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. 2023 Jun:75:154255.
doi: 10.1016/j.jcrc.2023.154255. Epub 2023 Feb 10.

Assessing a standardized decision-making algorithm for blood culture collection in the intensive care unit

Alana Siev  1 , Elana Levy  2 , Jen-Ting Chen  3 , Inessa Gendlina  4 , Austin Saline  5 , Parry Mendapara  2 , Michelle Ng Gong  6 , Ari Moskowitz  6
Affiliations

Assessing a standardized decision-making algorithm for blood culture collection in the intensive care unit

Alana Siev et al. J Crit Care. 2023 Jun.

Abstract

Purpose: Blood cultures are commonly ordered for patients with low risk of bacteremia. Indications for obtaining blood cultures are often broad and ill defined, and decision algorithms for appropriate blood cultures have not been comprehensively evaluated in critically-ill populations.

Methods: We conducted a retrospective analysis to assess the frequency of inappropriate blood cultures in the ICUs at Montefiore Medical Center based on an evidence-based guidance algorithm. Blood cultures were reviewed against this algorithm to determine their appropriateness. We calculated the prevalence of inappropriate blood culture and explored the reasons for these collected cultures.

Results: 300 patients were randomly selected from an initial cohort of 3370 patients. 294 patients were included and of these, 167 patients had at least 1 blood culture drawn. 125 patients had one or more inappropriate blood culture. 61.4% of blood cultures drawn were assessed to be inappropriate. The most common reason for inappropriate cultures was a culture drawn as a result of isolated fever or leukocytosis.

Conclusion: In a cohort of critically-ill patients, inappropriate blood cultures were common. The indications for blood cultures are often not evidence-based, and evidence-based algorithms to guide the collection of blood cultures may offer a way to decrease inappropriate culture orders.

Keywords: Blood cultures; Fever workup; ICU; Inappropriate cultures; Intensive care.

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Conflict of interest statement

Declaration of Competing Interest The authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1:
Figure 1:. Algorithm for bacterial blood cultures recommendations in nonneutropenic patients
The algorithm is not a substitute for clinical judgment. *Blood culture (BCx) required by US Centers for Medicare and Medicaid Services severe sepsis criteria of the Severe Sepsis and Septic Shock Early Management Bundle. †BCx positive for Candida species require routine follow-up blood culture (FUBCx). ‡Septic thrombophlebitis, infected endovascular thrombi, implantable cardioverter defibrillator (ICD)/pacemaker lead infections, intravascular catheter infections, and vascular graft infections. §Consider > 2 sets for suspected endocarditis. ||Patients at risk of endovascular infection: ICD/pacemaker, vascular graft, prosthetic valves and prosthetic material used for cardiac valve repair, history of infective endocarditis, valvulopathy in heart transplant recipient, unrepaired congenital heart disease, repaired congenital heart disease with residual shunt or valvular regurgitation, or within the first 6 months postrepair. ¶Before ordering BCx, assess the patient’s clinical history and perform a physical examination to identify infectious and noninfectious sources for the isolated fever episode and review the potential benefit added by BCx. £Prosthesis: joint or intravascular prosthesis. **Routine additional FUBCx for a single BCx with skin flora (eg, coagulasenegative staphylococci) in an immunocompetent patient are not necessary unless bacteremia is suspected or a prosthesis is present. ††Cellulitis in patients with comorbidities: immunocompromised hosts or those at risk of poor outcomes from sequelae from missed Staphylococcus aureus bacteremia. Abbreviations: BCx, blood culture; CAP, community-acquired pneumonia; HCAP, healthcare-associated pneumonia; PSI, Pneumonia Severity Index; S. aureus, Staphylococcus aureus; S. lugdunensis, Staphylococcus lugdunensis; UTI, urinary tract infection; VAP, ventilator-associated pneumonia; VO, vertebral osteomyelitis. [2]
Figure 2:
Figure 2:. Cohort selection
Figure 3:
Figure 3:. Pareto chart detailing reasons for inappropriate blood culture collection
See this image and copyright information in PMC

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