Identification of Potentially Unnecessary Micafungin Use Patterns: Opportunities for Antifungal Stewardship Interventions

Background: Echinocandins are used as first-line therapy for suspected and confirmed Candida spp, and its indiscriminate use may drive selection for echinocandin resistance. We evaluated patterns of use of micafungin to identify opportunities for antifungal stewardship. Methods: We identified all micafungin completed orders and microbiological test result data from July 2018 to November 2020 among hospitalized patients in Barnes-Jewish Hospital. Continuous micafungin courses with <48 hours of interruption were considered independent courses. We evaluated micafungin use in 3 scenarios in which its use may be unnecessary: (1) patients with blood cultures negative for Candida spp, (2) patients with recovery of yeast or Candida spp from tracheal aspirates, and (3) patients with recovery of yeast or Candida spp from urine cultures. We only included micafungin courses if they were initiated within 5 days of blood culture collection or up to 4 days after tracheal or urine culture collection to account for incubation and decision to initiate treatment. Results: We found 3,381 micafungin courses in 3,287 admissions. Of these, 2,532 courses had blood culture collection around micafungin initiation and were included in the first analysis: 1,879 (74%) were negative, 149 (6%) had Candida spp isolated in the blood, and 504 (20%) had positive blood cultures for other organisms. Micafungin was given for a median duration of 3 days (IQR, 2–7) to those with negative blood cultures and for 3 days (IQR, 1–5) to those with positive blood cultures without candidemia (p < 0.001), and prolonged durations of more than 5 days was seen in 768/1879 (41%) and 143/504 (28%) of courses, respectively (p <0.001). A total of 487 micafungin courses were initiated after tracheal aspirate culture collection. Those with yeast isolated (n = 100, 21%) received similar micafungin duration compared to those that had no yeast isolated [3 (2-7 IQR) vs. 3 (2-7) days, respectively; p = 0.56). Finally, a total of 844 micafungin courses started after urine culture collection. A total of 49 (6%) had yeast isolated from the urine and treatment duration was similar to those that did not [3 (1-6 IQR) vs. 3 (2-6) days, respectively; p = 0.87). Conclusions: Echinocandin treatment courses did not differ when a yeast was identified from a tracheal isolate or urine specimen. However, a substantial proportion of treatment courses were prolonged in those with negative Candida spp in the blood, suggesting opportunities for antifungal stewardship interventions.Funding: NoDisclosures: None

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A Sterile Collection Bundle Intervention Reduces the Recovery of Bacteria from Neonatal Blood Culture

Biomedicine Hub ◽

10.1159/000486703 ◽

2018 ◽

Vol 3 (1) ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Linze F. Hamilton ◽

Helen E. Gillett ◽

Adam Smith-Collins ◽

Jonathan W. Davis

Keyword(s):

Intensive Care ◽

Blood Culture ◽

False Positive ◽

Neonatal Intensive Care ◽

Intervention Group ◽

Group Versus ◽

Antibiotic Use ◽

Culture Collection ◽

Blood Cultures ◽

Before And After

Background: In neonatal intensive care, coagulase-negative Staphylococcus species can be both blood culture contaminants and pathogens. False-positive cultures can result in clinical uncertainty and unnecessary antibiotic use. Objective: This study sought to assess whether a sterile blood culture collection bundle would reduce the incidence of false-positive blood cultures in a regional neonatal intensive care unit. Method: Clinical data was collected from all infants who had blood cultures taken before and after the introduction of the sterile blood culture collection bundle intervention. This intervention required 2% chlorhexidine and full sterile precautions for blood culture collection. False-positive blood culture rates (presence of skin commensals and ≥3 clinical infection signs) were compared before and after the intervention. The number of days of unnecessary antibiotics associated with false-positive blood cultures was also analysed. Results: In the pre-intervention group (PRE) 197 cultures were taken from 161 babies. In the post-intervention group (POST) 170 cultures from 133 babies were acquired. Baseline demographics were similar in both groups. The rate of false-positive cultures in the PRE group versus the POST group was 9/197 (4.6%) compared to 1/170 (0.6%) (p < 0.05). Unnecessary antibiotic exposure was reduced in the PRE group in comparison to the POST group (27 vs. 0 days, p < 0.01). Conclusions: Implementation of sterile blood culture collection intervention reduced the number of false-positive results. This has potential benefit in reducing unnecessary antibiotic use.

