BACTERIOLOGY

Routine Use of Anaerobic Blood Culture Bottles for Specimens

Collected from Adults and Children Enhances Microorganism
Recovery and Improves Time to Positivity
Eric M. Ransom,a Carey-Ann D. Burnhamb,c,d

a Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
b Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
c Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
d Departments of Pediatrics and Medicine, Washington University School of Medicine, St. Louis, Missouri, USA

ABSTRACT The utility of anaerobic blood culture bottles remains controversial, especially
for specimens from children. Data are limited on the inclusion of an anaerobic bottle as
part of a blood culture “set” when using contemporary blood culture instruments and
media. Here, we evaluated the clinical utility of anaerobic blood culture bottles (FN Plus)
and aerobic bottles (FA Plus) for the BacT/Alert Virtuo blood culture system (bioMérieux).
A total of 158,710 bottles collected between November 2018 and October 2019 were
evaluated. There were 6,652 positive anaerobic bottles, of which 384 (5.8%) contained
403 obligate anaerobes. In patients ,19 years old, there were 389 positive anaerobic bot-
tles, with 15 (1.8%) containing 16 obligate anaerobes. If not for anaerobic bottles, all but
8 obligate anaerobes would have gone undetected. Furthermore, anaerobic bottles were
advantageous for some facultative anaerobes. Staphylococcus aureus from anaerobic bot-
tles demonstrated statistically significant increased recovery (1,992 anaerobic versus 1,901
aerobic bottles, P = 0.009) and faster mean time to positivity (1,138 versus 1,174 min,
P = 0.027). Only 25 microorganisms had statistically significant improved recovery and/or
faster time to positivity from aerobic versus anaerobic bottles, suggesting anaerobic bot-

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tles offer comparable growth for most species. Finally, if only an aerobic bottle had been
collected, 2,027 fewer positive cultures would have been detected and 7,452 fewer iso-
lates would have been reported, including cultures with S. aureus (413 isolates, 10.6%
less), Pseudomonas aeruginosa (9 isolates, 3.1% less) and Escherichia coli (193 isolates,
14.0% less). Taken together, these findings support the practice of routinely including an
anaerobic bottle for blood culture collection.

KEYWORDS anaerobes, BacT/Alert, anaerobic bacteremia, Virtuo, time to positivity,

blood culture Editor Nathan A. Ledeboer, Medical College of
Wisconsin
Copyright © 2022 American Society for

T he presence of bacteria in the bloodstream (i.e., bacteremia) is a potentially life-threatening

condition that may lead to sepsis and even death. Some investigations have demonstrated
that approximately 0.5 to 12% of bloodstream infections are attributed to obligate anaerobes
Microbiology. All Rights Reserved.
Address correspondence to Eric M. Ransom,
Eric.Ransom@case.edu, or Carey-Ann D.
Burnham, cburnham@wustl.edu.
(1–3). The rates of anaerobic bloodstream infection have varied over time, but the literature
The authors declare a conflict of interest. Both
reports a notable decrease in the late 1970s and 1980s, which may have been the result of pre- authors have received honoraria from
surgical infection prevention measures and broad-spectrum antimicrobial usage (4–6). A resur- bioMerieux for presenting on these findings.
Carey-Ann Burnham has received research
gence was observed in the 1990s and 2000s, likely due to improved culturing practices and support from bioMerieux unrelated to this
increasing numbers of patients with complex underlying diseases (5, 7). The prevalence of an- work.
aerobic bacteremia in children is often reported to be ,5%, less than that in adults (1, 5, 8–11). Received 4 April 2022
Returned for modification 3 May 2022
The infrequent recovery of obligate anaerobes in the setting of bloodstream infection has Accepted 11 August 2022
resulted in controversy around routine use of anaerobic bottles and in the argument that the Published 30 August 2022
use of anaerobic bottles should be limited or not routinely performed, especially for children.

