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Follow-Up Blood Cultures: When Should We Do It? · The SHEA Podcast

• 0:08
  SPEAKER_02: Welcome to the Impact of Blood Culture Practices on Antibiotic Stewardship and HAI Surveillance and Management Podcast Series, brought to you by the Society for Healthcare Epidemiology of America, Jay, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:32
  SPEAKER_02: I am Hana Wenders in an ambulatory antimicrobial stewardship from a citizen prism and health middle end, and I will serve as today's moderator.
• 0:40
  SPEAKER_02: Today is excited to launch this podcast where we will discuss the controversy surrounding follow-up blood cultures after initial bacteria episodes.
• 0:49
  SPEAKER_02: Mulential in some cases, like staff oriented and candidate infections, their utility is uncertain in others.
• 0:56
  SPEAKER_02: The frequency of obtaining blood cultures and the role in scenarios like leukocytosis and fevers will be explored.
• 1:03
  SPEAKER_02: I'm happy to introduce our speakers for today.
• 1:06
  SPEAKER_02: First, we have Dr.
• 1:07
  SPEAKER_02: Thayden.
• 1:08
  SPEAKER_02: Dr.
• 1:09
  SPEAKER_02: Taden is an assistant professor in the Duke University Division of Infectious Diseases.
• 1:14
  SPEAKER_02: His primary areas of research involve pathogenesis and epidemiology and management of gram-negative bloodstream infections.
• 1:24
  SPEAKER_02: And finally, we have Rachel Wattier.
• 1:27
  SPEAKER_02: Dr.
• 1:27
  SPEAKER_02: Wattier is a pediatric infectious diseases and antibiotic stewardship physician at the University of California, San Francisco, who she conducts research to improve judicious use of diagnostic tests and antibiotics and to advance the practice of pediatric antibiotic stewardship.
• 1:45
  SPEAKER_01: Hello, thank you for having me.
• 1:47
  SPEAKER_02: Thank you both for joining us.
• 1:49
  SPEAKER_02: Our first question for today is do you consider that follow-up blood cultures are standard of care after an initial positive blood culture?
• 1:58
  SPEAKER_02: And what evidence is there to support that consideration?
• 2:01
  SPEAKER_02: In your answer, if you could comment on what the role of obtaining repeat blood cultures specifically in gram-negative infections is.
• 2:10
  SPEAKER_02: Rachel, why don't you go first?
• 2:12
  SPEAKER_01: So I think this is a common practice, but it would be hard to say that there is a universal standard of care.
• 2:18
  SPEAKER_01: And it is very situation dependent in that we have more evidence for certain types of bloodstream infections than for others.
• 2:26
  SPEAKER_01: And that there's also a lot of controversy in particular situations.
• 2:31
  SPEAKER_01: So I'll I'll just talk through sort of my logic and how I approach the situation in my consult practice.
• 2:37
  SPEAKER_01: And I think the main question is is there information that I'm going to gain from this culture that will change what I recommend for the patient in a way that's going to benefit from them?
• 2:48
  SPEAKER_01: And that means really better cure or likelihood of recovery from the infection or some other component of their management will be benefited by this information.
• 2:58
  SPEAKER_01: So I think in part that's going to depend on the tendency of the particular organism to cause persistent bacteria fungemia.
• 3:07
  SPEAKER_01: So we know in the example of Staph aureus in Canada that these organisms have a greater tendency to persist and are harder to clear.
• 3:15
  SPEAKER_01: And so a lot of the evidence around follow-up blood cultures in these infections is related to things that we do, for example, removing central venous catheters, doing source control interventions, more diagnostic studies to figure out if there is a source that should be addressed.
• 3:32
  SPEAKER_01: And so I think that's really how I think about this question related to other situations too, in that some infections, we know, for example, in children who are otherwise healthy and have bacteremia due to streptococcus pneumonia, that that does not tend to be persistent.
• 3:49
  SPEAKER_01: And so we're not as likely to get as much information that would change the patient's management.
• 3:54
  SPEAKER_01: Another issue that I think about is patient-specific risk factors.
