Annotated Bibliography

In the past two decades, a significant amount of research has been conducted to identify the limitations of blood culture testing and evaluate potential improvements in education, clinical process, and technology.

The following annotated bibliography includes select studies published in the US from 2006 to present day.

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Sutton J, Fritsch P, MoodyM, Dinaro K, Holder C. Preventing Blood Culture Contamination using a Novel Engineered Passive Blood Diversion Device. Association for Professionals in Infection Control, June 2018 Minneapolis, MN [Abstract: EI – 101]
Bayfront Health St. Petersburg, St. Petersburg, FL

  • The reduction in the contamination rate of 0.025 to 0.012 was statistically significant.
  • During the post-intervention period, the diversion device was not used in 8 out of 9 contaminated cultures.
  • The diversion device was utilized in only 50% of blood draws during the post-intervention period.
  • The hospital estimates that each false positive blood culture adds $7,500 in costs, so implementing Kurin would save the hospital over $500,000 annually, after the cost of the product.

Allain, M. Top Scoring Abstracts From the 2018 National Association of Clinical Nurse Specialists Annual Conference: Not Your ‘‘Average’’ ED: A CNS-Led Project That Reduced Blood Culture Contaminations in One Emergency Department to Below Expected Levels. Clin Nurs Specialist 2018 May/June; E1-2
Crouse Hospital, Syracuse, NY

  • Baseline rates varied between 1.6 and 2.1%.
  • While using Kurin, rates fell to 0.8%, 50% below their best performance and 57% below their mean performance.
  • 7 of 9 contaminations during the study period occurred when Kurin was not used.
  • Using cost of contaminated cultures of $5200, Allain calculated that the hospital would save more than $185,000 per year.
  • There was an increased length of stay of 3.2 days associated with false positive blood cultures.

Garcia RA, Spitzer ED, Beaudry J, Beck C, Diblasi R, Gilleeny-Blabac M, Haugaard C, Heuschneider S, Kranz BP, McLean K, Morales KL, Owens S, Paciella ME, Torregrosa E. Multidisciplinary team review of best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremia, reducing contamination, and eliminating false-positive central line-associated bloodstream infections. Am J Infect Control. 2015 Nov 1;43(11):1222-37.
Stony Brook University Hospital, Stony Brook, NY

  • Skin, however, cannot be sterilized during antisepsis procedures because approximately 20% of bacteria are imbedded within deep layers of the epidermis and dermis.
  • Blood cultures should be obtained prior to starting antibiotic therapy to optimize the recovery of pathogens.
  • Estimated up to 50% of all blood cultures originate in the ED. Crowding in EDs is correlated with higher rates.
  • Improper collection of blood cultures is associated with suboptimal treatment of patients, increased financial burdens, and potential over-reporting of CLABSI.
  • Costs of a false positive blood culture range from $4500-$10,000.

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Gander RM, Byrd L, DeCrescenzo M, Hirany S, Bowen M, Baughman J. Impact of blood cultures drawn by phlebotomy on contamination rates and health care costs in a hospital emergency department. J Clin Microbiol. 2009 Apr;47(4):1021-4.
University of Texas Southwestern Medical Center, Dallas, Texas

  • Demonstrated the value of phlebotomists in reducing rates of false positive blood cultures.
  • Phlebotomists had a false positive blood cultures rate of 3.1 which was better than the non-phlebotomists (5.6 and 7.4).
  • Comparison of median patient charges between negative and false-positive episodes ($18,752 versus $27,472) showed a $8,720 difference while the median length of stay increased from 4 to 5 days.
  • By utilizing phlebotomists to collect blood cultures in the ED, contamination rates were lowered to recommended levels, with projected reductions in patient charges of approximately $4.1 million per year

Garcia RA, Spitzer ED, Kranz B, Barnes S. A national survey of interventions and practices in the prevention of blood culture contamination and associated adverse health care events. Am J Infect Control. 2018 May;46(5):571-576. Epub 2017 Feb 1.
Stony Brook University Hospital, Stony Brook, NY

  • 80% of respondents report a blood culture contamination rate less than 3%.
  • 90% of hospital protocols emphasize direct venipuncture.
  • About 60% report that hospitals likely submit CLABSI data to NHSN attributable to blood culture contamination.