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Determination of the etiology of a bloodstream infection most frequently relies on

the use of continuously monitored blood culture systems. Not all institutions routinely
use anaerobic bottles, particularly pediatric institutions. A survey by the Pediatric
Emergency Medicine Collaborative Research Committee polled 65 international institu-
tions and found routine anaerobic blood cultures were collected in only ;30% of
emergency departments and ;30% of intensive care units, even though most institu-
tions had the capability (12). Concerns expressed by survey participants included iatro-
genic anemia and low pretest probability.
Here, we evaluated the utility of routine inclusion of an anaerobic blood culture bottle
in the setting of a central laboratory serving academic and community hospitals with adult
and pediatric patients. The goal of this work was to reassess the utility of anaerobic blood
culture bottles in a large cohort by performing a 1-year retrospective review of microorgan-
ism recovery rates and times to positivity of obligate and facultative anaerobes.

MATERIALS AND METHODS

Clinical setting. The laboratory at the Barnes-Jewish Institute of Health serves Barnes-Jewish Hospital
(.1,250-bed tertiary-care academic medical center), St. Louis Children’s Hospital (.400-bed stand-alone
pediatric academic medical center) and, at the time of this study, three community hospitals in the St.
Louis metropolitan area. This study was reviewed and approved by the Washington University in St. Louis
Human Research Protection Office.
Culture and identification. Blood culture bottles submitted to the laboratory from November 2018
to October 2019 (n = 158,710) were evaluated. It is recommended across our institution to submit a blood
culture set consisting of a paired aerobic bottle and anaerobic bottle. When only one bottle is submitted
instead of a set, such bottles are still processed by the laboratory. For the uncommon instances when only a
single bottle is received, the most frequent reasons are a difficult blood collection, collection error, concern
for iatrogenic anemia, and the rare occurrence of only one bottle (of a two bottle set) being damaged in trans-
port. Bottles were continuously monitored until positive for up to 5 days at 37°C on the BacT/Alert Virtuo detec-
tion system (bioMérieux). Bottles inoculated with nonblood specimens (e.g., synovial fluid) or nonclinical samples
(e.g., proficiency testing) were excluded from this study. Microbes were cultured using the Kiestra total laboratory
automation system (Becton, Dickinson Microbiology Systems) and identified according to standard-of-care proce-
dures, including identification using the Bruker matrix-assisted laser desorption ionization–time of flight mass
spectrometry system (13–16). Time to positivity data were sourced from the Virtuo’s MYLA middleware system.
These data were merged with the microorganism identification taken from the Cerner Millennium laboratory in-
formation system. Importantly, data from coagulase-negative staphylococci were analyzed as follows: recovery of
coagulase-negative staphylococci from a single positive culture was reported as “coagulase-negative staphylo-
cocci,” but recovery from multiple cultures was reported to the species level. Additional culture and data compila-
tion details have been described previously (17).
Statistical analyses. Statistical significance was determined using a two-sided Fisher’s exact test and

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a P value limit of 0.05. P values were corrected for multiple testing using the Benjamini-Hochberg method in R.

RESULTS
Cohort summary. A total of 158,710 blood culture bottles were evaluated between
November 2018 and October 2019. There were 8,959 positive blood cultures consisting
of 13,592 total positive bottles. There were 551 positive blood cultures consisting of 823 positive
bottles from pediatric patients.
Figure 1 shows the 20 most commonly reported microbial identifications in our study
and the breakdowns by patient population (adult versus pediatric) and bottle type (aerobic
versus anaerobic). Most microorganisms in the top 20 were Gram positive, and the most fre-
quently recovered Gram-negative bacteria were Escherichia coli, Klebsiella pneumoniae, and
Pseudomonas aeruginosa. The only nonbacterial species in the top 20 was Candida glabrata.
The top 20 microbes consisted of 18 facultative anaerobes and 2 strict aerobes. Importantly,
facultative anaerobes had slightly higher or at least similar recovery counts from anaerobic
bottles compared to aerobic bottles (Fig. 1). On the other hand, the strict aerobes P. aeruginosa
and C. glabrata demonstrated a noteworthy (but expected) preference for aerobic bottles.
Additional details on positive bottles are found in Table S1 in the supplemental material.
Because this study aimed to compare findings between adults and children, we calculated
which species were recovered at a statistically significant lower-than-expected frequency
in pediatric patients, even when corrected for the smaller subset of positive pediatric bottles
(i.e., adjusted for multiple testing). Statistical significance was found for Staphylococcus homi-
nis (P = 0.004), E. coli (P = 0.008), Proteus mirabilis (P = 0.010), Streptococcus dysgalactiae

