Clinical Microbiology | Minireview

Laboratory approaches to determining blood culture

contamination rates: an ASM Laboratory Practices
Subcommittee report
Elizabeth L. Palavecino,1 Victoria L. Campodónico,2 Rosemary C. She3

AUTHOR AFFILIATIONS See affiliation list on p. 10.

ABSTRACT Blood culture contamination (BCC) is the presence of specific commensal

and environmental organisms cultivated from a single blood culture set out of a blood
culture series and that do not represent true bacteremia. BCC can impact quality
of care and lead to negative outcomes, unnecessary antibiotic exposure, prolonged
hospital stays, and substantial costs. As part of the laboratory’s quality management
plan, microbiology laboratory personnel are tasked with monitoring BCC rates, preparing
BCC rate reports, and providing feedback to the appropriate committees within their
healthcare system. The BCC rate is calculated by the laboratory using pre-set crite­
ria. However, pre-set criteria are not universally defined and depend on the individ­
ual institution’s patient population and practices. This mini-review provides practical
recommendations on elaborating BCC rate reports, the parameters to define for the
pre-set criteria, how to collect and interpret the data, and additional analysis to include
in a BCC report.

KEYWORDS blood culture, contamination, rates, report

D espite its limitations, blood culture (BC) remains the reference standard for the

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diagnosis of bloodstream infections (BSI) (1–5). While positive blood cultures are
indicated to detect active BSI, positive BC results may occur due to growth of a
contaminating microorganism that was introduced into the BC bottles during either
specimen collection or processing and that does not represent true BSI, affecting the
diagnostic value of the blood culture (1–5). Positive results may also occur due to
transient bacteremia, which may occur after a variety of daily activities such as tooth
brushing or medical procedures involving manipulation of mucous membranes. In this
case, microorganisms are present in the bloodstream for a short period of time before
being cleared from the bloodstream. The duration of transient bacteremia varies by
type of activity and ranges from 10 to 60 minutes post activity or procedure (6–8). It
is known that blood culture contamination (BCC) can impact quality of care and lead
to negative outcomes, unnecessary antibiotic exposure, prolonged hospital stays, and
substantial costs (1, 2). The work-up of contaminated cultures also greatly increases the
laboratory’s workload and unnecessarily prevents technologists from attending to other
important diagnostic tasks (2). The Center for Disease Control and Prevention (CDC) Editor Romney M. Humphries, Vanderbilt University
Medical Center, Nashville, Tennessee, USA
recommends that microbiology laboratories collaborate with infection prevention (IP)
and antimicrobial stewardship (AS) programs in designing and implementing interven­ Address correspondence to Elizabeth L. Palavecino,
tions to decrease BCC rates (9). A central line-associated bloodstream infection (CLABSI) epalave@wakehealth.edu.

is a laboratory-confirmed bloodstream infection not related to an infection at another The authors declare no conflict of interest.
site that develops within 48 hours of central line placement (10). Blood cultures yielding Published 5 December 2023
contaminants may result in a case of CLABSI as defined by the National Healthcare
Copyright © 2023 American Society for
Safety Network (NHSN) without being a true case of CLABSI. An increase in the reported
Microbiology. All Rights Reserved.

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number of CLABSI cases can be associated with reimbursement penalties (11). The
College of American Pathologists (CAP) and other accrediting organizations require
microbiology laboratories to monitor BCC rates, establish a threshold for an acceptable
rate of contamination, and provide feedback to phlebotomists or other health care
providers collecting BC samples (3). Many institutions monitor BCC rates among other
system-level healthcare quality metrics. There are currently several different approaches
to calculating BCC rates, and it is important for laboratories to apply the most appropri­
ate and a consistent method for their institution or system.
The focus of this document is on providing information and specific recommenda­
tions for microbiology laboratories to determine and track BCC rates. Information about
the clinical significance, costs, and actions to decrease BCC can be found elsewhere (1, 2,
12–14).

Definitions
For the laboratory to prepare a BCC report, it is important to understand the laboratory
parameters defined below.

Blood culture test (also referred to as blood culture)

A specimen of blood submitted for bacterial or fungal culture. A single blood culture
specimen may be divided or distributed into more than one bottle or tube (4).

Blood culture set

A blood sample collected from a single venipuncture and inoculated into one aerobic
and one anaerobic bottle (or one pediatric bottle for pediatric patients).

Blood culture series

All BC sets collected from the same patient over a period of time, as specified by the
pre-set criteria, usually 24 or 48 hours.

Blood culture contamination

The presence of specific commensal organisms cultivated from a single blood culture set

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out of one or more blood culture series.

Blood culture contamination rate

The proportion of blood cultures growing a contaminant.

Blood culture contamination report

Final data related to blood culture contamination presented by the laboratory to
collecting departments, leadership, and IP.

Determining the BCC rate

BCC rates are typically determined on a monthly or quarterly basis in order to be utilized
as part of a laboratory’s quality management plan. The calculation is performed by
dividing the number of contaminated blood cultures by the total number of eligible
blood culture sets processed during that time period, expressed as a percentage:

× 100%
Number of contaminated blood culture sets as determined by laboratory pre‐set criteria
Total number of all eligible blood culture sets collected

The number of contaminated blood cultures (the numerator) and the eligibility of a
culture for inclusion in the measure (the denominator) are determined using a labora­
tory’s pre-set criteria. Approaches to selecting these pre-set criteria are detailed in the
following section.