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Makam AN, Auerbach AD, Steinman MA. Blood culture use in the emergency department in patients hospitalized for community-acquired pneumonia. JAMA Intern Med. 2014 May;174(5):803-6.
University of Texas Southwestern Medical Center, Dallas, Texas

  • The proportion of cultures collected in the ED during these visits increased from 10% in 2002 to 20% in 2010.
  • The proportion of cultures collected in patients hospitalized with community-acquired pneumonia (CAP) increased from 29% in 2002 to 51% in 2010, a 76% relative increase.
  • One potential explanation for increasing culture rates is that the JCAHO/CMS core measure (PN-3b) announced in 2002 mandated that if a culture is collected in the ED, it should be collected prior to antibiotic administration. This encouraged providers to reflexively order cultures in all patients admitted with CAP for whom antibiotic administration is anticipated.

Hall and Lyman. Updated Review of Blood Culture Contamination. Clin Microbiol Rev. 2006 Oct; 19(4): 788–802.
University of Virginia School of Medicine, Charlottesville, Virginia

  • Rates vary widely from 0.6% to over 6%.
  • Rates have been on the increase.
  • Not everyone follows the recommendation of having two samples.
  • Positive predictive value goes up if two of two blood cultures were positive and both taken from the vein.
  • Skin antisepsis cannot entirely prevent the contamination of blood cultures

Zwang O, Albert RK. Analysis of strategies to improve cost effectiveness of blood cultures. J Hosp Med. 2006 Sep;1(5):272-6.
Denver Health Med Center, Denver CO

  • Positive predictive value of a positive blood culture was only 53%.
  • A 50% reduction in false positives would save approximately twice as much as a 50% reduction in false negatives.
  • Although only 6% of the blood cultures represented contaminants, their associated cost was more than twice that associated with the 87% that were true negatives.

Self WH, Speroff T, Grijalva CG, McNaughton CD, Ashburn J, Liu D, Arbogast PG, Russ S, Storrow AB, Talbot TR. Reducing blood culture contamination in the emergency department: an interrupted time series quality improvement study. Acad Emerg Med. 2013 Jan;20(1):89-97.
Vanderbilt University School of Medicine, Nashville, TN

  • The study objective was to develop and evaluate the effectiveness of a quality improvement (QI) intervention for reducing blood culture contamination in an ED.
  • The QI intervention involved changing the technique of blood culture specimen collection from the traditional clean procedure, to a new sterile procedure, with standardized use of sterile gloves and a new materials kit containing a 2% CHG skin antisepsis device, a sterile fenestrated drape, a sterile needle, and a procedural checklist.
  • During the baseline period, (4.3%) cultures were contaminated, compared to (1.7%) during the intervention period.

Hall RT, Domenico HJ, Self WH, Hain PD. Reducing the blood culture contamination rate in a pediatric emergency department and subsequent cost savings. Pediatrics. 2013 Jan;131(1):e292-7.
Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, Tennessee

  • Introduced a standardized sterile collection process to reduce peripheral blood culture contamination rate and unnecessary use of resources.
  • The peripheral blood culture contamination rate was reduced from 3.9% during the baseline period to 1.6% during the intervention period.
  • There was a yearly estimated savings of ~$250,000 in hospital charges.

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Bell M, Bogar C, Plante J, Rasmussen K, Winters S. Effectiveness of a Novel Specimen Collection System in Reducing Blood Culture Contamination Rates. J Emerg Nurs. 2018 Apr 20. pii: S0099-1767(17)30148-4.
Lee Health Fort Meyers, FL; Cape Coral, FL.

  • Study data was limited to only those blood cultures collected with the device. It does not reflect the impact on the overall blood culture contamination rate.
  • The data showed an 82.8% reduction in false positives.
  • Based on the historical 3.52% rate of blood-culture contamination for the health facilities, 2.92 false positives were prevented for every 100 blood cultures drawn.