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FIG 1 Twenty most commonly recovered microorganisms from adults and pediatric populations with
respect to positive aerobic and anaerobic bottles. CNS, coagulase-negative staphylococci; VGS, viridans
group streptococci.

(P = 0.032), C. glabrata (P = 0.041), Staphylococcus haemolyticus (P = 0.041), and Enterococcus

faecium (P = 0.043) (see Table S2). Nine species were recovered at a statistically significant
higher-than-expected frequency in pediatric patients following count correction: Serratia
marcescens (P = 0.003), viridans group streptococci (P = 0.003), Granulicatella adiacens
(P = 0.004), Streptococcus agalactiae (P = 0.010), Lactococcus lactis (P = 0.018), Staphylococcus
epidermidis (P = 0.018), Staphylococcus capitis (P = 0.027), Streptococcus pyogenes (P = 0.027),
and Corynebacterium striatum (P = 0.029) (see Table S2).
Cultures with anaerobes. To determine the utility of anaerobic bottles, we evaluated
obligate anaerobes recovered in our cohort. A total of 6,652 anaerobic bottles flagged posi-
tive, of which 384 bottles (5.8%) contained 403 obligate anaerobes. For pediatric patients,
there were 389 positive anaerobic bottles, of which 15 bottles (1.8%) contained 16 obligate
anaerobes. Cutibacterium sp. (formerly Propionibacterium sp.) was the most commonly
encountered obligate anaerobe, found in 121 bottles. Other common anaerobic genera
included Bacteroides (n = 82), Parvimonas (n = 28), Eggerthella (n = 21), Prevotella (n = 14),
Clostridium (n = 63; including C. tertium and Clostridioides difficile), and Fusobacterium
(n = 19). See Table 1 for a list of the most frequently recovered anaerobes by patient pop-

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ulation. The three most common anaerobes for adults were Cutibacterium sp., B. fragilis group,
and P. micra, and for pediatric patients, the most common anaerobes were P. micra and a
four-way tie of Cutibacterium species, B. fragilis group, Fusobacterium necrophorum, and
Clostridium sordellii. There was no statistically significant difference between the anaerobic

TABLE 1 Frequently encountered anaerobes from positive blood cultures from adult and
pediatric patients
Adult Pediatric

No. of No. of
Microorganism isolates % of total isolates % of total
Cutibacterium sp. 119 0.83 2 0.22
Bacteroides fragilis group 76 0.54 2 0.22
Parvimonas micra (Peptostreptococcus micros) 25 0.17 3 0.34
Clostridium perfringens 20 0.15 1 0.11
Eggerthella lenta 21 0.15 0 0.00
Prevotella sp. 13 0.09 1 0.11
Clostridium spp. not otherwise specifieda 8 0.06 1 0.11
Clostridium paraputrificum 8 0.06 0 0.00
Clostridium ramosum 8 0.06 0 0.00
Fusobacterium necrophorum 5 0.03 2 0.22
Clostridium sordellii 5 0.03 2 0.22
Fusobacterium nucleatum 4 0.03 1 0.11
aExcludes C. tertium and Clostridioides difficile.