• 3:57
  SPEAKER_01: So apart from the organism, does this patient in particular have reasons that they might have a more persistent or complicated bloodstream infection?
• 4:06
  SPEAKER_01: For example, having vascular prosthetic material or being immunocompromised.
• 4:11
  SPEAKER_01: And then I'm thinking about potential source control interventions that I might be able to do if I find that there is persistent bacteremia.
• 4:21
  SPEAKER_01: And then I think there are other situations in which doing a fallout blood culture could help to resolve some diagnostic uncertainty.
• 4:28
  SPEAKER_01: So, for example, if a patient has a central venous catheter and we're dealing with an organism that is a common commensal and that it may be a cause of a bloodstream infection, but it could also simply be a contaminant.
• 4:41
  SPEAKER_01: I think it can be helpful to get a fallout blood culture in those situations.
• 4:45
  SPEAKER_01: So for gram-negative infections, I'll defer to Josh because I know that there is diverging evidence in different studies.
• 4:52
  SPEAKER_01: And I think that's not surprising because there's a lot of heterogeneity in this group of infections.
• 4:57
  SPEAKER_01: But what I generally do is I apply that framework and thinking about is it an organism that has a greater tendency to persist and are there host factors?
• 5:07
  SPEAKER_01: So for example, I care for many patients who are going through cancer therapy or stem cell transplantation and have gram-negative bacteremias in the setting of central venous catheters, that sometimes we want to try to salvage those catheters, that it's really not in the patient's best interest to remove the catheter right then.
• 5:23
  SPEAKER_01: But if they had persistent bacteremia, we would remove the catheter.
• 5:27
  SPEAKER_01: So that's a situation that I would get a follow-up blood culture.
• 5:30
  SPEAKER_01: And for organisms in particular like Pseudomonas that have a greater tendency to persist and other glucose non-fermenters, I would generally do more follow-up blood cultures.
• 5:40
  SPEAKER_01: But in patients who are clinically doing well, have an uncomplicated gram-negative bacteremia with a typical organism from a urinary source, I tend not to recommend fallout blood cultures in that situation.
• 5:53
  SPEAKER_00: I agree with Rachel.
• 5:55
  SPEAKER_00: You know, in patients with gram-negative bloodstream infections, the short answer is I don't think that all patients necessarily need follow-up blood cultures.
• 6:03
  SPEAKER_00: However, in some patients, it's quite important to get follow-up blood cultures.
• 6:07
  SPEAKER_00: We and others have shown that in patients with gram-negative bloodstream infection, obtaining follow-up blood cultures is associated with decreased mortality.
• 6:14
  SPEAKER_00: And in fact, we and others have published some systematic reviews and meta-analyses showing an association between getting follow-up blood cultures and decreased mortality.
• 6:24
  SPEAKER_00: So it's an interesting finding, but what do you do with this information?
• 6:27
  SPEAKER_00: You know, does it mean that every single patient with gram-negative bloodstream infection needs a follow-up blood culture?
• 6:33
  SPEAKER_00: Well, probably not.
• 6:33
  SPEAKER_00: You know, surely there are patients, like Rachel mentioned, that are less complicated, who are otherwise healthy and responding well to therapy that do not need a follow-up blood culture.
• 6:43
  SPEAKER_00: Just to take a step back for a moment, it's fair to ask why we'd want to get a follow-up blood culture in the first place.
• 6:49
  SPEAKER_00: And in my opinion, it's just the same as what Rachel was mentioning.
• 6:52
  SPEAKER_00: The key point is that follow-up blood cultures allow you to identify patients with persistent bacteremia.
• 6:58
  SPEAKER_00: And so persistent bacteremia is a marker of complicated infection and it's been associated with bad outcomes.
• 7:04
  SPEAKER_00: You know, multiple studies, including multiple systematic reviews and meta-analyses, have shown that patients with persistent gram-negative bacteremia have increased mortality relative to patients with non-persistent infection.
• 7:16
  SPEAKER_00: But persistent bacteria has also been associated with other poor outcomes as well.
• 7:20
  SPEAKER_00: For example, we recently showed that patients with persistent gram-negative bloodstream infection are at increased risk of later recurrent bacteria.
