Effect of number of blood cultures and volume of blood on detection of bacteremia in children

doi:10.1016/S0022-3476(96)70388-8

The Journal of Pediatrics

Volume 128, Issue 2, February 1996, Pages 190-195

Presented in part at the Annual Meeting of the Ambulatory Pediatric Association, May 1994, in Seattle, Wash., and at the Annual Meeting of the Society for Academic Emergency Medicine, May 1994, in Washington, D.C.

https://doi.org/10.1016/S0022-3476(96)70388-8 Get rights and content

Abstract

OBJECTIVE: To determine whether bacteremia can be detected more rapidly and completely by (1) obtaining two blood cultures instead of one and/or (2) collecting a larger volume of blood. STUDY DESIGN: Prospective comparison of different strategies in 300 patients undergoing blood culture for suspected bacteremia. Each patient had two samples of blood, A (2 ml) and B (9.5 ml), obtained sequentially from separate sites. The B sample was divided into three aliquots: B1 (2 ml), B2 (6 ml), and ISO (1.5 ml, quantitative culture). RESULTS: A pathogen was isolated from one or more blood cultures in 30 patients (10% of cases). When measured at 24 hours, the pathogen recovery rate for the B2 sample (72%) was higher than that for the individual small-volume samples (A = 37%, B1 = 33%; p <0.01 for each comparison) and for the combination of the two small-volume samples (A + B1 = 47%; p = 0.04). At final (7-day) reading the pathogen recovery rate for the B2 sample (83%) was higher than that for B1 (60%; p = 0.02) and similar to the recovery rate observed with the combination of the two small-volume cultures (A + B1 = 73%; p = 0.55). CONCLUSIONS: Increasing the volume of blood inoculated into blood culture bottles improves the timely detection of bacteremia in pediatric patients and spares the patients the cost and pain of an additional venipuncture. (J PEDIATR 1996;128:190-5)

Section snippets

METHODS

Children 18 years of age or less seen at the Children's Hospital of Pittsburgh Emergency Department between February 1991 and February 1994 were eligible for study if, in the judgment of the examining physician, they required a blood culture as part of their evaluation. Because the investigation focused on patients with bacteremia, an effort was made to select children with clinical characteristics associated with a high likelihood of having bacteremia: age between 3 and 36 months; fever, with

RESULTS

Three hundred forty-two eligible patients were approached for enrollment during the study period. Thirty-five patients declined to participate, and seven were excluded because venipuncture was unsuccessful (either no blood culture specimen was obtained or only a single small-volume specimen was obtained); thus our study population consisted of 300 patients. Fifty-seven percent of patients were male. Sixty-two percent of enrollees were black, 35% were white, and 3% were of other races. The mean

DISCUSSION

The standard practice for diagnosing bacteremia in adults is to obtain two or more blood culture specimens containing a minimum of 10 ml of blood per bottle.1, 2, 3, 10 This strategy is supported by studies demonstrating enhanced detection of bacteremia with increasing numbers of blood cultures.1, 10 Despite these findings, the practice of obtaining multiple culture specimens or a large volume of blood is seldom extended to children. Although a single small-volume blood culture sample may be

Acknowledgements

We thank the pediatric house staff, nursing staff, and microbiology staff of Children's Hospital of Pittsburgh for their assistance with this project; Barbara H. Hanusa, PhD, for her guidance with the statistical analysis; Kenneth D. Rogers, MD, and Ellen R. Wald, MD, for their thoughtful review of the manuscript; and David Kazimer and Diane Weidner for their editorial assistance.

References (20)

DP Lombardi et al.
Anaerobic bacteremia: incidence, patient characteristics, and clinical significance
Am J Med
(1992)
AKM Zaidi et al.
Value of routine anaerobic blood cultures for pediatric patients
J Pediatr
(1995)
WJ Martin
Routine anaerobic blood cultures: reasons for continued use
Clin Microbiol Newsletter
(1992)
JA Washington
Blood cultures: principles and techniques
Mayo Clin Proc
(1975)
JA Washington
Conventional approaches to blood culture
JA Washington et al.
Blood cultures: issues and controversies
Rev Infect Dis
(1986)
P Chandrasekar et al.
Clinical issues of blood cultures
Arch Intern Med
(1994)
WA Durban et al.
Quantitative blood cultures in childhood bacteremia
J Pediatr
(1978)
IL Bennett et al.
Bacteremia: a consideration of some experimental and clinical aspects
Yale J Biol Med
(1954)
LM Bell et al.
Routine quantitative blood cultures in children with Haemophilus influenzae or Streptococcus pneumoniae bacteremia
Pediatrics
(1985)

There are more references available in the full text version of this article.