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Rupp ME, Cavalieri RJ, Marolf C, Lyden E. Reduction in Blood Culture Contamination Through Use of Initial Specimen Diversion Device. Clin Infect Dis. 2017 Jul 15;65(2):201-205.
University of Nebraska Medical Center, Omaha, NE

  • Study data was limited to only those blood cultures collected with the device. It does not reflect the impact on the overall blood culture contamination rate.
  • False positives increase laboratory costs by approximately 20%, are associated with a nearly 40% increase in antibiotic charges and can extend the length of hospital stay by up to 5 days.
  • False positive blood culture rate decreased from 1.78% to 0.22% with use of an Initial Specimen Diversion Device (ISDD).

Patton RG, Schmitt T. Innovation for Reducing Blood Culture Contamination: Initial Specimen Diversion Technique. J Clin Microbiol. 2010 Dec;48(12):4501-3.
Northwest Hospital and Medical, Seattle, WA.

  • >0.5ml and <2ml is adequate diversion to significantly reduce contamination.
  • Initial specimen diversion technology reduced contamination of blood cultures by excluding contaminants from the first portion of the venipuncture-obtained culture specimen.

Moeller D. Eliminating Blood Culture False Positives: Harnessing the Power of Nursing Shared Governance. J Emerg Nurs. 2017 Mar;43(2):126-132.
Advocate Health, Illinois

  • A new process decreased the blood culture contamination rate from a baseline rate of 5.37% to 1.76%.
  • The chief recommendation is to engage staff through clinical leadership.

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Bowen CM, Coleman T, Cunningham D. Reducing Blood Culture Contaminations in the Emergency Department: It Takes a Team. J Emerg Nurs. 2016 Jul;42(4):306-11.
Kennedy Health, Cherry Hill, NJ.

  • The plan targeted environmental and skin contaminates, teamwork, education, and feedback.
  • During the 8-week pilot, the monthly contamination rates were 1.96% and 0.3%, respectively. Subsequent data over 1 year revealed the contamination rates ranged from 0.2% to 1.51%, with a mean of 0.87%.

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Sinnott PL, Breckenridge JS, Helgerson P, Asch S. Using lean management to reduce blood culture contamination. Jt Comm J Qual Patient Saf. 2015 Jan;41(1):26-2.
Palo Alto Health Care System, Menlo Park, California, USA

  • Reduce the blood culture contamination rate using Lean management quality improvement methods, including a rapid process improvement workshop to identify root causes of variation in blood culture procedures and countermeasures (potential improvement strategies) to address each problem.
  • The blood culture contamination rate decreased significantly from 4.2% in the 19-month baseline period to 2.8% in the last 12 months of follow-up.
  • An estimated 261 contaminated blood culture were avoided in the follow-up period.

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Self WH, Talbot TR, Paul BR, Collins SP, Ward MJ. Cost analysis of strategies to reduce blood culture contamination in the emergency department: sterile collection kits and phlebotomy teams. Infect Control Hosp Epidemiol. 2014 Aug;35(8):1021-8.
Vanderbilt University School of Medicine, Nashville, TN

  • Compared hospital costs associated with three collection strategies: usual care, sterile kits, and phlebotomy teams.
  • Baseline contamination rates associated with usual care, sterile kits, and phlebotomy teams were 4.34%, 1.68%, and 1.10%, respectively.
  • Compared to usual care, annual net savings using the sterile kit and phlebotomy team strategies were $483,219 and $288,980, respectively.

Self WH, Mickanin J, Grijalva CG, Grant FH, Henderson MC, Corley G, Blaschke Ii DG, McNaughton CD, Barrett TW, Talbot TR, Paul BR. Reducing blood culture contamination in community hospital emergency departments: a multicenter evaluation of a quality improvement intervention. Acad Emerg Med. 2014 Mar;21(3):274-82.
Vanderbilt University School of Medicine, Nashville, TN.