• 7:29
  SPEAKER_00: That's with this exact same species in strain.
• 7:32
  SPEAKER_00: There's also been other studies that have shown that persistent bacteremia, it's essentially persistence as defined by uh persistent microbial DNA as opposed to cultures is associated with an increased risk of metastatic infection.
• 7:44
  SPEAKER_00: So, all in all, persistent bacteremia has been linked to multiple poor outcomes.
• 7:48
  SPEAKER_00: And I think it's helpful to identify these patients with complicated infections as early as possible, because they may have some issues with source control or antibiotic therapy that need to be corrected.
• 7:58
  SPEAKER_00: But clearly, though, not all patients are at equal risk of persistent bacteremia.
• 8:02
  SPEAKER_00: And given that follow blood cultures can have some negative side effects, such as potentially prolonging hospital stay, potentially complicating therapy if the fallout blood culture has a contaminant, I think it makes most sense to get followed blood cultures in patients who are at higher risk of a persistent bacteremia and then potentially forego them in patients who are at lower risk of persistent bacteremia.
• 8:22
  SPEAKER_02: Is there any data available to help guide how frequent blood cultures should be obtained in those situations that they are warranted?
• 8:30
  SPEAKER_02: And should they be repeated until a negative culture is obtained?
• 8:34
  SPEAKER_02: Josh?
• 8:34
  SPEAKER_00: So again, ultimately the goal is to identify patients with persistent bacteria.
• 8:39
  SPEAKER_00: This is associated with poor clinical outcomes.
• 8:42
  SPEAKER_00: Uh, and so patients at low risk of persistent bacteria don't necessarily need them.
• 8:46
  SPEAKER_00: But how do we know who does and who does not need them?
• 8:49
  SPEAKER_00: Well, there are multiple scoring systems that have been developed to essentially stratify patients in regard to their risks for persistent gram-negative bacteremia.
• 8:58
  SPEAKER_00: So, for example, a group from Italy, from the University of Bologna, last year published a systematic review and meta-analysis of papers that addressed factors that increase the risk of persistent bacteria.
• 9:11
  SPEAKER_00: And so they published a scoring system that included things like ESBL positive infections, unfavorable clinical response, end-stage renal disease, presence of central venous catheter, and in inappropriate antibiotic therapy as risk factors for persistent bacteremia.
• 9:28
  SPEAKER_00: Our group at EdukeCare also developed a scoring system that was published a couple of years ago in Clinical Microbiology and Infection.
• 9:35
  SPEAKER_00: Our scoring system is called AIMS, which is an acronym, where A is for antibiotics, as delayed appropriate antibiotic therapy increases risk of persistence.
• 9:45
  SPEAKER_00: I is for infection source, as specific sources such as endovascular infection and gastrointestinal infection increase risk of persistence.
• 9:54
  SPEAKER_00: M is for medical comorbidities.
• 9:56
  SPEAKER_00: Conditions such as hemodialysis dependence, cardiac device, and recent steroid use all increase the risk of persistent bacteremia.
• 10:04
  SPEAKER_00: And S is for species as serration bacteremia was associated with increased risk of persistence.
• 10:10
  SPEAKER_00: And there are other scoring systems as well.
• 10:12
  SPEAKER_00: The benefit of these kind of scoring systems are that they can be used to stratify patients by risk of persistent bacteremia, and they can ultimately help you decide whether or not a patient needs follow-up blood cultures.
• 10:24
  SPEAKER_00: So, for example, patients with positive scores in these systems, you know, personally, I think it would be a good idea to get follow-up blood cultures.
• 10:30
  SPEAKER_00: And if they're positive, I personally would continue to perform that until they are negative.
• 10:36
  SPEAKER_00: Because presumably there's a reason that the patient has persistent bacteria.
• 10:40
  SPEAKER_00: Is it an antibiotic issue?
• 10:42
  SPEAKER_00: Is it a source control issue?
• 10:43
  SPEAKER_00: And it would just be nice to know you had corrected that issue before setting the patient home.
• 10:48
  SPEAKER_02: Rachel, do you have anything to add on that one?
• 10:50
  SPEAKER_01: Yeah, I think those are great points.