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A Little Goes a Long Way: Pediatric Bloodstream Infections and Blood Culture Practices
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Kellogg et al. showed that this improved the detection of low-level bacteremia within the same incubation period as high-level bacteremia [17]. Additionally, studies by Isaacman et al. showed that increasing the blood volume (2 ml versus 6 ml) in each bottle significantly increased pathogen recovery—83% for a 6-ml culture versus 60% for a 2-ml culture [22]. As a result, in children with low body weight, maximizing the safe amount of blood collected can increase the sensitivity of detection of bacteremia.
Unlike adult blood cultures, pediatric blood culture practices are less clear-cut. The various existing guidelines differ on blood collection volume and culture conditions due to the unique characteristics of pediatric blood culture, such as the potential for increased contamination and low blood volume. There are some specialized products marketed for pediatric populations to address these issues, including initial specimen diversion devices and low-volume blood culture bottles. However, there are scant studies looking at their effectiveness. This review discusses the current epidemiology of pediatric bacteremia, the most recently published evidence for the pediatric blood culture practices, and where technology may be going in the future for detection of pediatric bloodstream infections.
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Turkish pediatric residents’ knowledge, perceptions, and practices of blood culture sampling
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Pediatrics is one of the medical specialties in which blood cultures for bloodstream infections are performed very frequently. This study aimed to evaluate pediatric residents’ knowledge and perceptions of blood culture sampling.
Between June 2019 and September 2019, a questionnaire comprising 20 questions about blood culture sampling was sent via email to participants who were pediatric residents at five different hospitals in Turkey. There were 11 true/false and nine multiple-choice questions that assessed three aspects of culture sampling: indications, sampling practice and knowledge, and contamination. The percentage of correct answers was used to calculate an overall score and subsection scores.
A total of 132 pediatric residents [102 (77%) female] with a mean age of 28.3 ± 2.8 years completed the questionnaire. Forty-five (35%) were in their 1st year of residency. Sixty (46%) participants reported that they had not performed blood culture sampling in the last week. There was a negative relationship between years in training and the number of cultures performed (Kendal's tau-b = −0.297, p < 0.001). The overall median score was 65 (range, 35–90) and it seemed to increase with years of training. The lowest median score was in the contamination subscale and only one (0.76%) participant correctly answered all questions concerning contamination.
Residents who obtained the majority of blood cultures had the lowest knowledge levels. Therefore, it is evident that the knowledge levels of pediatric residents must be increased in order to improve blood culture sampling practices in centers where they perform blood culture sampling.
The Art and Science of the Pediatric Blood Culture
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Verification of blood volume for blood culture and detection rate in pediatrics
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This study was conducted to estimate the blood culture volume that should be collected from pediatric patients to improve diagnostic abilities.
Blood cultures from neonates and children aged up to 18 years were collected and the volume was measured for over a 1-year period. During the intervention period, examiners were instructed to draw 3 mL of blood for culture, if possible. The pre-intervention period was from June 1 to August 31, 2016. The post-intervention period was from September 1, 2016, to May 30, 2017. The rate of positive detections was calculated and compared between pre and post-intervention periods.
We collected 1352 samples and measured 1327 bottles. During the pre-intervention period, 340 cases were collected with a median blood volume of 1.64 mL; 9 cases (2.7%) were true-positive. During the intervention period, 1012 cases were ordered with a median blood volume of 2.41 mL; 19 cases (1.9%) were true-positive. After intervention, blood volume was increased significantly (p < 0.01). However, there was no significant difference in the rate of positive detections during the study periods (p = 0.254).
In the pediatric clinical setting in a Japanese municipal hospital, the positive detection rate did not improve even when the collected blood volume was increased. One milliliter of blood volume may be adequate for the pediatric bottle in children.
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The most important is the volume of blood cultured [10–22]. Contrary to widespread belief, the volume of blood cultured in infants and young children is an important variable, albeit one limited by the practical limitations in how much blood can be obtained from these patients [23–33]. Prior to the mid-1980s many, if not most, blood culture bottles only accepted 4–5 mL of blood, about half of what is now recommended for bottles that do not contain additives that allow for use of lower blood volumes.
Current blood culture systems were developed and evolved, in part, based on our knowledge of the critical factors in the recovery of pathogenic microorganisms from blood, changes in the spectrum of pathogens causing bloodstream infections, changes in technology and changes in expectations for blood culture system performance.
The aim was to review historical data about development of blood culture systems and how that knowledge will continue to influence newer generations of technology for detecting and identifying bloodstream pathogens.
Sources were literature review of published papers, previous select reviews, and updated guidelines.
This review focuses on how blood culture systems evolved in response to changes in our knowledge about the critical factors for recovering bloodstream pathogens, the spectrum of pathogens that cause bacteraemia and fungaemia, changes in technology, and changes in expectation of performance.
As we move into an era characterized by molecular identification of bloodstream pathogens, and eventually direct detection of pathogens in blood, the historical knowledge that drove the development and subsequent evolution of contemporary blood culture systems also will drive development and incremental improvements in molecular methods. Our knowledge of bloodstream infections is not static; these systems reflect changes in that knowledge.