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Drawing blood cultures through intravascular catheters: Controversy and update

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.37 ◽

2019 ◽

Vol 40 (4) ◽

pp. 457-459 ◽

Cited By ~ 1

Author(s):

Leonard A. Mermel

Keyword(s):

Blood Culture ◽

Central Venous Catheter ◽

Venous Catheter ◽

Culture Collection ◽

Blood Cultures ◽

Central Venous ◽

Intravascular Catheters

AbstractStudies published between 1999 and 2011 demonstrated increased blood culture contamination with catheter-drawn cultures compared with percutaneously-drawn cultures. Studies published between 2012 and 2015 reported that use of antiseptic barrier caps on central venous catheter hubs significantly reduces the incidence of catheter-drawn blood culture contamination. Local guidelines regarding sites for blood culture collection should reflect institution-level blood culture contamination rates for percutaneously-drawn and catheter-drawn cultures using currently available technologies that reduce contamination at both sites.

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Yield of positive blood cultures in pediatric oncology patients by a new method of blood culture collection

The Pediatric Infectious Disease Journal ◽

10.1097/00006454-199607000-00011 ◽

1996 ◽

Vol 15 (7) ◽

pp. 615-620 ◽

Cited By ~ 32

Author(s):

ATHANASIOS G. KADITIS ◽

AENGUS S. O'MARCAIGH ◽

K. HABLE RHODES ◽

AMY L. WEAVER ◽

NANCY K. HENRY

Keyword(s):

Blood Culture ◽

Pediatric Oncology ◽

Culture Collection ◽

Blood Cultures ◽

New Method ◽

Oncology Patients

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107. Impact of a Rapid Blood Culture Identification Panel at a Community Teaching Hospital: a Pre-Post Quasi-Experiment

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.152 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S68-S69

Author(s):

Catherine Trinh ◽

Steven Richardson ◽

Benjamin Ereshefsky

Keyword(s):

Targeted Therapy ◽

Blood Culture ◽

Culture Collection ◽

Blood Cultures ◽

Gram Stain ◽

Post Intervention ◽

Gram Positive ◽

Days Of Therapy ◽

Culture Identification ◽

The Impact

Abstract Background Rapid diagnostic tests (RDT) for positive blood cultures can lead to quicker identification of organisms and key resistance elements. As a result time to targeted therapy may decrease, thus reducing the duration of broad, empiric antibiotic use. The purpose of this study was to determine the impact of implementing the BioFire® FilmArray® Blood Culture Identification (BCID) Panel for gram-positive organisms on antimicrobial process measures and patient outcomes at an academic community hospital. Methods This was a single-center, pre-post intervention, quasi-experimental study evaluating hospitalized adult patients who had at least one positive blood culture with gram-positive organisms from June 1, 2018 to August 31, 2018 and June 1, 2019 to August 31, 2019. Patients in the pre-intervention group were randomized and post-intervention patients were matched by identified organism. The primary outcome was the time to targeted therapy from blood culture collection. Secondary outcomes included time to targeted therapy from positive Gram stain, vancomycin and anti-pseudomonal β-lactam length of therapy (LOT), institutional vancomycin days of therapy (DOT), length of stay (LOS), and estimated hospitalization costs. Results A total of 75 patients in each group were included. The time to targeted therapy from blood culture collection was significantly decreased after RDT implementation [32.9 (23.2–51.8) hours vs. 49.2 (37.1–76.3 hours, p < 0.001)], as was time to targeted therapy from Gram stain results [8.5 (0–25.2) hours vs. 30 (19.4–52.9) hours, p < 0.001]. No difference was found between the groups with respect to LOS or estimated hospitalization cost. Overall the vancomycin LOT [0.86 (0.09–2.38) days vs. 2.18 (1.37–4.34) days, p = 0.001] and anti-pseudomonal β-lactam LOT for MRSA, MSSA, Streptococcus, and Enterococcus subgroup [1.15 (0.06–2.07) vs. 1.78 (1.28–2.89) days, p = 0.026] were significantly decreased in the post-RDT group. Figure 1: Institutional Use of Vnacomycin Conclusion Implementation of a rapid diagnostic test on gram-positive blood cultures was associated with decreased time to targeted therapy from blood culture collection, time to targeted therapy from positive culture, and vancomycin LOT. Disclosures All Authors: No reported disclosures

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Blood Culture Collection through Peripheral Intravenous Catheters Increases the Risk of Specimen Contamination among Adult Emergency Department Patients

Infection Control and Hospital Epidemiology ◽

10.1086/665319 ◽

2012 ◽

Vol 33 (5) ◽

pp. 524-526 ◽

Cited By ~ 18

Author(s):

Wesley H. Self ◽

Theodore Speroff ◽

Candace D. McNaughton ◽

Patty W. Wright ◽

Geraldine Miller ◽

...

