Journal of Hospital Infection 87 (2014) 1e10

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Journal of Hospital Infection

journal homepage: www.elsevierhealth.com/journals/jhin

Review

Blood culture contaminants

S. Dawson*
Department of Microbiology, Great Western Hospital, Swindon, UK

A R T I C L E I N F O S U M M A R Y

Article history: Blood cultures are an essential diagnostic tool. However, contamination may impact on
Received 3 October 2013 patients’ care and lead to increased patient stay, additional tests, and inappropriate
Accepted 23 February 2014 antibiotic use. The aim of this study was to review the literature for factors that influence
Available online 26 March 2014 the rate of blood culture contamination. A comprehensive literature search was performed
using Medline and CINAHL on blood culture contamination. Hospitals/units should have in
Keywords: place a protocol for staff on how to take blood cultures, incorporating use of an aseptic
Blood cultures technique. Studies have shown that several key factors in the process may lower
Contamination contamination rates such as adherence to a protocol, sampling by peripheral venepuncture
Cross-infection route rather than via an intravascular catheter, use of sterile gloves, cleaning tops of blood
culture bottles with antiseptics and inoculating blood culture bottles before other blood
tubes, samples being taken by a phlebotomy team, monitoring contamination rates, and
providing individual feedback and retraining for those with contaminants. Although skin
antisepsis is advocated there is still debate on which antiseptic is most effective, as there
is no conclusive evidence, only that there is benefit from alcohol-containing preparations.
In conclusion, hospitals should aim to minimize their blood culture contamination rates.
They should monitor their rate regularly and aim for a rate of
3%.
ª 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Introduction controls, found a significant difference in means between cases

Blood cultures are used in clinical practice to investigate a
suspected systemic infection. Those that grow a true pathogen
can assist clinicians with identifying the cause of the patients’
sepsis and provide antibiotic sensitivities, whereas growth of
contaminants may be detrimental to patients’ care. Contami-
nation results from a number of sources: the patient’s skin; the
equipment used to take the sample and transfer it to the cul-
ture bottle; the hands of the person taking the blood sample; or
the general environment.1 It can lead to clinical misinterpre-
tation and result in extra expense due to increased length of
stay of patients, additional laboratory tests, and use of inap-
propriate antibiotics.2e4 A recent retrospective matched
caseecontrol study, which evaluated 142 false positives and
* Address: Department of Microbiology, Great Western Hospital,
Swindon SN3 6BB, UK. Tel.: þ44 (0) 1793 604800.
E-mail address: Susan.dawson@gwh.nhs.uk.
and controls in relation to total costs [£5,001.5 (US$7,502.2);
95% confidence interval (CI): £3,283.9 ($4,925.8) to £6,719.1
($10,078.6); P < 0.001] and length of hospital stay of 5.4 days
(95% CI: 2.8e8.1; P < 0.001).2 Similarly Gander et al. found a
median $8,720 additional charge for each contaminated event
compared to negative cultures, but in their study the median
length of stay only increased marginally from four days (95% CI:
4e5) to five days (95% CI: 4e7).4
Contaminants can also result in antibiotics being given un-
necessarily.3,5,6 In a multivariate analysis contaminants were
independently correlated with a 39% increase in intravenous
antibiotic charges.3 In their 12-week study, Souvenir et al.
found that antimicrobials were used to treat nearly one-half of
patients with contaminated blood cultures, with vancomycin
being misused in 34% of patients; Lee et al. also noted that 41%
of their pseudobacteraemia cases were unnecessarily treated
with systemic antibiotics, of which glycopeptides accounted
for 20%.5,6 Algorithms have now been developed to assist