  • Measured the effect of implementing a sterile blood culture collection process.
  • At Hospital A, during the baseline period, 165 of 3,417 (4.83%) cultures were contaminated as compared to 142 of 5,238 (2.71%) during the intervention period. At Hospital B, during the baseline, 63 of 2,509 (2.51%) cultures were contaminated. But with the full sterile process, 51 of 1,865 (2.73%) cultures were contaminated.
  • Hospital B experienced poor adherence. So, a simplified sterile process used during intervention period 2 was associated with a significant reduction in contamination, with 17 of 1,860 (0.91%) cultures contaminated.
  • Monitoring the implementation process was important to identify and overcome operational challenges.

Marini MA, Truog AW. Reducing false-positive peripheral blood cultures in a pediatric emergency department. J Emerg Nurs. 2013 Sep;39(5):440-6.
Children’s Hospital Boston, Boston, MA, USA.

  • Reduced the rate of false-positive peripheral blood cultures using blood culture kits, a dedicated team obtaining peripheral blood cultures, and following up with staff who draw a contaminated peripheral blood cultures.
  • The rate of false-positive peripheral blood cultures decreased from the baseline rate of 2.1%. to 1.4%.

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Weddle G, Jackson MA, Selvarangan R. Reducing blood culture contamination in a pediatric emergency department. Pediatr Emerg Care. 2011 Mar;27(3):179-81.
Children’s Mercy Hospitals and Clinics, Kansas City, MO

  • Reduced the rate of false-positive peripheral blood cultures by educating staff about hospital policy, using a blood culture-drawing kit, having a dedicated team obtaining peripheral blood cultures, and following up with staff who draw a contaminated peripheral blood culture.
  • The false-positive peripheral blood culture rate in the emergency department dropped from 2.1% to 1.4%.
  • Before intervention, 44 patients were called back to the emergency department, and 25 were admitted because of blood culture contamination. After intervention, a total of 9 patients were called back, and 5 were admitted.

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Harding AD, Bollinger S. Reducing blood culture contamination rates in the emergency department. J Emerg Nurs. 2013 Jan; 39(1): e1-6.
Southcoast Hospitals Group, New Bedford, MA, USA

  • Developed and implemented a corrective action plan to lower contamination rates including: private conversations with staff members associated with higher numbers of contaminated draws, ensuring availability of necessary blood culture collection supplies, re-education of all staff surrounding blood culture collection best practices, monthly feedback on blood culture contamination rates, and continuing private conversations as necessary.
  • The average rate of blood culture contamination dropped from 1.82% to 1.01% after the interventions, a 44% decrease in hospital-wide blood culture contamination rates.
  • Annualized cost avoidance of approximately $614,000.

Boyce JM, Nadeau J, Dumigan D, Miller D, Dubowsky C, Reilly L, Hannon CV. Obtaining blood cultures by venipuncture versus from central lines: impact on blood culture contamination rates and potential effect on central line-associated bloodstream infection reporting. Infect Control Hosp Epidemiol. 2013 Oct;34(10):1042-7.
Yale-New Haven Hospital, New Haven, Connecticut

  • Evaluated the impact of a new blood culture policy that discouraged drawing blood samples from central lines.
  • The proportion of blood samples obtained for culture from central lines decreased from 10.9% to 0.4%.
  • The proportion of blood cultures that were contaminated decreased from 84 (1.6%) of 5,274 to 21 (0.5%) of 4,245.
  • Based on estimated excess hospital costs of $3,000 per contaminated blood culture, the reduction in CBCs yielded an estimated annualized savings of $378,000 in 2012 when compared to 2010.
  • In mid-2010, 3 (30%) of 10 reported CLABSIs were suspected contamination compared with none of 6 CLABSIs reported from mid-November 2010 through June 2012.