• 10:52
  SPEAKER_01: I will say in pediatric infectious diseases, our uh evidence base tends to be less robust.
• 10:58
  SPEAKER_01: So unfortunately, we don't have great scoring systems or risk stratification for determining, you know, which patients should have repeat blood cultures.
• 11:08
  SPEAKER_01: But in terms of just the frequency, the number, quantity of repeat cultures, I think this is situation dependent.
• 11:15
  SPEAKER_01: And this is something that's very hard to answer with observational data because we really only know the results of the cultures according to the frequency that they were done.
• 11:26
  SPEAKER_01: And, you know, I I've done um research on doing blood cultures daily.
• 11:30
  SPEAKER_01: And, you know, the the challenge is we we know what we found when we did blood cultures daily, but we don't know the counterfactual of what we would have found if we had not done them daily.
• 11:41
  SPEAKER_01: So I think that's just a limitation to acknowledge that we we may have a hard time getting around.
• 11:47
  SPEAKER_01: But on the principle that we're doing the blood cultures to gain information that we hope will benefit the patient, we should repeat them until we have sufficient information that we've met our microbiologic endpoint.
• 12:01
  SPEAKER_01: And then we should stop.
• 12:02
  SPEAKER_01: Now, I think the microbiologic endpoint, of course, is to clear the infection.
• 12:07
  SPEAKER_01: And I think this is a little bit hard because some infections, like Staph aureus in Canada, can have intermittent bloodstream infection.
• 12:15
  SPEAKER_01: So you might not always detect bacteremia each time you culture, but you might detect it on maybe like every other day.
• 12:22
  SPEAKER_01: So that can be a little hard.
• 12:24
  SPEAKER_01: And you think there is some data to suggest with Staph aureus that you probably want at least two uh days of negative cultures.
• 12:31
  SPEAKER_01: But for other situations, and particularly situations where the patient is doing well and you believe that you've obtained source control, it's probably sufficient just to do one follow-up blood culture and um then stop if that's negative.
• 12:44
  SPEAKER_01: I think the other thing to say is that the follow-up blood culture alone will not change the patient's outcome, that you really do have to respond to that information and be exploring source control interventions that can help to clear that infection.
• 12:59
  SPEAKER_02: So when should we actually discourage follow-up blood cultures?
• 13:04
  SPEAKER_01: I think there are many harms of blood cultures.
• 13:08
  SPEAKER_01: And these are well described both in patients, primarily in patients who don't have bacteremia or other bloodstream infections, but I think these also apply to patients who have had a bloodstream infection, and then you're getting blood cultures that are not giving you further information to benefit that patient.
• 13:25
  SPEAKER_01: And these include identifying false positive results.
• 13:28
  SPEAKER_01: And half of all positive blood cultures are falsely positive, in that they're recovering commensal organisms that were not present in the patient's bloodstream and causing their infection, and they're actually just being picked up from the skin or the environment.
• 13:43
  SPEAKER_01: And these lead to more blood cultures, more antibiotics, often longer hospital stays, and more hospital costs.
• 13:50
  SPEAKER_01: And then there are other issues.
• 13:52
  SPEAKER_01: So depending on how at your institution cultures are collected from central venous catheters, these fault blood cultures actually might be collected in a different way than routine lab tests.
• 14:05
  SPEAKER_01: And they might actually lead to more exposure of that central venous catheter to contamination.
• 14:11
  SPEAKER_01: So introducing new contamination events that lead to future bloodstream infections.
• 14:16
  SPEAKER_01: And I think that's not widely recognized, but important to say and important to know how blood cultures are collected from central venous catheters at your institution so that you can think about that in terms of blood culture practice.
• 14:29
  SPEAKER_01: If you think about the quantity of blood that is drawn for these blood cultures and often the number of bottles, and in particular, if patients have multiple central venous catheter lumens and they're receiving multiple cultures from each of those lumens, it can actually add up to quite a lot of blood volume, such that if your patient, say, is already anemic or receiving transfusions, that they might actually need additional transfusion units due to the amount of blood that's being drawn in repeat blood cultures.