0195-6701/$ e see front matter ª 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jhin.2014.02.009
2 S. Dawson / Journal of Hospital Infection 87 (2014) 1e10
clinicians with differentiating pathogens from contaminants in
blood cultures. Weinstein and Doern consider that in addition
to clinical findings (e.g. fever, leucocytosis) the two most
valuable criteria are the identity of the organism and the
number of blood culture sets positive vs number obtained.7 The
time to detection of the positive result and number of bottles
positive in a set are not of value, as there is too much overlap
between true pathogens and contaminants.7 The development
of new, rapid, organism identification techniques such as
matrix-assisted laser desorptioneionization time-of-flight mass
spectrometry and polymerase chain reaction will enable lab-
oratories to speed up the identification of organisms from
blood samples and cultures, thereby limiting misinterpreta-
tion, over-investigation and inappropriate treatment for
contaminants.8,9
Methods
A comprehensive literature search was performed, which
included during December 2013 using Medline and CINAHL to
retrieve papers in English from 1990 onwards using the search
terms ‘blood culture contaminant’ and ‘blood culture
contamination’.
Contamination rates
Variation in rates between hospitals
Reports from NHS Trusts and equipment suppliers suggest
that rates could be as high as 10%.10 However, it is accepted that
the complete elimination of all blood culture contamination is
not feasible, especially in patients where venous access is
difficult and aseptic technique is compromised.11 The Clinical
and Laboratory Standards Institute recommends that an
acceptable range should be
3%.12 Similarly the Department of
Health (England) has suggested that contamination rates should
be <3%.1 Studies have shown that this rate is achievable: in the
Q-Tracks study of the College of American Pathologists, 356
laboratories during their first year of participation had median
rates of 2.89% (interquartile range: 2.15e3.67) which is lower
than this limit.13 In north-west England 12 hospitals have audi-
ted their contamination rate, ranging from 2.1% to 8.2%, and
half of these achieved the 3% benchmark.14
Variation in rates between departments
Contamination rates may vary within different areas of the
hospital. In one Canadian hospital Gibb et al. found that the
rate was highest in the emergency department at 4.1%
compared to 1.8% in all other units combined (P < 0.001).15 It
has been suggested that rapid staff turnover, lack of ongoing
training, workload, and the nature of the presenting patients in
emergency department may contribute to this.16 Recent
studies have demonstrated that overcrowding in emergency
departments can also contribute.17,18 Lee et al. found in their
multivariate analyses that emergency department over-
crowding was independently associated with blood culture
contamination (odds ratio (OR): 1.58; P ¼ 0.04) and similarly
Halverson et al. found that periods of increased crowding were
significantly associated (P < 0.01) with increased rates of
contamination [relative risk (RR): 1.23 compared to least busy
quartile].17,18
Contaminated blood cultures may also be a challenge in
infants and children, particularly in those aged <12
weeks.19e21 Ramsook et al. studied samples taken in a paedi-
atric emergency room, finding that contamination rates were
highest in those aged less than three months at 4.5%, for those
aged three to 36 months at 2.8%, and least in those aged >36
months at 0.9%.20
Variation due to method for classification of
contaminants
Contaminants are defined as a growth of bacteria in the
blood culture bottle that were not present in the patient’s
bloodstream and that were introduced during sample collec-
tion.10 There is no ‘gold standard’ used to classify contami-
nants; some opt for clinical opinion of the significance of the
isolate, whereas others classify them depending on the species
of organism isolated. For example, the Q-Tracks study uses a
definition in which isolates are considered to be contaminants
if one or more of the following organisms were identified in only
one of a series of blood culture specimens: coagulase-negative
staphylococci, Propionibacterium acnes, Micrococcus spp.,
‘viridans’ group streptococci, Corynebacterium spp. and Ba-
cillus spp.13 However, this method may lead to misclassifica-
tion of some organisms that may be causing infections, such as
coagulase-negative staphylococci causing central line in-
fections, ‘viridans’ group streptococci causing endocarditis,
etc. The Q-Probes study compared the contamination rates
between blood cultures classified using clinical and organism/
laboratory methods, finding that the contamination rate by
clinical assessment was 2.1%, which was lower than laboratory
assessment rate based on organism of 2.5% (P ¼ 0.005).22
Factors influencing contamination rate
Many organizations have produced a protocol or guidance to
advise healthcare workers on the process of taking blood cul-
tures. These include the World Health Organization (WHO), the
American Society of Microbiologists, and the Clinical and Lab-
oratory Standards Institute.12,23,24 In the UK the Department of
Health and Health Protection Scotland have developed rec-
ommendations; the latter are evidence-based and graded using
the Healthcare Infection Control Practices Advisory Committee
criteria.1,25,26 The use of protocols can help ensure that
healthcare workers taking samples use the same method.
Qamruddin et al. evaluated the effectiveness of using a pro-
tocol: 766 questionnaires were completed by those taking
cultures, and they found that, when healthcare workers com-
plied with the protocol, blood culture contamination rate was
2.6%, but without compliance it was significantly higher at
10.53% (OR: 4.35; 95% CI: 1.84e12.54).27
There are several steps in the process of taking blood cul-
tures that may influence the contamination rate. This review
will now examine these and consider the evidence from studies.
Method of obtaining sample
Blood samples can be taken by a variety of methods such as
via peripheral venepuncture or via intravenous catheter. Two
 S. Dawson / Journal of Hospital Infection 87 (2014) 1e10 3
Table I
Interventions to lower blood culture contamination rates
Study Site Details Results
Intervention: BC taken at insertion of intravascular catheter
Stohl et al.31 Two ICUs (general and Retrospective study of 2736 CVC BC BCs taken at time of CVC insertion were
medical) in a 775-bed samples taken at insertion and more frequently contaminated (225/
hospital 10,340 peripheral cultures over 5.5 2736 8%) than peripheral cultures (378/
years 10,340; 4%) (P < 0.001)
Self et al.32 Emergency department 505 BCs taken via newly inserted BC CRs taken via PIVC were 6.53% and
peripheral intravenous catheters those obtained by dedicated venep-
were matched to cultures obtained uncture 3.56%. Relative risk of conta-
by dedicated venepuncture from the mination: 1.83 (95% CI: 1.08e3.11).
same patient within 10 min This equates to 2.97 (95% CI:
0.29e7.51) additional contaminated
cultures per 100 cultures.
Smart et al.33 Emergency department BC samples were taken from 437 No significant difference was found in
patients at IV catheter insertion and CR between BC taken via freshly
286 were peripheral samples with inserted IV cannula (4.3%) compared
needle change before bottle with venepuncture with needle change
inoculation. after sampling (4.2%; P > 0.9)