Keyword(s):

Emergency Department ◽

Relative Risk ◽

Blood Culture ◽

Confidence Interval ◽

Culture Collection ◽

Blood Cultures ◽

Intravenous Catheter ◽

Peripheral Intravenous Catheter ◽

Emergency Department Patients ◽

Intravenous Catheters

Five hundred five blood cultures collected through a peripheral intravenous catheter (PIV) in an emergency department were matched to cultures obtained by dedicated venipuncture from the same patient within 10 minutes. The relative risk of contamination for cultures collected through PIVs compared with dedicated venipuncture was 1.83 (95% confidence interval, 1.08–3.11).

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1169. Preventing Central Line-Associated Bloodstream Infections in Long-Term Acute Care

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1032 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S418-S419

Author(s):

Jerry Jacob ◽

Ann Morace ◽

Jisuk Park ◽

Nina Renzi

Keyword(s):

Blood Culture ◽

Bloodstream Infections ◽

Central Line ◽

Culture Collection ◽

Blood Cultures ◽

Fiscal Year ◽

Intervention Period ◽

Central Lines ◽

Clabsi Rate

Abstract Background Long-term acute care hospitals (LTACHs) care for chronically, critically ill patients with high utilization of central lines and high risk for morbidity from central line-associated bloodstream infections (CLABSIs). Our 38-bed LTACH noted a substantial increase in the incidence of CLABSIs (as defined by the National Healthcare Safety Network) between fiscal year (FY) 2016 and FY 2018 (Figure 1). Detailed case review identified a large number of CLABSIs which were clinically consistent with blood culture contaminants from central lines. Feedback from bedside staff also suggested gaps between practice and evidence-based measures for central line care. Methods A three-pronged CLABSI prevention project was implemented in July 2018 consisting of (1) staff education regarding daily chlorhexidine (CHG) bathing for all patients, combined with an electronic audit report to identify patients without active CHG orders; (2) change in practice to the use of venipuncture alone for blood culture collection, combined with an electronic audit report to identify blood cultures collected from central lines; and (3) a recurring 6-part educational series for nurses focused on central line care. The pre-intervention period was defined as the 12-month period between July 1, 2017 and June 30, 2018 (FY 2018). The primary outcome was the fiscal year CLABSI rate. A secondary outcome was the proportion of blood cultures drawn from central lines. Results After 9 months of the intervention, one CLABSI had been reported for FY 2019 year-to-date at a rate of 0.4 per 1,000 CL-days, representing an 86% decrease from the FY 2018 rate of 2.8 per 1,000 CL-days. The 12-month rolling CLABSI rate decreased to 1.6 per 1,000 CL-days (Figure 2). The proportion of blood cultures collected from central lines decreased from 10.5% (69/658) to 4.5% (15/334), representing a 57% reduction. The proportion of patients ordered and receiving CHG bathing in the intervention period was >95%. Conclusion A multidisciplinary effort focused on CHG bathing, central line care, and blood culture collection led to a substantial reduction in CLABSIs in our LTACH. The use of electronic audit reports was particularly useful in achieving high adherence to practice changes. Disclosures All authors: No reported disclosures.

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Estimated Clinical and Economic Impact through Use of a Novel Blood Collection Device To Reduce Blood Culture Contamination in the Emergency Department: a Cost-Benefit Analysis

Journal of Clinical Microbiology ◽

10.1128/jcm.01015-18 ◽

2018 ◽

Vol 57 (1) ◽

Cited By ~ 4

Author(s):

Erik Skoglund ◽

Casey J. Dempsey ◽

Hua Chen ◽

Kevin W. Garey

Keyword(s):