• 14:58
  SPEAKER_01: And then I think also to add, if your cultures are drawn peripherally, it's just painful to collect them and that we should be thinking about how to minimize pain and distress and any unnecessary lab draws that we're doing.
• 15:09
  SPEAKER_00: So certainly in general, just we can follow blood cultures in particular, they are going to be less helpful in patients who are in generally lower risk of persistent bacteremia.
• 15:20
  SPEAKER_00: So if you're using one of these scoring systems I mentioned earlier, so these are patients who would score zero.
• 15:25
  SPEAKER_00: So these are patients who are just less complex.
• 15:28
  SPEAKER_00: You know, they are patients who have responded well to therapy, who are immunocompetent.
• 15:32
  SPEAKER_00: You know, they don't have any indwelling hardware such as lines or pacemakers.
• 15:36
  SPEAKER_00: They're ephebrile feeling better, they don't have highly antibiotic resistant infections.
• 15:42
  SPEAKER_00: In these patients, follow-up blood cultures have less value and perhaps can complicate matters by potentially, as Rachel mentioned, lengthening hospital stay and uh lengthening the course of antibiotics.
• 15:53
  SPEAKER_00: And of course, followed blood cultures can potentially lead to false positive results that can complicate therapy, you know, because if you get a follow-up blood culture and it grows a quad negative staff, well, well, what do you do with this information?
• 16:04
  SPEAKER_00: Do you treat it?
• 16:05
  SPEAKER_00: Do you not?
• 16:06
  SPEAKER_00: Do you get more follow-up blood cultures?
• 16:08
  SPEAKER_00: So in these settings, it's probably not necessary and probably should be discouraged to get to get followed blood cultures.
• 16:14
  SPEAKER_02: So switching gears a little bit, are repeat blood cultures necessary in persistent fever, for example, with neutropenic fever or leukocytosis despite previous negative blood cultures.
• 16:27
  SPEAKER_02: And in that same vein, are initial blood cultures warranted in isolated fever or leukocytosis?
• 16:35
  SPEAKER_02: Josh, you want to go first?
• 16:37
  SPEAKER_00: Well, if a patient has persistent fever, then that certainly warrants a set of blood cultures.
• 16:42
  SPEAKER_00: Though ongoing blood cultures, kind of serial blood cultures, are probably not helpful unless there's been a change in the patient's clinical status, like new sepsis, for example.
• 16:53
  SPEAKER_00: Uh I'm not aware of any data that supports kind of serial blood cultures in this setting.
• 17:00
  SPEAKER_00: And then some of the other scenarios that you that you mentioned, things like isolated fever, isolated leukocytosis, are also associated with low rates of bacteremia, even less than 5% in some studies.
• 17:13
  SPEAKER_00: So I think in these settings it's very reasonable to not get followed blood cultures.
• 17:18
  SPEAKER_00: And there are other clinical scenarios as well where blood cultures are probably not super helpful, like uncomplicated cellulitis, perhaps uncomplicated UTI in a hospitalized patient, and even non-severe pneumonia.
• 17:31
  SPEAKER_00: You know, blood cultures are often not positive in these settings and so probably should not be uh obtained.
• 17:37
  SPEAKER_01: I think similar to Josh, it's it's really very dependent on the pretest probability of having a bloodstream infection.
• 17:47
  SPEAKER_01: And then that's when you're thinking about up front, should I even collect a blood culture at all?
• 17:52
  SPEAKER_01: There are many scenarios in which the pretest probability of bloodstream infection is very low, despite a patient having fever or leukocytosis.
• 18:01
  SPEAKER_01: And you know, here most children who are evaluated for fevers are evaluated in ambulatory settings and clearly don't need blood cultures routinely.
• 18:09
  SPEAKER_01: There are a few situations, such as very young infants or patients who have risk factors like immunocompromised status, in which blood cultures are warranted because there is a high pretest probability of bloodstream infection.
• 18:23
  SPEAKER_01: But then if you're thinking about repeat blood cultures for those particular patients, the question becomes okay, so what's the conditional probability that they will have a bloodstream infection identified if they did not have one identified on their initial cultures and in many cases are now receiving empiric antibiotic therapy.