Intervention: insertion of intravascular catheter samples in paediatric population

Ramsook et al.20 Paediatric emergency Single aerobic BC bottle taken from BC CR for samples taken by IV catheter:
department 2431 patients either via IV catheter 3.4% (44/1295) compared to 2% (22/
or peripheral venepuncture. 1084) for venepuncture (P ¼ 0.043)
Norberg et al.21 Children’s hospital Pre-intervention cultures were 4108 BCs obtained (pre intervention:
emergency department obtained simultaneously with PIV 2108; post intervention: 2000).
catheter insertion and post- BC CR decreased from pre 9.1% to post
intervention specimens were taken 2.8% (P < 0.001).
by a separate dedicated procedure
Weddle et al.36 Paediatric emergency Phlebotomy policy was changed so Pre-intervention BC CR: 6.7% (120/
department that BCs had to be obtained by a 1796)
second venepuncture and not during Post-intervention BC CR: 2.3% (23/
insertion of PIV catheter. 1229)
Significant difference: P ¼ 0.001
OR: 2.96 (CI: 1.96e4.57)
Isaacman et al.37 Paediatric emergency BCs obtained in 99 children through CR for both methods 1.0%
department newly inserted IV catheter and (95% CI: 0e3.0%)
butterfly needle at separate
venepuncture site
Hall et al.38 Paediatric emergency Introduction of a sterile BC BC CR reduced from 3.9% to 1.6% during
department collection process via PIV catheter intervention period (P < 0.001)
and development of web-based
education
Intervention: antisepsis of bottle tops
Schifman et al.22 640 institutions Q-Probes study of the College of 95.5% of laboratories routinely applied
American Pathologists antiseptic to the top of the broth bottle
before specimen inoculation. This
group had a significantly lower CR
(2.3%) compared to the remaining
laboratories (3.4%) (P ¼ 0.018).