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Snyder SR, Favoretto AM, Baetz RA, Derzon JH, Madison BM, Mass D, Shaw CS, Layfield CD, Christenson RH, Liebow EB. Effectiveness of practices to reduce blood culture contamination: A Laboratory Medicine Best Practices systematic review and meta-analysis. Clin Biochem. 2012 Sep;45(13-14):999-1011.
Battelle Centers for Public Health Research and Evaluation, Associated Laboratory Consultants, Centers for Disease Control and Prevention, University of Maryland, United States

  • Review the effectiveness of three practices for reducing blood culture contamination rates: venipuncture, phlebotomy teams, and prepackaged preparation/collection (prep) kits.
  • All studies for venipuncture and phlebotomy teams favored these practices. For prep kits 6 studies’ effect sizes were not statistically significantly different from no effect.

Murillo TA, Beavers-May TK, English D, Plummer V, Stovall SH. Reducing contamination of peripheral blood cultures in a pediatric emergency department. Pediatr Emerg Care. 2011 Oct;27(10):918-21.
Arkansas Children’s Hospital, Little Rock, AR

  • Determined the ED Contamination rate and evaluate an educational intervention.
  • Positivity rate during the pre-study phase was 6.8%; 114 were contaminants and 40 were pathogens. Positivity rate during the intervention phase was 6.3%; 124 were contaminants and 33 were pathogens.
  • Contamination rates of individual practitioners ranged from 0% to 17% (PRE) and from 0% to 21% (POST).
  • The rate in the ED for peripherally drawn blood cultures is approximately 5% monthly. For each culture positive for organism, the chance of contamination is 75% or higher.

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Story-Roller E, Weinstein MP. Chlorhexidine versus Tincture of Iodine for Reduction of Blood Culture Contamination Rates: A Prospective Randomized Crossover Study. J Clin Microbiol. 2016 Dec;54(12):3007-3009.
Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

  • Of the 6,095 total blood culture sets obtained, 667 (10.94%) were positive and 238 (3.90%) were contaminated.
  • Of the 3,130 blood cultures obtained using IT, 340 (10.86%) were positive and 123 (3.93%) were contaminated. Of the 2,965 blood cultures obtained using CHG, 327 (11.03%) were positive, and 115 (3.88%) were contaminated.
  • The rates of contaminated blood cultures between the two antiseptic agents were not different statistically.

Septimus EJ, Hayden MK, Kleinman K, Avery TR, Moody J, Weinstein RA, Hickok J, Lankiewicz J, Gombosev A, Haffenreffer K, Kaganov RE, Jernigan JA, Perlin JB, Platt R, Huang SS. Does chlorhexidine bathing in adult intensive care units reduce blood culture contamination? A pragmatic cluster-randomized trial. Infect Control Hosp Epidemiol. 2014 Oct; 35 Suppl 3: S17-22.
Hospital Corporation of America, Nashville, Tennessee.

  • Universal decolonization with CHG bathing resulted in a significant reduction in blood culture contamination.

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Washer LL, Chenoweth C, Kim HW, Rogers MA, Malani AN, Riddell J 4th, Kuhn L, Noeyack B Jr, Neusius H, Newton DW, Saint S, Flanders SA. Blood culture contamination: a randomized trial evaluating the comparative effectiveness of 3 skin antiseptic interventions. Infect Control Hosp Epidemiol. 2013 Jan;34(1):15-21.
University of Michigan Health System

  • The overall blood culture contamination rate for the study population was 0.76%.
  • Intent-to-treat rates of contaminated blood cultures were not significantly different among the 3 antiseptics.

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Marlowe L, Mistry RD, Coffin S, Leckerman KH, McGowan KL, Dai D, Bell LM, Zaoutis T. Blood culture contamination rates after skin antisepsis with chlorhexidine gluconate versus povidone-iodine in a pediatric emergency department. Infect Control Hosp Epidemiol. 2010 Feb;31(2):171-6.
University of Pennsylvania School of Medicine, Philadelphia, USA.

  • The blood culture contamination rate decreased from 24.81 to 17.19 contaminated cultures per 1,000 cultures after implementation of chlorhexidine, a 30% relative decrease.
  • Skin antisepsis with chlorhexidine significantly reduces the blood culture contamination rate among young children, as compared with povidone-iodine.

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