Emergency Department ◽

Blood Culture ◽

Economic Impact ◽

Hospital Costs ◽

Cost Savings ◽

Cost Benefit ◽

Culture Collection ◽

Blood Cultures ◽

Hospital Length Of Stay ◽

Decision Analysis Model

ABSTRACTBlood culture contamination results in increased hospital costs and exposure to antimicrobials. We evaluated the potential clinical and economic benefits of an initial specimen diversion device (ISDD) when routinely utilized for blood culture collection in the emergency department (ED) of a quaternary care medical center. A decision analysis model was created to identify the cost benefit of the use of the ISDD device in the ED. Probabilistic costs were determined from the published literature and the direct observation of pharmacy/microbiology staff. The primary outcome was the expected per-patient cost savings (microbiology, pharmacy, and indirect hospital costs) with the routine use of an ISDD from a hospital perspective. The indirect costs included those related to an increased hospital length of stay, additional procedures, adverse drug reactions, and hospital-acquired infections. Models were created to represent hospitals that routinely or do not routinely use rapid diagnostic tests (RDT) on positive blood cultures. The routine implementation of ISDD for blood culture collection in the ED was cost beneficial compared to conventional blood culture collection methods. When implemented in a hospital utilizing RDT with a baseline contamination rate of 6%, ISDD use was associated with a cost savings of $272 (3%) per blood culture in terms of overall hospital costs and $28 (5.4%) in direct-only costs. The main drivers of cost were baseline contamination rates and the duration of antibiotics given to patients with negative blood cultures. These findings support the routine use of ISDD during blood culture collection in the ED as a cost-beneficial strategy to reduce the clinical and economic impact of blood culture contamination in terms of microbiology, pharmacy, and wider indirect hospital impacts.

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157. Reducing Blood Culture Contamination Rates Through the Use of a Red Top Tube Discard

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy209.027 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S12-S13

Author(s):

Bharat Ramlal ◽

Rosemary Renouf ◽

Jaber Aslanzadeh

Keyword(s):

Blood Culture ◽

Effective Means ◽

Accurate Determination ◽

Laboratory Diagnosis ◽

The United States ◽

Culture Collection ◽

Blood Cultures ◽

Contamination Rate ◽

Blood Contamination ◽

Blood Draw

Abstract Background Septicemia is a major cause of death in the United States and accounts for up to $16.7 billion in annual health care expenses. Blood culture is the gold standard for laboratory diagnosis of bacteremia and resultant septicemia; however, false-positive blood cultures hinder the accurate determination of true bacteremia with often serious implications. The goal of this study was to determine the efficacy of collecting a 1 mL discard in a red tube prior to blood culture collection and to assess its effectiveness in reducing contamination rates in Hartford Hospital Emergency Department (HHED). Methods During the months of June to December 2017 blood cultures were collected by the phlebotomy team using ChloraPrep (chlorhexidine) as the sole disinfecting agent. Blood cultures consisted of BD BACTEC plus Aerobic/F and BD BACTEC Lytic/10 Anaerobic drawn at the same time and monitored on BD BACTEC FX instrument for 5 days. Prior to collecting blood cultures 1 mL of blood was collected in a red top tube and discarded. Monthly and overall contamination rates were then compared with 2016 in which a red top discard tube was not used. Results During June to December 2016, there were a total of 9,576 blood cultures collected with a total of 178 contaminants and an overall contamination rate of 1.9%. During June to December 2017, there were a total of 9,133 blood cultures collected with a total of 73 contaminants and an overall contamination rate of 0.8%. During both years, our contamination rates were well below the CLSI recommendation; however, a significant reduction in blood culture contamination was observed after the use of a Red Top discard tube (0.8% vs. 1.9%) (Figures 1–3). Conclusion The cost of a standard blood draw with Red Top tubes is minimal (few cents) while a single collection using an initial specimen diversion device (ISDD) can range from $15 to $18. During the course of this study, the use of a standard Red Top discard cost approximately $456 (2017); if an ISDD was used instead, this would have generated $136,995 in healthcare cost. At our institution, we were able to keep our contamination rates below 1% after the implementation of a standard Red Top discard tube. This suggests that the use of a Red Top discard prior to blood culture collection is an effective means for reducing and maintaining a low blood contamination rate. Disclosures All authors: No reported disclosures.

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The San Luigi Gonzaga Hospital experience: improving blood and urine culture preanalytical quality by shared protocols

Microbiologia Medica ◽

10.4081/mm.2017.6602 ◽

2017 ◽

Vol 32 (2) ◽

Author(s):

Angela Samiolo ◽

Elena Ardizzi ◽

Angela Ardizzola ◽

Ornella Bianco ◽

Anna Rita De Luigi ◽

...