Intervention: type of gloves

Kim et al.45 Single-centre trial 10,520 BCs taken by interns in a
involving medical wards prospective cluster randomized
and intensive care unit cross-over controlled trial.
Interventions were use of sterile
gloves every time venepuncture
performed or optional sterile gloving
(worn only if needed such as re-
palpating vein after disinfection)
BC classified as possible contaminants.
CR was 0.6% for routine sterile gloving
and 1.1% for optional (adjusted OR:
0.57; 95% CI: 0.37e0.87; P ¼ 0.009).
BC classified as likely contaminants. CR
was 0.5% for routine sterile gloving and
0.9% for optional (adjusted OR: 0.51;
95% CI: 0.31e0.83; P ¼ 0.007).
(continued on next page)
4 S. Dawson / Journal of Hospital Infection 87 (2014) 1e10

Table I (continued )
Study Site Details Results
48
Self et al. Emergency department Change of technique from Baseline period BC CR: 4.3%
traditional clean procedure to new Intervention period BC CR: 1.7%
sterile procedure with use of sterile (P < 0.001)
gloves, new materials kit containing
2% chlorhexidine skin antisepsis
device, sterile fenestrated drape,
and a procedural checklist.
Monitored using an interrupted time-
series study.

Intervention: needle changes

Spitalnic et al.49 Meta-analysis Analysis of eight studies that
compared BC CR with or without a
needle change prior to inoculation of
BC bottles.
Weighted contaminant rate of 2% if
needle changed prior to inoculation
compared to 3.7% if needle not
changed.
Weighted overall difference: 1.25%
(95% CI: 0.75e1.75%; P < 0.001).

Intervention: use of prepacked kits/packs

Thomas et al.11 UK hospital Introduction of BC packs and training BC CR reduced from 9.2% to 3.8%
for staff using kits. following pack introduction.
Snyder et al.29 Meta-analysis Seven studies comparing BC CR when Not statistically significant.
pre-packaged kit was used for taking Mean OR: 1.12; 95% CI: 0.94e1.35.
BCs No recommendation made for or
against using pre-packaged kits.
Bamber et al.54 UK hospital Introduction of BC packs and staff BC CR reduced from 43% to 25% of total
training number of positive BC.
Dhillon et al.55 UK hospital Introduced BC packs and training BC CR significantly reduced from 8.7%
programme to 3%.
P < 0.001 following introduction of
packs.
Weightman and Kerr56 UK hospital Introduction of BC kits and staff BC CR reduced from 6% prior to
training. In addition BC CRs were fed interventions to an average of 2.7% post
back to each clinical directorate interventions
every three months.
Marini et al.57 Emergency department Introduction of BC packs with BC CRs reduced from 2.1% to 1.4% with
education for staff. Feedback on CR intervention
provided.

Intervention: which type of healthcare worker takes BC sample

Gander et al.4 Emergency department Total of 5432 BCs were taken from ED west: BC CR
of 968-bed tertiary care two emergency departments (EDs): Phlebotomy: 3.1%
teaching hospital ED west and ED non-west. Non-phlebotomy: 7.4%
Significant difference: P < 0.001
ED non-west: BC CR
Non-phlebotomists: 5.6%
BC CR phlebotomists ED west and non-
phlebotomists ED non-west significant
difference: P < 0.001
Bekeris et al.13 356 institutions Q-Tracks study of the College of BC CR significantly lower in institutions
American Pathologists using dedicated phlebotomy team
(P < 0.001).
Institutions where nursing staff did not
collect BCs had average BC CR of 2.17%
and those where virtually all BC
collected by nursing personnel had
average BC CR of 4.21%.
 S. Dawson / Journal of Hospital Infection 87 (2014) 1e10 5

