of fever, leukocytosis, or other signs of infection more than 72 hours following initiation
of antimicrobial therapy
● Known or suspected site of infection with limited antimicrobial penetration (such as an abscess or
joint space infection)
● Presumed source of infection in abdomen or central nervous system
● Presence of prosthetic vascular grafts, intravascular lines, or cardiac pacemakers
● Presence of pathogens that are known or suspected to be multiply resistant to standard
antibacterial agents
● Unknown source for initial bacteremia

RAPID DIAGNOSTIC TOOLS

Molecular methods such as nucleic acid amplification, matrix-assisted laser desorption/ionization

time-of-flight mass spectrometry, and next-generation sequencing can be used for the rapid
identification of microorganisms directly in blood culture bottles [34-36]. In addition, in certain cases,
such methods can be used for detection of selected antimicrobial resistance determinants. Outcome
studies are needed to determine the role of rapid molecular diagnostic methods in clinical
management and antibiotic stewardship.

Thus far, examples of clinical data include:

● A prospective study including more than 1400 patients with suspected bacteremia or sepsis in
which blood cultures and a polymerase chain reaction (PCR)-based assay capable of detecting
five organisms (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae,
Pseudomonas aeruginosa, and Escherichia coli) were performed [37]. The PCR-based assay
had a shorter mean time to species identification than blood cultures (4 to 8 hours versus 2 to 3
days); the sensitivity and specificity of the PCR-based assay for patients with positive blood
culture were 90 percent. The rate of negative blood culture with a positive PCR result was 10
percent; the significance and appropriate clinical interpretation of this finding is uncertain.

● A randomized trial including more than 600 patients with positive blood cultures for whom
evaluation included standard blood culture processing (control group), performance or rapid
multiplex PCR (rmPCR) with templated interpretation comments, or rmPCR with templated
comments in addition to real-time antimicrobial stewardship [38]. Use of rmPCR with templated
comments was associated with a reduction in treatment of contaminants (11 versus 25 percent)
and use of broad-spectrum antibiotics (44 versus 56 hours); addition of antimicrobial stewardship
was associated with enhanced antimicrobial de-escalation (34 versus 21 hours).

INFORMATION FOR PATIENTS

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Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These
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who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-
mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topic (see "Patient education: Sepsis in adults (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Blood cultures should be obtained (prior to initiation of antimicrobial therapy) for any patient in
whom there is suspicion of bacteremia, including hospitalized patients and selected outpatients
with fever and leukocytosis or leukopenia. However, a normal white blood count does not rule out
bacteremia. Circumstances in which blood cultures are especially important include sepsis,
meningitis, osteomyelitis, arthritis, endocarditis, peritonitis, pneumonia, and fever of unknown
origin. (See 'Indications to evaluate for bacteremia' above.)

● Prior to initiation of antimicrobial therapy in adults, at least two, preferably three, sets of blood
cultures taken from separate venipuncture sites should be obtained. The technique, number of
cultures, and volume of blood are more important factors for detection of bacteremia than timing
of culture collection. (See 'Collection method' above.)

● Important measures to reduce contamination include effective disinfection of the venipuncture

site and avoiding blood culture collection through existing intravenous lines. The appropriate
volume for adults is a minimum of 10 mL (and preferably 20 mL) of blood; the appropriate
volumes for children are summarized in the table (table 1). (See 'Technique' above and 'Volume
of blood' above and 'Timing' above.)

● There are two clinical patterns of bacteremia: intermittent and continuous. Intermittent
bacteremia implies that bacteria are present in the blood for periods of time followed by
nonbacteremic periods; this is the most common pattern. Continuous bacteremia usually reflects
a persistent endovascular infection such as endocarditis. (See 'Types of bacteremia' above.)

● Organisms for which it can be difficult to distinguish between pathogenicity and contamination
include Cutibacterium (formerly Propionibacterium) acnes, Corynebacterium species, Bacillus
species, and coagulase-negative staphylococci; the likelihood of pathogenicity is increased if the
organism is observed in multiple blood cultures obtained from separate venipunctures. (See
'Contamination' above.)

● Various molecular methods can be used for the rapid identification of microorganisms directly in
blood culture bottles. In addition, in certain cases such methods can be used for detection of
selected antimicrobial resistance determinants. Outcome studies are needed to determine the
role of rapid molecular diagnostic methods in clinical management and antibiotic stewardship.
(see 'Rapid diagnostic tools' above)

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Topic 2133 Version 30.0

GRAPHICS

Blood culture volumes in pediatric patients (blood culture set may use only one
bottle)

Blood volume (mL) for first Blood volume (mL) for

Patient weight (kg)
culture set second culture set

≤1.0 2 -

1.1 to 2.0 2 2

2.1 to 12.7 4 2

12.8 to 36.3 10 10

>36.3 20 to 30 20 to 30

When ≤10 mL of blood is collected, it should be inoculated into a single aerobic blood culture bottle.

Adapted from: Miller JM, Binnicker MJ, Campbell S, et al. A guide to utilization of the microbiology laboratory for diagnosis of
infectious diseases: 2018 update by the Infectious Diseases Society of America and the American Society for Microbiology.
Clin Infect Dis 2018; 67:813.

Graphic 55558 Version 7.0

Contributor Disclosures
Gary V Doern, MD Nothing to disclose Denis Spelman, MBBS, FRACP, FRCPA, MPH Nothing to
disclose Elinor L Baron, MD, DTMH Nothing to disclose

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