• 18:42
  SPEAKER_01: And this is quite low in a study that I did back in 2015 in patients who are receiving cancer therapy or transplantation and had persistent fevers.
• 18:53
  SPEAKER_01: Really, the predominant yield of bloodstream infections is in that first day when blood cultures are first collected.
• 19:00
  SPEAKER_01: And then subsequently, for each ongoing day of fever, which can be quite prolonged, there was an equivalent probability of identifying either a new positive bloodstream infection that wasn't identified on that initial culture and a contaminant.
• 19:15
  SPEAKER_01: And we discussed the harms of contaminants.
• 19:18
  SPEAKER_01: The difficult thing is that, you know, I think these are patients with a very uh high risk for subsequent bloodstream infections for various reasons.
• 19:27
  SPEAKER_01: And we can't say that the probability of breakthrough bloodstream infection with a new organism is absolutely zero.
• 19:34
  SPEAKER_01: So I think there are situations where we need to think about repeating blood cultures in a patient who has had them and they were negative.
• 19:41
  SPEAKER_01: And the main factors that I identified in that study and that have been reported in other situations are there's an important change in the patient's clinical status, such as new clinical instability, as Josh mentioned.
• 19:56
  SPEAKER_01: I think if there's something very different in the way that the patient's illness is progressing, and in particular, situations where you're considering broadening antibiotic therapy, it should definitely repeat blood cultures.
• 20:07
  SPEAKER_01: And then otherwise, there are patients who have very intermittent fevers where they don't really meet a definition of defervesing, but they have maybe one fever a day.
• 20:17
  SPEAKER_01: The longer between those intermittent fevers, we did find that there was more yield in blood cultures that were done if the fevers had spaced out and then started happening again.
• 20:28
  SPEAKER_01: Otherwise, I think it's a judgment call in many situations.
• 20:31
  SPEAKER_01: What we've moved to in our pediatric oncology and stem cell transplant units is to try to do cultures every 48 hours in patients who are having persistent fever with neutropenia, but we do include some conditions for changing clinical status, new evidence of focal infection, desire to broaden their antibiotics.
• 20:52
  SPEAKER_01: So there is some discretion about repeating cultures.
• 20:55
  SPEAKER_01: And then I also want to add in pediatric critical care units, there's a project called the Bright Star Collaborative.
• 21:02
  SPEAKER_01: And that group has published consensus guidelines on when blood cultures should be collected in patients who are in critical care units.
• 21:10
  SPEAKER_01: And those are very helpful guidelines because quite honestly, we don't always have great evidence to inform what we should do.
• 21:16
  SPEAKER_01: And a lot of these decisions are made based on consensus.
• 21:20
  SPEAKER_01: But I think one of the most valuable parts of those guidelines is that blood culture should not be done before the patient is examined and before there's a discussion with the patient's nurse.
• 21:31
  SPEAKER_01: So I think we gain a lot of valuable information from those observations and discussions that might actually change our thinking about the need for repeating blood cultures.
• 21:40
  SPEAKER_02: Those are some great points.
• 21:41
  SPEAKER_02: Thank you for that insight.
• 21:43
  SPEAKER_02: The last one we have today is what training should those personnel collecting blood cultures receive to minimize the risk of contamination.
• 21:53
  SPEAKER_01: I think it's important for our personnel to be supported and empowered to question.
• 22:00
  SPEAKER_01: And clarify whether the blood cultures are necessary.
• 22:03
  SPEAKER_01: And I think this is just part of a general culture of safety and quality, but a lot of our local practice change has been based on nurses actually promoting more judicious practice about the collection of repeat blood cultures and sharing observations of experiences from prior institutions in which they spaced out blood cultures.
• 22:24
  SPEAKER_01: And this has actually been a big part of our CLABC reduction program is trying to balance the need to identify new infections with the potential risk of contamination at the time of collection.
• 22:36
  SPEAKER_01: Otherwise, it's really important to have standardization of practice.
• 22:39
  SPEAKER_01: And a lot of this is locally dependent.