Table I (continued )
Study Site Details Results
20
Ramsook et al. Paediatric emergency Single aerobic BC taken from 2431 BC CR: venepuncture, IV catheter,
department patients either via IV catheter oroverall (nurse: 1.2%, 3.4%, 2.8%;
peripheral venepuncture. Nurses phlebotomist: 2.6%, e, 2.6%,
and laboratory phlebotomists used respectively). Overall CR did not
different antiseptics protocols for
significantly differ for phlebotomists
skin preparation and nurses 2.6% vs 2.8% (P ¼ 0.807) but
for venepuncture only nurses had a
lower CR.
Schifman et al.22 640 institutions Q probes study of the College of CR significantly higher (2.7%) in
American Pathologists institutions if <90% BC collected by
phlebotomy team compared to other
institutions (2.3%) (P ¼ 0.039)
Snyder et al.29 Meta-analysis Five studies were included in the Result favoured use of phlebotomy
analysis teams.
Mean OR 2.58 (95% CI: 2.07e3.20).
Weightman and Kerr56 UK hospital Introduction of BC kits and staff Phlebotomists taking BCs, CR: 0.8%
training Non-phlebotomists taking BCs, CR: 4.3%
Weinbaum et al.59 Medical and surgical Comparison of BC CR between house Higher rate of BC CR from house staff
units in an acute-care staff with phlebotomy team. A (4.8%) compared with BC team (1.2%)
community hospital commercial skin prep kit was used (P < 0.001).
with 487 beds. also introduced. Unit A, unit B: house staff (no skin prep
kit): 8.4%, 4.8%; phlebotomy team (with
skin prep kit): 1.2%, 1.0%; house staff
(with skin prep kit): 4.8%, e,
respectively.
Difference in BC CR for house staff with
and without skin prep kit was not
statistically significant (P ¼ 0.173).
Surdelscu et al.60 Community teaching BCs were drawn by phlebotomy BC drawn by phlebotomy team had
hospital team, nurses, nurses’ aides and lower CR of 2.6% compared to those
physicians drawn by non-phlebotomists of 5.6%
Intervention: Surveillance
Bekeris et al.13 356 institutions College of American Pathologists Q- Progressive decrease in BC CR.
Tracks study. Data collected during By fifth year of participation the
five-year study (1999e2003). median institution had reduced its BC
rate by 0.67% (P < 0.001).
Gibbs et al.15 Tertiary care teaching Phlebotomists were given individual Pre-feedback year CR: 2.6%
hospital in Canada CR feedback and retraining on Post-feedback year CR: 1.4%
collection technique The rate of contamination in BC
collected by non-phlebotomists did not
change.
Larkin et al.64 UK hospital Various interventions were Previous average BC CR of 6.4% reduced
introduced: education, DVD and to BC CR of 2.6% post intervention
changing skin antisepsis and then
individual feedback of contaminated
BC was introduced with retraining
for those with contaminants.
Youssef et al.65 Acute tertiary care Introduced routine labelling of BC BC CR 2.6% reduced to 1.5% after the
teaching hospital in USA bottles with initials of healthcare procedural change.
workers who drew them and then Significant decrease (P < 0.001).
provide them individually with
feedback on BC contaminants
Hopkins et al.66 US hospital Protocols were developed to BC CR reduced from 3.7% to 1.7% with
standardize the collection method the interventions
for BC. BC CR was collected and
reported monthly
(continued on next page)
6 S. Dawson / Journal of Hospital Infection 87 (2014) 1e10

Table I (continued )
Study Site Details Results
66
Harding et al. US hospital Education on BC collection and BC CR dropped for the whole hospital
feedback to staff on BC CR monthly from 1.82% pre interventions to 1.01%
post interventions.

Intervention: Education
Lin et al.68 Emergency department BCs taken by nursing staff. Phase 1 Pre-intervention BC CR was 3.4%; in
of the study evaluated educational phase 1 this decreased to 2.67% and in
intervention only and phase 2 phase 2 to 2%.
evaluated education and one-to-one
feedback of BC CR
BC, blood culture; CR, contamination rate; CVC, central venous catheter; PIV, peripheral intravascular catheter; IV, intravenous catheter;
OR, odds ratio; CI, confidence interval.