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TABLE 2 Polymicrobial nature of bottles growing obligate anaerobes

Single bottle positive
Both bottles
No. of species/culture Aerobic Anaerobic positive
1 5a 298 8a
2 0 24 39
3 0 6 9
$4 0 1 2
aAll isolates were Cutibacterium species.

epidemiology for adult and pediatric patients, as expected given the low prevalence. While
the overall rates of anaerobic bacteremia were low in our adult and pediatric cohorts (con-
sistent with the literature), anaerobe detection remains useful for clinicians to evaluate the
need for anaerobic antimicrobial coverage.
To further determine if anaerobic bottles are necessary for the recovery of obligate anae-
robes, we evaluated which bottles contained obligate anaerobes. The vast majority of obligate
anaerobes were recovered only from the anaerobic bottle (Table 2). Eight positive aerobic bot-
tles contained 8 obligate anaerobes, all from the Cutibacterium genus. No obligate anaerobes
were recovered from aerobic bottles collected from pediatric patients. Overall, the recovery of
obligate anaerobes was largely dependent on collecting an anaerobic bottle.
Next, we assessed the polymicrobial nature of cultures containing obligate anaerobes.
The majority of blood cultures containing obligate anaerobes were monomicrobial (79.3%,
n = 311) (Table 2). Of these, only 2.6% had both the aerobic and anaerobic bottles flag
positive. These cultures grew Cutibacterium species. Of the polymicrobial cultures that
grew at least one obligate anaerobe, it was more common that both bottles flagged posi-
tive (61.7%) than the anaerobic bottle only (38.3%).
Microorganisms recovered more frequently from anaerobic bottle. Anaerobic
bottles can support the growth of facultative anaerobes, in addition to obligate anaerobes.
To determine the utility of anaerobic bottles for all recovered microorganisms, we identified
which microorganisms had a statistically significant increased recovery from the anaerobic
bottle. As shown in Table 3, 12 taxa had statistically significant improved recovery from an-
aerobic bottles. While the majority were obligate anaerobes, Staphylococcus aureus and
Streptococcus intermedius are facultative anaerobes. Unfortunately, many microorganisms
did not attain statistical significance due to their low prevalence but are known to have pre-

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ferred growth conditions. For example, some established obligate anaerobes were found
exclusively in anaerobic bottles but failed to demonstrate statistical significance because they
were recovered only once or twice.
A common perception is that anaerobic bottles have inferior growth conditions compared
to aerobic bottles for most microorganisms. Of note, only 15 taxa demonstrated statistically
significant improved recovery from aerobic bottles (Table 4), and most of these were still

TABLE 3 Microbes with statistically significant improved recovery counts in anaerobic bottles
Adults (n)a Pediatric patients (n)a

Microorganism Significance (P value) Aerobic Anaerobic Aerobic Anaerobic

Cutibacterium sp. 3.7E224 8 111 0 2
Bacteroides fragilis group 1.5E222 0 74 0 2
Parvimonas micra (Peptostreptococcus micros) 6.0E28 0 25 0 3
Clostridium perfringens 6.3E26 0 20 0 1
Eggerthella lenta 6.3E26 0 21 0 0
Prevotella sp. 7.9E23 0 13 0 1
Staphylococcus aureusb 9.2E23 1,799 1,879 102 113
Clostridium paraputrificum 0.027 0 8 0 0
Clostridium ramosum 0.027 0 8 0 0
Fusobacterium necrophorum 0.046 0 5 0 2
Streptococcus intermediusb 0.046 0 7 0 0
Veillonella parvula 0.046 0 7 0 0
an corresponds to the total number of cultures containing the microorganism.
bFacultative anaerobe.

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TABLE 4 Microbial species with a statistically significant difference in recovery counts in aerobic bottles
Adults (n)a Children (n)a

Microorganism Significance (P value) Aerobic Anaerobic Aerobic Anaerobic

Pseudomonas aeruginosa 8.4E237 244 36 12 4
Candida albicans 8.2E220 75 2 7 0
Micrococcus sp. 1.0E213 52 1 3 0
Candida parapsilosis 4.6E212 49 1 0 0
Bacillus sp. (not B. anthracis) 5.2E27 79 24 7 3
Candida tropicalis 3.1E25 32 5 3 0
Sphingomonas sp. 3.6E25 20 0 0 0
Candida krusei 1.3E24 14 0 4 0
Stenotrophomonas maltophilia 3.0E24 23 2 0 0
Candida glabrata 3.3E24 74 29 0 0
Acinetobacter sp. 4.8E24 27 3 3 1
Cryptococcus neoformans 5.6E23 12 0 0 0
Achromobacter sp. 9.2E23 11 0 0 0
Burkholderia cepacia complex 0.018 10 0 0 0
Candida orthopsilosis 0.031 9 0 0 0
an = number of isolates.

