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2001 Copyright © 2001, American Society for Microbiology. All Rights Reserved.
Vol. 39, No. 6
Three Days of Incubation May Be Sufﬁcient for Routine Blood Cultures with BacT/Alert FAN Blood Culture Bottles
PAUL P. BOURBEAU*
JANICE K. POHLMAN†
Geisinger Medical Center, Danville, Pennsylvania
Received 12 January 2001/Returned for modiﬁcation 22 February 2001/Accepted 27 March 2001
BacT/Alert FAN blood culture bottles have been shown to enhance the recovery of bacteria and yeast from blood compared with standard BacT/Alert bottles. It is well established that standard BacT/Alert blood culture bottles require no more than 5 days of incubation for the detection of routine bacteria and yeast. It is less clear, however, whether FAN bottles also routinely require 5 days of incubation. To address this question, we recently reviewed the results of 17,887 blood culture sets collected in FAN blood culture bottles at Geisinger Medical Center. Of these cultures, 1,780 were positive for bacteria or yeast, yielding a total of 1,242 clinically signiﬁcant isolates. The numbers of isolates recovered on days 1, 2, 3, 4, and 5 were as follows: (values in parentheses are percentages of total signiﬁcant isolates): 877 (71%), 269 (22%), 65 (5%), 18 (1%) and, 13 (1%), respectively. In total, 97.5% of all clinically signiﬁcant isolates were detected in the ﬁrst 3 days of incubation. Of the 31 signiﬁcant isolates detected on day 4 or 5 of incubation, 17 were detected in concurrent blood cultures within the ﬁrst 3 days of incubation. Chart reviews were conducted for the 13 patients with the remaining 14 isolates detected on day 4 or 5 to determine whether therapy was changed due to this blood culture result. Therapy was changed for only 1 patient. These results suggest that it may not be necessary to routinely incubate FAN blood culture bottles for more than 3 days. When the continuous-monitoring automated blood culture instruments were ﬁrst introduced, 6- or 7-day incubation periods were generally utilized. It became established over time that no more than 5 days of incubation were required for these systems, and indeed regulatory agencies generally now require 5-day minimum incubation periods. There have been recent reports that 5 days of incubation may not be required for BacT/Alert FAN blood culture bottles (1, 2) or for other automated blood culture systems (3, 5, 7). The purpose of this study was to determine the time to detection for clinically signiﬁcant isolates of bacteria and yeast in our laboratory when both a FAN aerobic bottle and FAN anaerobic bottle were used for routine blood cultures.
MATERIALS AND METHODS BacT/Alert FAN blood culture bottles (Organon Teknika Corp., Durham, N.C.) replaced standard BacT/Alert blood culture bottles for all routine blood cultures at Geisinger Medical Center (Danville, Pa.) in May 1997. With the exception of some pediatric blood cultures collected using Pedi-Bacti bottles and occasional “straggler” standard blood culture bottles, all blood cultures since that date have been collected with FAN bottles. Except for occasional cultures collected with only a single FAN aerobic bottle, sets were collected with both a FAN aerobic bottle and a FAN anaerobic bottle. Phlebotomists are instructed to collect 10 ml for each bottle from all patients weighing 25 kg or more. Smaller volumes are collected from patients weighing Ͻ25 kg according to guidelines published by the laboratory. Volumes were not veriﬁed for any of the blood culture sets reviewed in this study. We retrospectively reviewed the results of 17,887 consecutive blood culture sets collected in FAN bottles. Isolates were judged to be clinically signiﬁcant or probable contaminants by infection control personnel using Geisinger Medical Center infection control standards, which are based on published, external standards (4). The ﬁrst positive bottle in a set was used to calculate the time to positivity for that set. When two or more organisms were detected from one bottle, the time that the instrument signaled a positive result was used as the time to positivity for all organisms from that bottle. When a different organism was detected in the paired bottle, the time that the instrument signaled a positive result for the paired bottle was used as the time to positivity for the additional organism. If a patient had a clinically signiﬁcant blood culture isolate that was ﬁrst detected on day 4 or 5 of incubation and the patient did not have a concurrent blood culture with the same isolate detected within the ﬁrst 3 days of incubation, the patient’s medical record was reviewed. All medical record review was done by one of us (J.K.P.), an infectious-diseases clinician. This purpose of this review was to determine whether the patient’s antimicrobial therapy or overall management was altered based on a positive blood culture result.