recent reviews of the literature which compared these
methods concluded that the contamination rate is lower when
blood samples are taken by peripheral venepuncture compared
with intravenous catheters. Falagas et al. analysed six studies
which provided data for 2677 blood culture pairs and found that
a culture obtained from an intravascular catheter had less
specificity (OR: 0.33; 95% CI: 0.18e0.59) and lower positive
predictive value (OR: 0.41; 95% CI: 0.23e0.76) compared to a
culture taken by peripheral venepuncture.28 However, the
studies looked at different types of catheter (the most
frequently used was temporary central venous catheters, 50%)
and practice in obtaining cultures (in three of the studies the
blood was discarded prior to obtaining a specimen). Similarly a
meta-analysis by Snyder et al. looked at nine studies which
included a range of hospital patients.29 Their meta-analysis
found an OR of 2.69 (95% CI: 2.03e3.57) which strongly fav-
oured venepuncture over catheter blood collection for
reducing blood culture contamination rates.29 Four of these
studies were also included in the Falagas et al. review. Bates
et al. consider that intravascular devices are probably associ-
ated with contaminants because of both colonization of the
line and breakdowns in sterile procedure when blood cultures
are drawn through these devices.3 When Boyce et al.30 updated
their blood culture policy, which discouraged staff from taking
blood samples from central lines, they found that their rates of
blood cultures taken via lines decreased from 10.9% to 0.4%. In
their multi-interventional study, blood culture contamination
rates fell from 1.6% to 0.5%, and they noted that it may have
contributed to a reduction in the number of reportable central-
line-associated bloodstream infections.30 However, studies
looking at contamination rates when samples are taken at
insertion of vascular catheters have also shown that the rate is
increased compared to peripheral cultures (Table I).31e33
Recently Levin et al. suggested that the contamination rates
could be lowered for newly inserted central lines if the sample
was not taken via the lumen exposed to the guidewire. They
found that blood culture contamination rates were 19% for wire
hub samples and 5% for non-wire hub samples.34
Although contamination rates may be increased when
samples are taken via central venous catheters or peripheral
intravascular catheters, others consider that there may be
reasons for using this route such as speed, ease, and lack of
trauma in critically ill patients.35 Also, in order to minimize the
number of venepunctures in children, blood culture specimens
may be obtained simultaneously with intravenous
(intravascular) catheter placement in many emergency de-
partments, even though several studies show that there is
usually a lower blood culture contamination rate when samples
are taken by venepuncture (Table I).20,21,36,37 However,
recently Hall et al. have managed to demonstrate a low blood
culture contamination rate of 1.6% when taking samples via
newly inserted catheters by following a sterile technique
protocol.38
Antisepsis
The most frequent source of contaminated percutaneous
blood cultures is often thought to be the skin of the patient at
the site where the cultures are obtained.19
Even if antisepsis is used at the venepuncture site to
decrease the bacterial counts of the resident flora it may never
be fully effective, as Selwyn and Ellis have shown that about
20% of skin bacteria are located in deep layers of the skin and
protected by follicles, crevices, or lipids.39
There is debate over which antiseptic is best for skin
cleansing, the most widely used agents being alcohol, chlor-
hexidine and iodine products.40 Caldeira et al.’s meta-analysis
reviewed six trials, demonstrating that alcoholic chlorhexidine
was better than non-alcoholic povidone-iodine [relative risk
(RR): 0.33; 95% CI: 0.24e0.46] in 4757 blood cultures from two
trials; also that alcoholic solutions were better than non-
alcoholic products (RR: 0.53; 95% CI: 0.31e0.90) in 21,300
blood cultures from four studies. Comparison of chlorhexidine
versus iodine compounds was not conclusive. Overall they
concluded that alcoholic products appear to be superior to
non-alcoholic solutions as skin antiseptics prior to venous
puncture in prevention of blood culture contamination.40
Similarly a review by Malani et al. of four studies, all of
which were included in the Caldeira et al. meta-analysis, also
concluded that there is no clear evidence to suggest which is
the best antiseptic to be used, although there is a possible
benefit from use of alcohol-containing antiseptics.41 The most
recent systematic review by Maiwald and Chan, which included
the analyses by Malani et al. and Caldeira et al., found no
evidence to support the use of chlorhexidine alone, plus good
evidence favouring chlorhexidineealcohol over aqueous com-
petitors but not for competitors combined with alcohol.42
Washer et al. have suggested that the choice of antiseptic
should be based on cost and preference as their trial of three
antiseptics showed no difference in contaminant rates.43
 S. Dawson / Journal of Hospital Infection 87 (2014) 1e10