commonly recovered from anaerobic bottles. For example, Pseudomonas aeruginosa demon-
strated statistically significant improved recovery from aerobic bottles, but 12.7% of total bot-
tles containing P. aeruginosa were anaerobic bottles. A similar trend was observed from only
pediatric patients for P. aeruginosa (25.0%). In addition, while Candida species are traditionally
thought to prefer aerobic growth, the species C. glabrata was frequently recovered from the
anaerobic bottle.
Time to positivity under aerobic and anaerobic growth conditions. Another approach
to evaluating growth of blood cultures is assessing time to positivity. Figure 2 shows the
time to positivity of obligate anaerobes versus all other microbes in our study and in pediat-
ric patients only. The mean and median times to positivity of all positive bottles were 21.1 h
and 16.1 h, respectively. Obligate anaerobes were found to be more evenly dispersed across
the standard 5-day incubation (Fig. 2), and this was also shown by the mean and median
times to positivity: mean and median times for obligate anaerobes were 58.2 h and 47.7 h,
respectively, and for all other microbes were 20.0 h and 15.9 h, respectively.
Figure 3 shows the time to positivity of specific obligate anaerobes by genus: Clostridium

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(Fig. 3A), Fusobacterium (Fig. 3B), and other anaerobes (Fig. 3C). Nearly all Clostridium isolates
flagged positive in under 48 h, with C. perfringens flagging positive quickly, under 17 h. All
Fusobacterium isolates flagged positive under 72 h. Other common obligate anaerobes were
usually detected between 1 and 3 days (Fig. 3C).
To determine the utility of anaerobic bottles in relation to time to detection, we
identified microorganisms with a statistically significant faster time to positivity in an-
aerobic or aerobic bottles. These analyses largely excluded most obligate anaerobes
due to the lack of an aerobic bottle growth for comparison. Interestingly, anaerobic
bottles were found to have a statistically significant faster time to positivity for two key
facultative anaerobes, P. mirabilis (P = 0.039) and S. aureus (P = 0.027) (Table 5). Only 14
microbial taxa had statistically significant faster times to positivity in aerobic bottles
(Table 5), including the key pathogen P. aeruginosa as well as multiple coagulase-nega-
tive staphylococci, which are often considered skin contaminants. Statistically signifi-
cant faster time to positivity in aerobic bottles was observed only with the Candida
species C. glabrata, likely due to the low prevalence of other species.
Impact without anaerobic bottles. Another measure to assess anaerobic bottle
utility was to reevaluate microbiological outcomes of our cohort in the absence of an
anaerobic bottle. If only an aerobic bottle was collected over our study period, 2,027
more cultures (22.6%) would have been reported negative and 7,452 fewer isolates
(48.8%) would have been reported. We would have reported only 8 cultures with obli-
gate anaerobes, all Cutibacterium species. Other key facultative pathogens would also
have been detected less frequently: S. aureus (413 isolates, 10.6% fewer), P. aeruginosa

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FIG 2 Time to positivity of bottles that contained obligate anaerobes compared to all remaining bottles.
(A) All bottles; (B) only bottles from pediatric patients. Positive bottles were plotted in 30-min intervals.

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(9 isolates, 3.1% fewer), and E. coli (193 isolates, 14.0% fewer). Finally, the exclusion of
anaerobic bottles would have led to 724 (48.0%) more cultures being monomicrobial.
This study was not able to predict or report on the outcomes if two aerobic bottles
had been collected rather than a paired aerobic and anaerobic bottle.

