Evaluation of Fever/Diagnosis of Bacteremia/Evaluation of Sepsis (see Fever, Bacteremia, and Sepsis)
Rationale
Isolation of the Etiologic Organism(s) Allows for Identification of the Responsible Microorganism, Determining the Sensitivity Pattern, and Allows for Later Antibiotic De-Escalation
In General, Routine “Panculture” of All Available Sites is Not Recommended (Unless the Clinical Source of Sepsis is Not Readily Apparent), Due to the Risk of Inappropriate Antimicrobial Use (BMJ Qual Saf, 2017) [MEDLINE]
Clinical Efficacy
Presence of Bacteremia
Only 50% of Patients are Bacteremic at the Time of Sepsis Diagnosis (Crit Care Med, 1989) [MEDLINE]
Canadian Study of Blood Cultures for Sepsis in the Emergency Department Before and After Antibiotic Administration (Ann Intern Med, 2019) [MEDLINE]: n = 325
Pre-Antimicrobial Blood Cultures were Positive for ≥1 Microbial Pathogens in 31.4% of Patients
When the Results of Other Microbiological Cultures were Included, Microbial Pathogens were Found in 67.6% of Patients (CI: 57.7% to 76.6%)
Blood Culture Yield is Not Improved with Sequential Draws or Timing with Fever Spikes
Sterilization by Antimicrobial Therapy
Sterilization of Cultures May Occur within Minutes-Hours of Antibiotic Administration (Clin Infect Dis, 2013) [MEDLINE] and (Pediatrics, 2001) [MEDLINE]
Canadian Study of Blood Cultures for Sepsis in the Emergency Department Before and After Antibiotic Administration (Ann Intern Med, 2019) [MEDLINE]: n = 325
Pre-Antimicrobial Blood Cultures were Positive for ≥1 Microbial Pathogens in 31.4% of Patients
Post-Antimicrobial Blood Cultures were Positive for ≥1 Microbial Pathogens in 19.4% of Patients: sensitivity of post-antimicrobial culture was 52.9% (CI: 42.8% to 62.9%)
Antibiotic Stewardship Data from the 2014 National Healthcare Safety Network Annual Hospital Survey (Clin Infect Dis, 2016) [MEDLINE]
De-Escalation of Antibiotic Therapy is Associated with Less Resistant Microorganisms, Fewer Side Effects, and Lower Costs
Blood Cultures are Required to Facilitate Future Antibiotic De-Escalation When the Organism is Identified and its Sensitivity is Elucidated
De-Escalation of Antibiotic Therapy is Associated with Less Resistant Microorganisms, Fewer Side Effects, and Lower Costs (Clin Infect Dis, 2016) [MEDLINE]
Blood Culture Antigen Detection Assays (VERIGENE, etc) are Routinely Utilized to Rapidly Identify the Organism and its Resistance Pattern
Recommendations (2016 Surviving Sepsis Guidelines; Intensive Care Med, 2017) [MEDLINE]
Routine (Appropriate) Cultures are Recommended Prior to Starting Antibiotic Therapy in Patients with Suspected Sepsis (Best Practice Statement): assuming that this results in no significant delay (<45 min) in starting antibiotics
At Least Two Sets of Blood Cultures (Aerobic and Anaerobic) with a Single Time of Draw are Recommended (Best Practice Statement)
In Patients with an Intravascular Catheter in Place with a Suspicion of Line-Related Sepsis, at Least One Set of Blood Cultures Should Be Obtained from the Catheter (with Simultaneous Peripheral Blood Cultures)
In Patients with an Intravascular Catheter in Place without a Suspicion of Line-Related Sepsis, at Least One Set of Blood Cultures Should Be Obtained Peripherally (No Recommendation is Made Regarding the Second Site of Blood Culture)
Technique
Two Sets (Aerobic and Anaerobic) Blood Cultures are Recommended to Assess for Bacteremia
In Patients with Intravascular Catheter (Present for >48 hrs), One Set of Blood Cultures Should Be Obtained from the Catheter and One Set Peripherally
Blood Culture Yield Has Not Been Shown to Be Improved with Sequential Draws or Timing to Fever Spikes
References
Sepsis syndrome: a valid clinical entity. Methylprednisolone Severe Sepsis Study Group. Crit Care Med. 1989;17(5):389 [MEDLINE]
Comparison of 2 blood culture media shows significant differences in bacterial recovery for patients on antimicrobial therapy. Clin Infect Dis 2013; 56(6):790–797 [MEDLINE]
Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics 2001; 108(5):1169–1174 [MEDLINE]
Revisiting the panculture. BMJ Qual Saf. 2017 Mar;26(3):236-239. doi: 10.1136/bmjqs-2015-004821. Epub 2016 Feb 19 [MEDLINE]
Blood Culture Results Before and After Antimicrobial Administration in Patients With Severe Manifestations of Sepsis: A Diagnostic Study. DOI: 10.7326/M19-1696 [MEDLINE]