RESULTS Overall, 1,780 cultures were positive for 1,800 bacterial or yeast isolates, including 1,242 clinically signiﬁcant isolates and 558 probable contaminants (Table 1). A total of 1,211 of the 1,242 clinically signiﬁcant isolates were recovered in a least one bottle in a set within the ﬁrst 3 days of incubation. Of the remaining 31 isolates, 17 were recovered in concurrent blood cultures within the ﬁrst 3 days of incubation. Nine signiﬁcant isolates were recovered on day 4 of incubation. These included single isolates of Pseudomonas aeruginosa, Staphylococcus aureus, Enterobacter cloacae, Klebsiella pneumoniae, an unidentiﬁed non-lactose-fermenting gram-negative bacillus (GNB), an unidentiﬁed anaerobic GNB, and three anaerobic gram-positive cocci (two from the same patient, recovered from separate cultures). A chart review for each of these eight patients revealed that no changes in antimicrobial therapy were made as a result of any of these positive blood cultures. None of these eight patients expired during this septic episode. Five signiﬁcant isolates were recovered on day 5 of incubation. These included single isolates of Cryptococcus neofor2079
* Corresponding author. Mailing address: Division of Laboratory Medicine, Geisinger Medical Center, Danville, PA 17822-0131. Phone: (570) 271-7467. Fax: (570) 271-6105. E-mail: pbourbeau@geisinger .edu. † Present address: FDA Center for Drug Evaluation and Research, Rockville, MD 20857.
2080 BOURBEAU AND POHLMAN J. Serratia marcescens Other GNB Acinetobacter anitratus Aeromonas sp. Pseudomonas aeruginosa Bacteroides sp.242 438 26 42 20 15 1 1 2 5 8 558 . aureus Micrococcus sp. MICROBIOL. Stenotrophomonas maltophilia Yeasts Candida albicans Candida glabrata Candida krusei Candida parapsilosis Candida tropicalis Cryptococcus neoformans Anaerobes Bacteroides fragilis group Fusobacterium nucleatum Anaerobic GNB Clostridium sp. not S. Haemophilus inﬂuenzae Neisseria meningitidis Oxidase-positive GNB Pasteurella multocida Pseudomonas aeruginosa Pseudomonas ﬂuorescens gp. Anaerobic gram-positive cocci Anaerobic gram-positive bacilli Total 219 76 37 46 27 39 2 2 2 9 4 20 200 2 12 41 5 22 3 5 11 5 2 0 1 2 2 2 4 4 39 0 5 7 0 0 0 2 0 7 0 0 9 2 877 (71) 185 3 22 15 0 0 1 0 0 1 227 (41) 71 64 0 1 7 8 1 0 0 2 1 0 16 0 0 6 1 6 0 3 3 0 0 2 0 0 2 0 1 0 4 1 1 7 3 1 10 5 0 34 1 3 1 3 269 (22) 206 15 13 4 7 1 0 1 2 0 249 (45) 24 10 0 1 4 3 1 1 0 0 0 0 3 0 0 4 1 1 0 0 2 0 0 1 0 0 0 0 0 0 1 0 0 0 2 0 0 0 2 3 0 1 0 0 65 (5) 30 3 3 1 6 0 0 1 1 0 45 (8) 3 1 0 0 0 1 0 0 0 0 0 1 2 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 2 0 1 1 3 18 (1) 9 1 4 0 1 0 0 0 0 1 16 (3) 4 1 0 0 0 2 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 2 1 13 (1) 8 4 0 0 1 0 0 0 2 6 21 (4) 321 152 37 48 38 53 4 3 2 11 5 21 221 2 12 53 7 29 3 8 16 5 2 3 1 2 4 2 6 4 45 1 6 14 5 1 10 7 3 46 2 5 13 9 1. Aerobic gram-positive cocci Bacillus sp. TABLE 1. Cardiobacterium hominis Chryseomonas luteola Flavobacterium sp. CLIN. Aerobic gram-positive bacilli Neisseria sp. Anaerobic gram-positive cocci Total Probable contaminants Staphylococcus sp. aureus Streptococcus pneumoniae Beta-hemolytic streptococci Other streptococci Enterococci Aerobic gram-positive bacilli Enterobacteriaceae Citrobacter freundii Citrobacter koseri Enterobacter aerogenes Enterobacter agglomerans Enterobacter cloacae Escherichia coli Hafnia alvei Klebsiella oxytoca Klebsiella pneumoniae Morganella morganii Proteus mirabilis Providencia stuartii Salmonella sp. (%) of organisms recovered on day: 1 2 3 4 5 Total Signiﬁcant isolates Gram-positive cocci Staphylococcus aureus Staphylococcus sp. Time to recovery of microorganisms from blood cultures with BacT/Alert FAN bottles Organism No. not S.