National guidelines also vary in the antiseptic recommended.
The UK Department of Health guidelines recommend using 2%
chlorhexidine in 70% isopropyl alcohol (CHX-IPA) to disinfect
the skin whereas Health Protection Scotland suggests 70% iso-
propyl alcohol, citing a lack of specific evidence to suggest that
CHX-IPA should be used preferentially.1,25
The effectiveness of any antiseptic skin preparation is
directly related to the technique of application and length of
time it is allocated to remain in contact with the skin before
the procedure.44 Guidelines incorporate the importance of
allowing the antiseptic to dry and also emphasize that it is
important that the area is not re-palpated after disinfecting to
avoid cross-contamination from the collector’s fingers.1,25
It has also been shown that rates are significantly lower
when blood culture bottle tops are cleaned with antiseptic
(P ¼ 0.018) (Table I).22
Gloves
Gloves are used as personal protective equipment, and
recently the use of sterile gloves has been shown to lower rates
compared to clean (non-sterile) gloves which are widely used
when taking blood samples (Table I).45 Non-sterile gloves may
potentially cause contamination and have in the past been
implicated as a source of pseudobacteraemia.46 However,
although rates are lower with sterile gloves, the use of indi-
vidually packaged sterile gloves would undoubtedly increase
the cost of performing blood cultures, and it is not known
whether this increased cost would be offset by the potential
savings from the incremental reduction in contamination
rates.47 If introduced by hospitals, they would need to evaluate
this. Recently Self et al. incorporated sterile gloving in their
protocol when they changed from a clean procedure to a sterile
procedure and overall there was a significant fall in contami-
nation rates from 4.3% to 1.7% (Table I).48
Needle changing
Changing needles between taking blood for culture and
inoculating bottles has been suggested as a method to decrease
contamination rates; this is based on the theory that the
needle used for phlebotomy may be contaminated.19 In a meta-
analysis, Spitalnic et al. showed a significant reduction in blood
culture contamination rates if inoculation was done after a
needle change, although this must be weighed against the risk
of needlestick injury (Table I).49 Vacuum-activated transfer
devices have been developed recently to prevent the necessity
of using a hollow-bore needle to inoculate blood culture bot-
tles, and this allows phlebotomists to engage the safety
mechanisms on safety needles after withdrawal from the pa-
tient.19 In Great Britain the Health and Safety Executive reg-
ulations now encourage the use of safer sharps incorporating
protection mechanisms, and, in line with this, Department of
Health guidance recommends a winged collection set in pref-
erence to syringe and needle for taking blood cultures.1,50
Cross-contamination from other collection tubes
A review on pseudobacteraemia found evidence that blood
cultures could be contaminated if other collection tubes were
inoculated prior to blood culture bottles.51 One pseudo-
bacteraemia outbreak of Klebsiella aerogenes was thought to
7
be due to phlebotomists inoculating contaminated ESR
(erythrocyte sedimentation rate) tubes containing citrate prior
to inoculating blood culture bottles.52 Similarly Hoffman et al.
documented contaminated blood cultures thought to be cross-
contaminated by inoculating ethylenediaminetetra-acetic acid
(EDTA) tubes contaminated with Serratia marcescens prior to
filling blood culture bottles.53 In mock trials they showed that
reflux from the tube to syringe may occur while vacuum tubes
are being filled; therefore if EDTA tubes are contaminated with
Serratia this could be transferred to blood culture bottles.53
WHO guidance lists instructions on order of tube fill, and
blood cultures are recommended as being first.23
Use of packs
Packs have been advocated as they contain the equipment
needed to take a blood culture and so ease the process, but
they can add to the cost and so need to decrease rates of
contamination to be cost-effective. Some studies have found
them of value as they lowered blood culture contamination
rates; however, many of the trials also included other in-
terventions, such as education and training, which may have
contributed (Table I).11,54e57 Snyder et al. carried out a meta-
analysis of seven studies, but concluded that they were not
able to make a recommendation for or against these pre-
packaged kits (mean OR: 1.12; 95% CI: 0.94e1.35).29 More
evaluation of their contribution to lowering blood culture
contamination rates is needed.
Staff competency
As Rowley and Clare state, ‘blood culture collection is a
learned skill that requires competency training and assessment
with a particular focus on aseptic technique’.58 They consider
that outside of ‘specialist units and dedicated staff groups,
blood culture collection is not a routine procedure for many
health professionals’ and that ‘lack of competency assessment,
limited exposure and experience of venepuncture and blood
bottle inoculation is more likely to result in contaminated