• 22:42
  SPEAKER_01: So I don't want to go into a great amount of detail, but common practices such as not drawing cultures from peripheral devices, like peripheral arterial lines, for example, that have a high risk of being contaminated, applying appropriate hygienic technique at the time of collection and inoculation of the blood cultures into the bottles.
• 23:02
  SPEAKER_01: And then just in general, trying to reduce the number of attempts that are done.
• 23:07
  SPEAKER_01: And there is some evidence that having a dedicated team to collect blood cultures that collects them very frequently can improve or reduce blood culture contamination rates.
• 23:18
  SPEAKER_01: And then I think it is important to track the culture contamination rates.
• 23:22
  SPEAKER_01: And this is something that we've been doing for some time in our emergency departments.
• 23:26
  SPEAKER_01: And that's helpful to identify opportunities to retrain and keeps leadership accountable for potential harm of contamination.
• 23:35
  SPEAKER_00: Yeah, I'd just like to kind of reiterate some of the things that Rachel mentioned.
• 23:39
  SPEAKER_00: I guess I agree with everything.
• 23:40
  SPEAKER_00: You know, so certainly training is an important aspect of minimizing blood culture contamination.
• 23:46
  SPEAKER_00: Truth is a pretty complicated process, and contamination can occur at multiple steps.
• 23:51
  SPEAKER_00: So, of course, providers need to be trained on the process, including hand hygiene, skin antisepsis, blood culture, bottle disinfection, blood culture collection sites, and so on.
• 24:02
  SPEAKER_00: But in addition, I think it's just important to perform surveillance and ongoing feedback for personnel that are drawing blood cultures.
• 24:10
  SPEAKER_00: At my institution, for example, the rate of blood culture contamination is much higher in the emergency room than it is on the inpatient floors.
• 24:18
  SPEAKER_00: And there are many reasons for this.
• 24:20
  SPEAKER_00: In the ED, blood cultures are primarily obtained by ED nurses, and training in ED nurses can be uneven.
• 24:28
  SPEAKER_00: First of all, there's just a higher number of staff, and of course, it's more difficult to train and to assess competency with this higher number of people.
• 24:35
  SPEAKER_00: There's also a high amount of turnover among the ED nurses, and so that can make training more uneven.
• 24:42
  SPEAKER_00: And of course, the ED can often just be a frankly more chaotic place where providers are pulled in in multiple different directions.
• 24:49
  SPEAKER_00: But also there's no system in place to provide feedback to ED providers that have blood culture contamination events.
• 24:56
  SPEAKER_00: However, in contrast to that, on the inpatient floor, we have dedicated phlebotomy personnel.
• 25:02
  SPEAKER_00: So it's a smaller group of people, and training and competency on technique is better.
• 25:08
  SPEAKER_00: They get regular individual feedback on contamination events.
• 25:12
  SPEAKER_00: And uh contamination is actually a metric that they are accountable for as part of their performance reviews.
• 25:19
  SPEAKER_00: And ultimately, they're they're quite proud of their competency because their contamination rates are quite low and they should be proud.
• 25:26
  SPEAKER_00: And as Rachel mentioned, there is a body of literature showing that dedicated phlebotomy services improve contamination rates.
• 25:33
  SPEAKER_00: So, so in total, you know, I think having a dedicated phlebotomy service is helpful, but also to provide these personnel with regular feedback and also consider making contamination rates a formal component of their performance reviews.
• 25:48
  SPEAKER_02: Awesome.
• 25:49
  SPEAKER_02: Well, thank you both for such a fantastic conversation.
• 25:53
  SPEAKER_02: We appreciate you joining us today.
• 25:55
  SPEAKER_01: Thanks.
• 25:56
  SPEAKER_01: That was fun.
• 25:57
  SPEAKER_01: Thank you.
• 25:57
  SPEAKER_01: I really appreciate the opportunity to join you.
• 26:00
  SPEAKER_02: You can find more educational content like this podcast on today's online education center, learning CE, at www.learningce.j-online.org.
• 26:13
  SPEAKER_02: This concludes today's episode of the impact of blood culture practices on antibiotic stewardship and HAI surveillance and management series.
• 26:23
  SPEAKER_02: Thank you for tuning in.