DISCUSSION
Blood cultures represent some of the most important diagnostic specimens evaluated in
clinical microbiology laboratories. Advancements in continuously monitored blood culture
systems, such as culture media and hardware, continue to improve microorganism detection
and time to positivity while mitigating the impact of antimicrobial treatment prior to blood
collection. As these systems advance, large retrospective studies are necessary to thoroughly
reevaluate the recovery of underrepresented microbial subgroupings, like anaerobes. The
goal of this study was to determine the utility of anaerobic bottles using the Virtuo system
paired with FA Plus (aerobic) and FN Plus (anaerobic) resin culture bottles. We found that
anaerobic bottles were almost always required for the recovery of obligate anaerobes. In
addition, we found that facultative anaerobes often demonstrated equivalent, or in some
cases superior, time to positivity and total recovery counts from anaerobic bottles compared
to aerobic bottles. These findings support the routine collection of anaerobic bottles.
Anaerobic bottles and their necessity have been a topic of debate in the literature. Some
previous studies concluded anaerobic bottles should be reserved for specific patient popula-
tions (18, 19): neonates with abdominal concerns and adult or pediatric patients with animal

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FIG 3 Time to positivity of obligate anaerobes Clostridium (A), Fusobacterium (B), and other anaerobes
(C). Positive bottles were plotted in 30-min intervals.

bites, immunosuppression, sinus infection, or complicated delivery (20, 21). Other studies
have favored inclusion of the anaerobic bottle, even in pediatric patients (11, 22–24). The
Clinical and Laboratory Standards Institute (CLSI) recommends routine use of paired aerobic
and anaerobic blood cultures, in part, “because the data are conflicting and inconclusive
and because the recommendation that anaerobic blood culture bottles be limited to use in
select patient populations has never been validated by controlled clinical studies to define
these patient populations” (21). The presented study helps address the need for additional
literature by using a high bottle count, 158,710 bottles, and by evaluating adult and pediat-
ric patients. This volume is critical, given the low prevalence of obligate anaerobes, especially
from pediatric patients.
Our data show that pathogenic microorganisms would not have been detected in
some cases from both adult and pediatric patients without the anaerobic bottle. These
included Fusobacterium species that can cause serious health complications in minors

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TABLE 5 Microorganisms with statistically significant differences in time to positivity from

aerobic or anaerobic bottlesa
Aerobic Anaerobic

Microorganism Mean (min) n Mean (min) n P

Proteus mirabilis 972 99 792 107 0.039
Staphylococcus aureus 1,174 2,059 1,138 2,140 0.027
Staphylococcus epidermidis 1,146 614 1,354 634 1.6E210
Streptococcus pneumoniae 568 105 722 87 2.5E24
Staphylococcus hominis 1,093 75 1,652 66 5.0E24
Pseudomonas aeruginosa 1,239 258 1,935 40 7.2E24
Staphylococcus haemolyticus 1,076 58 1,699 48 6.6E23
Candida tropicalis 1,293 35 3,004 5 8.8E23
Haemophilus influenzae 926 16 1,884 13 0.016
Staphylococcus pettenkoferi 1,308 4 2,675 3 0.017
Pediococcus acidilactici 1,482 6 2,093 6 0.027
Staphylococcus capitis 1,554 74 1,978 73 0.043
Corynebacterium striatum 1,350 27 1,765 29 0.043
Staphylococcus lugdunensis 1,103 32 1,338 37 0.043
aBoldface indicates bottle with faster time to positivity (aerobic vs anaerobic).

and B. fragilis, which can necessitate anaerobic coverage adjustments. However, even
with reviewing a year’s worth of data from a large health institution, statistical significance
in analyses was hindered by the low counts of uncommon anaerobes (Table 3). In contrast,
other pathogens, especially yeasts, demonstrated better recovery from aerobic media than
from anaerobic media. This improved recovery of yeasts from aerobic media has also been
mentioned by CLSI (21).
Most pathogens are facultative anaerobes, and we found that most microorganisms
recovered from blood cultures were facultative anaerobes (25). This study found that only 25
microorganisms (mostly facultative anaerobes but also conventional aerobic organisms, like
Candida species and P. aeruginosa) demonstrated statistically significant improved recovery
and/or time to positivity from aerobic bottles compared to anaerobic bottles. In addition, our
data showed that an anaerobic bottle is statistically favored by the key pathogen S. aureus,
which was found in 28.6% of all positive blood culture bottles. These findings question if the
aerobic bottle is sufficiently superior to the anaerobic bottle for recovery of facultative anae-
robes to justify its sole use, as proposed elsewhere (20, 26). A definitive explanation for why