samples’.58 In some hospitals, to ensure that staff are familiar
with taking blood cultures, the task is carried out by phlebot-
omists. Several studies have shown that contamination rates
are lower when taken by phlebotomists compared to other
healthcare workers (Table I).4,13,20,22,56,59,60 In a meta-analysis
of five studies Snyder et al. found a mean OR of 2.58 (95% CI:
2.07e3.20) which strongly favoured phlebotomy teams for
reducing blood culture contamination rates.29 Similarly in the
Q-Tracks study of 356 institutions blood culture contamination
rates were significantly lower in facilities that used a dedicated
phlebotomy team (P < 0.001). Institutions that did not use
nursing staff had an average rate of 2.17%, but those in which
virtually all blood cultures were collected by nursing personnel
had an average rate of 4.21%.13 However, Denno et al. in their
emergency department, where dedicated phlebotomists were
not available, found that their emergency nurses were highly
motivated and effective; by including in their intervention
educating and monitoring the nurses they lowered blood cul-
ture contamination rates from 12% to 3%.61 If hospitals decide
to introduce a phlebotomy service they will have to monitor
contamination rates to ensure they remain low, thereby
demonstrating that they are cost-effective. They will also need
to ensure adequate training for other healthcare workers if this
8 S. Dawson / Journal of Hospital Infection 87 (2014) 1e10
service is not provided 24 h a day. Current guidelines by the
Infectious Diseases Society of America now recommend that
taking blood cultures for investigation of a line infection should
be done by a phlebotomist, if available.62
Monitoring of rates
Surveillance is of value when it is combined with feedback
of healthcare-associated infection to clinicians, as it has pre-
viously been shown to lead to a decrease in the number of in-
fections.63 Thompson and Madeo consider that providing direct
feedback of contamination rates to those who perform blood
culture may increase both ownership and awareness.5 In the
Q-Tracks programme, the continued monitoring of BC CR by
institutions was associated with a progressive decline in blood
culture contamination rate, and by the fifth year of partici-
pation the median institution had decreased its blood culture
contamination by 0.67% (P < 0.001).13 Several studies have
shown that reporting rates monthly to staff and individual
feedback with retraining may lead to lower contamination
rates (Table I).15,64e67 When compared to education alone,
feedback and education have been found to be more effective
(Table I).68
Conclusion
Blood culture contamination rates are a mandatory quality
issue for most hospitals. However, Denno and Gannon point out
that ‘because no single factor causes contaminated blood
cultures, the most successful efforts to reduce contamination
likely involve more than one practice change’.61 Therefore
there is the need to adopt a variety of strategies such as suf-
ficiently educating clinicians on the correct techniques, pro-
vision of appropriate resources/equipment, and monitoring of
contamination rates.44
Evidence reinforces that hospitals/units should have in
place a protocol for compliance by all staff. This should be
based on national protocols and evidence from studies. It is
essential that staff receive training and that the process en-
compasses use of an aseptic technique. Studies have shown
that several key factors in the process can lower contamination
rate, such as sampling by peripheral venepuncture route rather
than via an intravenous catheter, use of sterile gloves, cleaning
tops of blood culture bottles with antiseptics, inoculating blood
culture bottles before other blood tubes and use of phlebotomy
teams.13,22,28,29,45,53 However, there are also some aspects of
the process which are still debated. Although skin sepsis is
advocated, there is no conclusive evidence on which is the
preferred antiseptic, only that there is benefit from alcohol-
containing preparations. The use of sterile gloves, pre-
packaged packs, and blood culture/phlebotomy teams have
been demonstrated to lower contamination rates; however,
the cost-effectiveness of these interventions may need to be
demonstrated.11,13,29,45,54e57 From a safety aspect, studies
have also shown that changing needles before inoculating
blood culture bottles can lower blood culture contamination
rates; however, this method is no longer advocated due to risk
of sharps injuries, and therefore use of needle safety devices is
encouraged.
Hospitals or units should monitor their blood culture
contamination rates as it has also been demonstrated that such
monitoring with feedback to staff can assist in lowering
rates.15,64,65 Studies also show that individual feedback with
retraining for those with higher blood culture contamination
rates is of value.15,64,65 Overall, units should aim to keep their
rates to a minimum (
3% as recommended in national stan-
dards), although for some units such as the emergency
department or neonatal unit this may be challenging.12
Conflict of interest statement
None declared.
Funding sources
None.
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