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^☆: From the Department of Pediatrics, University of Pittsburgh School of Medicine; University of Pittsburgh School of Nursing; and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania

^☆☆: Supported in part by a grant from the General Clinical Research Center of Children's Hospital of Pittsburgh (NIH 5M01 RR00084) and by a grant from the Research Advisory Committee of Children's Hospital of Pittsburgh.

^★: ^aNow at the A. I. duPont Institute, Wilmington, Del.

^★★: Reprint requests: Daniel J. Isaacman, MD, Chief, Division of Pediatric Emergency Medicine, Children's Hospital of the King's Daughters, 601 Children's Lane, Norfolk, VA 23507.

^♢: 0022-3476/96/$5.00 + 0 9/20/69218

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The Journal of Pediatrics

Abstract

Section snippets

METHODS

RESULTS

DISCUSSION

Acknowledgements

References (20)

Anaerobic bacteremia: incidence, patient characteristics, and clinical significance

Am J Med

Value of routine anaerobic blood cultures for pediatric patients

J Pediatr

Routine anaerobic blood cultures: reasons for continued use

Clin Microbiol Newsletter

Blood cultures: principles and techniques

Mayo Clin Proc

Conventional approaches to blood culture

Blood cultures: issues and controversies

Rev Infect Dis

Clinical issues of blood cultures

Arch Intern Med

Quantitative blood cultures in childhood bacteremia

J Pediatr

Bacteremia: a consideration of some experimental and clinical aspects

Yale J Biol Med

Routine quantitative blood cultures in children with Haemophilus influenzae or Streptococcus pneumoniae bacteremia

Pediatrics

Cited by (131)

A Little Goes a Long Way: Pediatric Bloodstream Infections and Blood Culture Practices

The drop in reported invasive pneumococcal disease among adults during the first COVID-19 wave in the Netherlands explained.

Turkish pediatric residents’ knowledge, perceptions, and practices of blood culture sampling

The Art and Science of the Pediatric Blood Culture

Verification of blood volume for blood culture and detection rate in pediatrics

Development of new methods for detecting bloodstream pathogens

Effect of number of blood cultures and volume of blood on detection of bacteremia in children☆,☆☆,★,★★,♢

Abstract

Section snippets

METHODS

RESULTS

DISCUSSION

Acknowledgements

Am J Med

J Pediatr

Clin Microbiol Newsletter

Blood cultures: principles and techniques

Mayo Clin Proc

Conventional approaches to blood culture

Blood cultures: issues and controversies

Rev Infect Dis

Clinical issues of blood cultures

Arch Intern Med

Quantitative blood cultures in childhood bacteremia

J Pediatr

Bacteremia: a consideration of some experimental and clinical aspects

Yale J Biol Med

Routine quantitative blood cultures in children with Haemophilus influenzae or Streptococcus pneumoniae bacteremia

Pediatrics