Best Practices in Blood

Culture
Optimal Recovery of
Organisms in Blood Culture

Special Reference to CLSI 47P

Key Points

• Timing of drawing blood culture

• Number of blood culture sets

• Volume of blood inoculated

• Use of resin media

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“When is the best time to
draw blood cultures on a
patient with suspected
sepsis?”
 Chills Blood Cultures

BACTEREMIA
Temp LEVEL

0 30 60

Time (min)
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What is the best time to draw
blood cultures?
• Answer:

Draw blood cultures as close as

possible to the episode of chills or fever.
Do NOT delay, as recovery of
microorganisms diminishes with time
after the fever spike.

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“How many blood culture
sets do I need to draw?”
 NUMBER OF SETS
100
90
80
70
60
50 Blood Culture
40 Set

30
20
10
0
1 2 3

• Weinstein MP, Reller LB, Murphy JR, and

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Lichtenstein
Diagnostic KA Rev Inf Dis 5:35, 1983
Systems
 100
90
80
70
60
50 Blood Culture
40 Set
30
20
10
0
1 2 3 4

Cockerill, CID 2004

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How many blood culture sets
should be drawn?
• Answer:

At least 2 and preferably 3 blood culture sets should be drawn

on each patient per episode.
(CLSI states 2-3 blood culture sets)

NEVER draw only 1 blood culture set during the initial

evaluation of a septic patient.
(CLSI emphasizes this point)

Note: A “set” is defined by the number of independent

venipunctures

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How far apart should the sets be
collected?
• Answer:
1.Blood culture sets should be obtained within 5
minutes of each other, since the reticulendothelial
system will clear both transient and intermittent
bacteremias within 15 - 30 minutes
(CLSI states they should be obtained simultaneously,
or over a short timeframe)
2. In suspected subacute infective endocarditis, draw 3
blood culture sets spaced 1 hour apart
(CLSI lists this as an option to consider)

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“How much blood should I
draw from the patient?”
 Effect of Volume

100
90
80
70
60
% Relative 50
Yield 40
30
20
10
0
5 10 15 20 25 30 35 40 45 50 55 60
ml
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How much blood should be drawn
for blood culture?
• Answer:

1. The volume of blood is the single-most critical factor in

optimizing the sensitivity of blood culture

2. For most 2 bottle sets, at least 10ml, and preferably 20 ml

of blood should be obtained and divided between the 2
bottles of the set. The 2 sets (4 bottles) should have between
a minimum of 20 ml & preferably 40 ml total of blood
inoculated.
(CLSI states 20-30 ml of blood per set)

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“The patient is already on
antibiotics, would resin-
based media help to
recover the organism?”
Answer

• YES!!
• It is important to recover the organism from
the blood to help manage the patient properly
• Identification of the organism
• Determination of appropriate therapy
• Determination of underlying disease

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Patients on Antibiotics

• In the US, approximately 30-40% of

patients are already on antibiotics when
the first blood culture is obtained!!!

• In many Asian countries the percentage

is much higher!

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META-ANALYSIS OF BACTEC RESIN
MEDIA PERFORMANCE
• 43 CLINICAL TRIALS
• 1982-1996
• 130,503 SETS EVALUATED
• RESIN vs NON-RESIN
• RESULTS:
• OVERALL: 18.3% INCREASED YIELD
• ON Rx: 35.4% INCREASED YIELD

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Analysis
• In patients overall, resin media are superior to
media without resins

• The difference is greatest in those patients

already on antibiotics…and too many patients
are on antibiotics when blood cultures are
obtained!

• Therefore, best practice would be to use resin

media routinely!

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 BACTEC RESIN TECHNOLOGY
CH CH2 CH CH2 CH CH2 CH CH2 CH CH2

CH2 CH CH2 CH CH2

SO3- H+

SO3- H+ CH CH2

Cationic Exchange Resin Polymeric Adsorbent Resin

• Are non-ionic and cationic exchangers that neutralize many different
antibiotics and other potentially inhibitive substances which might be
present due to the pre-treatment of the patient
• Help to lyse blood cells so that intra-cellular organisms are set free
• Provide the organisms with growth-centres to enhance speed and recovery
rate (up to 40% more)
• No interference with Gram stain readings

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“How long do I need to hold my
blood culture bottles?”

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Answer
• A 5-day protocol is adequate for detection of the majority
of positive blood cultures with BACTEC 9240/9050
(CLSI recommendation is 5-day incubation for automated
systems only)
• Only 0.3% of clinically-significant positive blood cultures
were not detected by day 5, as compared to day 7, and
therefore a 5-day protocol is more cost-effective with
BACTEC
• Huang, et al., European Journal of Clinical
Microbiology 17: 637. 1998
• Only 0.5% of significant positives were not detected by
day 5; all isolates from endocarditis patients were
detected by day 5 (Cockerill, et al. CID 2004)

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“Can Time-to-Positivity help diagnose
patients with Catheter-related
Bacteremia?”

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Answer: Yes
• Several studies have shown that the difference in time-to-
positivity between blood cultures drawn simultaneously
from a peripheral vein and the catheter can help distinguish
catheter-related from non-catheter-related bacteremia
• (CLSI recommends as one of the methods for diagnosis)

 Typically, a difference in time-to-detection of 2-3 hours

has a high sensitivity and specificity for catheter-related
bacteremia
Blot, et al., Lancet 354:1071, 1999
Malgrange, et al., Journal of Clinical Microbiology 39:
274, 2001
Gaur, et al., Clinical Infectious Diseases 37: 469, 2003

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 CONCLUSIONS:Clinical
Issues
• Detection of bacteremia is
important clinically
• Isolation of organism(s) from blood
cultures can help in the
management of the patient
• Appropriate therapy leads to
decreased mortality

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CONCLUSIONS: Laboratory
Issues
• Optimal recovery requires resin-containing
media
• At least 2 blood culture sets should be drawn
• An adequate volume of blood should be
drawn
• Most organisms are recovered in 5 days
• Following the CLSI guideline can help
laboratories achieve “best practices for blood
culture”

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