Keyword(s):

Blood Culture ◽

Risk Analysis ◽

Prospective Observational Study ◽

Urine Culture ◽

Blood Cultures ◽

Time Intervals ◽

The Individual ◽

Sampling Procedures ◽

Prospective Monitoring

Background and aims: Reduction in the number of blood culture and urine culture contamination samples. Materials and methods: We have designed a partly retrospective and partly prospective observational study. On one hand, we have been striving for the creation, dissemination and promotion of shared operational rules in all departments/hospital services to improve the quality of the levy; on the other hand, we analysed data. We considered blood cultures and urine cultures analysed in the laboratory from March to August 2015, and from March to August 2016. The data were processed with R and the incidence of contaminated samples was calculated by dividing the number of blood cultures/urine cultures contaminated by the total. The results of 2015 and 2016 were compared by χ2. To highlight the possible differences between departments and identify those at higher risk of contamination, the data of each year were stratified dividing departments into five groups: Medicine, Surgery, Critical Area, Specialties and ER. To assess the strength of the association, a risk analysis was carried out using the risk ratio (RR). The RR was calculated by dividing the contamination rates of 2015 by the those of 2016. The value of α was set at 0.05. Results: After implementation of the shared protocols, blood culture contamination was substantially reduced (−56.8%, P=1.783e-05), confirmed by an RR of 2.2 (95%CI: 1.54±3.27). The evidence is strengthened by the finding of a lower number of isolates belonging to the group of possible contaminants (−32.7%, P=2.042e-07) and confirmed by an RR of 1.5 (95%CI: 1.27±1.73). Urine culture data analysis showed no change in the incidence of contamination between 2015 and 2016 (P=0.8808), as confirmed by a non-informational RR (95%CI: 0.62±1:46). Even the analysis of the individual areas showed no change in the two semesters, as confirmed by the risk analysis that does not show any association between outcome and group. Conclusions: The results confirm the value of multidisciplinary work and encourage us to continue the path of standardisation and updating of the sampling procedures, as well as the prospective monitoring and comprehensive analysis of the data collected for longer time intervals.

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Urine Culture Contamination: A College of American Pathologists Q-Probes Study of 127 Laboratories

Archives of Pathology & Laboratory Medicine ◽

10.5858/2008-132-913-uccaco ◽

2008 ◽

Vol 132 (6) ◽

pp. 913-917 ◽

Cited By ~ 11

Author(s):

Leonas G. Bekeris ◽

Bruce Allen Jones ◽

Molly K. Walsh ◽

Elizabeth A. Wagar

Keyword(s):

Urine Culture ◽

Average Rate ◽

Substantial Effect ◽

Culture Collection ◽

Contamination Rate ◽

Urine Specimen ◽

Patient Instruction ◽

Female Patients ◽

Study Results ◽

Low Performance

Abstract Context.—While urine culture contamination may not be completely avoidable, some laboratories have lower contamination rates than others. A College of American Pathologists (CAP) 1998 Q-Probes study showed that many interventions commonly assumed to reduce contamination were not demonstrably effective. This article revisits the issue. Objective.—To examine the frequency of urine culture contamination, review current laboratory practices in the collection of urine culture specimens, and determine practice characteristics that may be associated with the contamination rate. Design.—Laboratories participating in a CAP Q-Probes study were required to prospectively collect data on 120 consecutive urine culture specimens and provide information on the patient's demographics (age and sex), the location where the specimen was collected, how the specimen was handled, the number of isolates in quantities greater than or equal to 10 000 colony-forming units (CFU)/mL, and whether the laboratory considered the specimen to be contaminated. Specific inclusion and exclusion criteria were provided to the participants. Each laboratory completed a supplemental questionnaire that probed for specific laboratory urine culture collection practices. Results.—One hundred twenty-seven laboratories participated in the study. Results from a total of 14 739 urine specimens were received. For the purpose of this study, a urine specimen was determined to be contaminated if the culture yielded more than 2 isolates in quantities greater than or equal to 10 000 CFU/mL. Using these criteria the median institution had a contamination rate of 15.0%. Laboratories in the 10th percentile (low performance) had an average contamination rate of 41.7%, while laboratories in the 90th percentile had an average rate of 0.8%. The collection site had no influence on the contamination rate, but postcollection processing, especially refrigeration of the specimen, had a substantial effect. Providing instruction to patients produced a statistically significant lowering of contamination rates for specimens from male patients (P = .006) but not for female patients, except when written instructions were provided in the emergency room, in which case specimen contamination rates for both male and female patients dropped (P = .01). Conclusions.—The median contamination rates remain at a level comparable to the results seen in a previous Q-Probes study, and some laboratories have very high contamination rates. Specimen refrigeration is associated with lower overall urine culture specimen contamination rate. Providing patient instruction is also associated with lower contamination rates under specific circumstances.

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