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many facultative anaerobes did not demonstrate improved growth in aerobic bottles remains
elusive. One possibility is that aerobic bottles are not that superior to anaerobic bottles for
facultative anaerobes. Another partial explanation could be that certain drug classes like the
aminoglycosides target aerobic respiration, thus selecting for improved anaerobic growth.
Another component of this study was to compare the epidemiology from positive
blood cultures in adult and pediatric patients. Overall, there were large similarities between
these patient populations, including the recovery of obligate anaerobes from anaerobic bot-
tles. The key pathogens E. coli, P. mirabilis, and E. faecium had lower-than-expected recoveries
from pediatric patients. We hypothesize that these differences may have been due to differing
treatments (i.e., broad use of vancomycin selecting for E. faecium) or gastrointestinal risk fac-
tors (i.e., more gastrointestinal complications in adults). C. glabrata was also noticeably absent
from the pediatric data. Theoretically, this too could have been due to treatment differences
(i.e., decreased fluconazole usage in pediatric patients). Our study also uncovered some statisti-
cally significant recovery differences between adult and pediatric patients, predominantly skin
microorganisms (see Table S2 in the supplemental material). For example, the species S. homi-
nis, S. dysgalactiae, and S. haemolyticus were specific to adults, while the species S. epidermidis,
S. capitis, C. striatum, and viridans group streptococci were found at higher-than-expected fre-
quencies in pediatric patient bottles. While recovery of these skin colonizers likely represented
skin contamination, these findings could potentially be explained by skin microbiota differen-
ces between adult and pediatric patients.
This study was a retrospective review of positive blood culture bottles. A major strength
of this work is that the findings and conclusions are based on real-world laboratory data

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FIG 4 Trends in blood volumes submitted for culture, stratified by culture medium type and adult versus
pediatric patients. Data are based on blood volume measurements obtained from the Virtuo system.

and therefore accurately represent true clinical endpoints. For example, each blood culture
bottle should contain 10 mL of blood, but in practice the volume submitted can vary, as
shown in Fig. 4. It is worth noting that regardless of the blood volume, the main findings

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and conclusions on the necessity of an anaerobic bottle would be minimally impacted: obli-
gate anaerobes were recovered in our study and their recovery was largely dependent on
the anaerobic bottle. If optimal blood volumes had been obtained, the data may have dem-
onstrated increased recovery of obligate anaerobes, further supporting our conclusions.
Future studies will evaluate the clinical relevance of obligate anaerobes from blood culture
using chart review to assess antimicrobial usage and patient outcomes. Another important
future study moving forward is a multicenter and multiyear review of obligate anaerobes from
pediatric patients to improve statistical power. The present study was limited in statistical
power due to low prevalences despite serving a large pediatric population and pooling a year
of data. This limitation was addressed by incorporating data from adults, which showed similar
trends overall.
In conclusion, our data support the routine collection of paired aerobic and anaerobic bot-
tles for blood cultures on the Virtuo blood culture system. This will ensure obligate anaerobes
are recovered and some facultative anaerobes will have faster time to positivity and improved
recovery. Use of paired blood culture bottles provides clinicians with the best diagnostic
testing approach and patient care and thus supports other professional guidelines, including
those of CLSI, the Infectious Diseases Society of America, and the American Society for
Microbiology (27).

SUPPLEMENTAL MATERIAL
Supplemental material is available online only.
SUPPLEMENTAL FILE 1, PDF file, 0.5 MB.

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Benefits of Anaerobic Blood Bottles
ACKNOWLEDGMENTS
We thank the microbiology staff in the Central Laboratory at Barnes-Jewish Hospital
for their ongoing efforts for the patients of the BJC Healthcare system. We also thank
colleagues in Laboratory and Genomic Medicine and Infectious Diseases for feedback
on the study design and manuscript.
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