Based on our experience. When a 5-day incubation protocol was used. In a subsequent study. 39. we recovered 97% of all clinically signiﬁcant bacterial and fungal isolates within the ﬁrst 3 days of incubation using FAN blood culture bottles. 61 species or groups of bacteria and yeast were included in the 1. Cornish et al. Indeed. (2). care must be taken when trying to compare the performance of different blood culture systems. The patient with the positive blood culture for C.1% of signiﬁcant isolates would have been missed had a 4-day.VOL. Importantly. demonstrated that all clinically signiﬁcant episodes of bloodstream infections were detected within 4 days of incubation when paired FAN aerobic and FAN anaerobic bottles were utilized (2). While it is likely that there are other species of bacteria that may require more than 3 days of incubation for routine detection. we do not monitor the ﬁll volume on a routine basis. In our institution. demonstrated that a BacT/Alert FAN aerobic bottle combined with a BacT/Alert standard anaerobic bottle detected 95% of all clinically signiﬁcant isolates within 3 days of incubation (1). In essence. However. For adults. Cornish et al. the recommended volume is 10 ml in each of the two bottles in a standard set of FAN bottles. Two issues raised by Cornish et al. They stated that 3 days of incubation may be all that is routinely required for blood culture bottles using the AccuMed ESP-384 blood culture system. However. None of these ﬁve patients expired during this septic episode.000 FAN blood culture sets can be analyzed. In our study. however. Should that capacity . In conclusion. the patient was already being treated with amphotericin B. Nonetheless. Enterococcus faecium. suggesting that 5 days of incubation may not be necessary for these systems as well. Beyond that. DISCUSSION When the continuous-monitoring automated blood culture instruments were ﬁrst introduced. The second issue. noted in their study published in 1998 that only blood culture bottles with adequate ﬁll volume (Ͼ8 ml) were included in their analysis (1). neoformans. it became established that no more than 5 days of incubation were required for the BacT/Alert blood culture system when standard BacT/Alert blood culture bottles were used (6. only 0. rather than a 5-day. Reisner and Woods evaluated the time to positivity for blood and sterile-body-ﬂuid cultures with BACTEC 9240 using Plus Aerobic/F and Standard Anaerobic/F bottles (7). it is not clear to us that this was truly a signiﬁcant isolate. unless paired side-by-side studies are conducted. They concluded that 4 days of incubation were adequate for bacteria while 6 days were necessary for yeast. The E. faecium isolate was from one set from a cystic ﬁbrosis patient. which routinely required the ﬁfth day of incubation. and yeasts in comparison to the standard BacT/Alert blood culture bottles. reported that. any study result represents a snapshot in time for a particular blood culture system. were designed to enhance the recovery of fastidious bacteria. they addressed this issue by including all bottles (adequate or inadequate ﬁll volume) and still were able to detect all clinically signiﬁcant episodes of bloodstream infections within 4 days of incubation (2). aureus. the fact remains that this study encompassed all FAN blood culture results for an 18-month period in a tertiary-care medical center. K. we publish recommended ﬁll volumes for blood cultures based on the weights of the patients. In a subsequent study. incubation period been utilized (3). 8). and bottles occur on a routine basis. Similar observations have been made with other automated blood culture systems. no species of bacteria were recovered in either of these studies. Over time. Similar studies have been performed with other automated blood culture systems to determine whether a 5-day incubation period is required for these systems as well. They are the relationship of inadequate or inappropriate ﬁll volumes for blood culture bottles to the time to recovery of organisms and the times to detection for certain fastidious organisms. with the AccuMed ESP blood culture system. the results of over 27.5% of common pathogens were recovered in the ﬁrst 3 days of incubation (5). is more difﬁcult to deﬁnitively address. In our study. S. They raised a concern as to whether bottles with lesser volumes might require longer in- cubation for detection of signiﬁcant isolates. we have demonstrated that 3 days of incubation may be all that is necessary for the detection of routine bacteria and yeast when utilizing BacT/Alert FAN blood culture bottles. Ampicillin was added to the patient’s therapy based on this culture result. 6. Doern et al. Additional studies in other institutions are merited to conﬁrm this observation. we continue to employ a 5-day blood culture incubation protocol. pneumoniae. at the time of the positive blood culture report. merit discussion (1). We and others have asked whether 5 days of incubation are necessary for the FAN blood culture bottles. BacT/Alert FAN blood culture bottles. bacteria from patients receiving antimicrobial therapy. Changes in media. which were introduced at a later time than the standard bottles. our current instrumentation has the capacity to hold bottles for 5 days. 2001 INCUBATION TIME FOR BacT/Alert FAN CULTURE BOTTLES 2081 mans.or 7-day incubation periods were generally utilized. Cornish et al. Han and Truant more recently reported that 95. In our laboratory. the data generated in the study certainly include some bottles with inadequate ﬁll volumes. 97% of signiﬁcant isolates in our study were recovered within 3 days of incubation. there were a total of only 14 clinically signiﬁcant isolates from 13 patients that were recovered on day 4 or 5 of incubation that had not been detected by either a paired bottle from the same set or from a concurrent blood culture. and Fusobacterium nucleatum. The time to recovery of probable contaminants is also listed in Table 1. The CSF culture also grew C. in part due to regulatory requirements. whether certain fastidious species of bacteria may routinely require longer periods of incubation. they transiently vented some of the anaerobic bottles in this study. Thus. Ninety-three percent of probable contaminants were recovered in the ﬁrst 3 days of incubation. such as Actinobacillus actinomycetemcomitans.242 clinically signiﬁcant isolates. For only 1 of these 14 isolates was there any change in antimicrobial therapy based on this positive result. so this study did not utilize the more-traditional aerobic-anaerobic blood culture bottle combination. No change in treatment resulted from the positive cultures from any of the other three patients. When our numbers are combined with those of Cornish et al. software. neoformans also had concurrent testing performed on cerebrospinal ﬂuid (CSF) with a positive cryptococcal antigen test result.
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