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Selecting laboratory criteria

The laboratory interpretation of BCC is based on the application of pre-set laboratory
criteria. Pre-set criteria are not universally defined and may depend on the individual
institution’s patient population and practices. Table 1 lists the parameters that need to be
defined by each laboratory.

Organisms
The main parameter used by clinical laboratories to differentiate true bacteremia from
contamination is the identity of the organism isolated (15). Certain microorganisms
are rarely considered contaminants, while other organisms almost always represent
contaminants when isolated from BC (2, 5).
The microorganisms most frequently considered contaminants include those present
on the skin as normal commensals: Staphylococcus spp. other than S. aureus [commonly
referred to as coagulase-negative Staphylococcus spp. (CoNS); some laboratories also
exclude S. lugdunensis], Corynebacterium spp., Bacillus spp., and Cutibacterium (Propioni­
bacterium) acnes. However, additional microorganisms can be considered contaminants.
See Table 2 for published recommendations from professional organizations.
CoNS are the most common blood culture contaminants with S. epidermidis being
the most common species identified. Among non-S. epidermidis CoNS, isolation of S.
capitis, S. caprae and S. hominis is typically associated with BCC, while about 60%–80% of
S. haemolyticus have been reported to be associated with infection (16). As mentioned
above, many laboratories do not consider S. lugdunensis a contaminant even if isolated
only from one set of blood cultures due to its frequent clinical significance (17, 18).
Patient characteristics such as patient’s age group, immunologic status, presence
of catheters, and other foreign devices should be assessed as these factors can influ-
ence the selection of commensal organisms and the number of BC sets required for
identifying BCC and CLABSI (1). Organisms generally considered potential contaminants
may more often be considered pathogenic in certain patient populations. For example,
in patients at risk of mucosal barrier injury (due to cancer chemotherapy, surgical
procedures, or gastrointestinal pathology, etc.), viridans group streptococci recovered
from a single blood culture set likely represents true bacteremia rather than BCC.
For determining CLABSI rates, the CDC provides a list of organisms considered

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“common commensals” (19). This list is very extensive (>500 microorganisms), making
the use of this list cumbersome for certain methods of tracking and estimation of overall
BCC rates for laboratory purposes. Organisms such as Gemella spp., Granulicatella spp.,
Leuconostoc spp., Pediococcus spp., Globicatella spp., which may be considered contami­
nant organisms by some laboratories when not recovered from multiple BC sets, are
excluded from the CDC list of common commensal organisms for CLABSI purposes (19).
Consensus guidelines recommend peripheral venipuncture as the preferred method
for collecting BC samples. Catheter-drawn BC has a higher risk of contamination (12).
If a BC sample is obtained from a catheter or port, a peripheral BC sample should be

TABLE 1 Parameters to be defined for setting up the laboratory criteria for determining BCC rates

Parameter Choices Comments

Organisms to be included as
contaminants
Time range for including BC sets
Eligible BC sets for analysis
Patient population
Frequency of report
Typical vs typical plus additional organisms
24- vs 48-hour period
Exclusion vs inclusion of single BC sets and BC
sets collected from central lines
Separate BCC reports for pediatric and
immunosuppressed patients
Monthly vs quarterly
Most laboratories select the typical commensal organisms (see Table 2). Additional
organisms can be included if isolated frequently as BCC
24 hours is appropriate for most laboratories, while 48 hours may be considered by
some institutions depending on their blood culturing practices
Exclusion of single BC is potentially more accurate for calculating BCC rates in adults
It may be beneficial to create separate reports in case of large population of these
groups, but it requires additional data analysis and resources
Depends on number of BCs performed at an institution and baseline BCC rate. Typically
monthly, but quarterly calculations may be required for smaller institutions

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TABLE 2 List of organisms typically considered skin contaminants according to different publications and professional organizationsa

Reference #2 Reference #3 (CAP) Reference #4 (CLSI) Reference #5 (ASM)

Standard organisms
considered contaminants
Additional organisms that are
considered contaminants
a
CAP, College of American Pathologists; CLSI, Clinical and Laboratory Standards Institute; ASM, American Society for Microbiology; CoNS, coagulase-negative Staphylococcus
spp.
CoNS
Cutibacterium acnes
(and related species)
Corynebacterium spp.
(and related genera)
Bacillus spp.
ther than Bacillus anthracis
Micrococcus spp.
CoNS
Cutibacterium acnes
Corynebacterium spp.
Bacillus spp.
ther than Bacillus anthracis
Viridans group streptococci
CoNS
Cutibacterium acnes
Corynebacterium spp.
Bacillus spp.
ther than Bacillus anthracis
Viridans group streptococci
Micrococcus spp.
Aerococcus spp.
CoNS
Cutibacterium acnes
Corynebacterium spp.
Bacillus spp.
ther than Bacillus anthracis
Viridans group streptococci
Micrococcus spp.
Lactobacillus spp.
Nutritionally variant Streptococcus
(Abiotrophia and Granulicatella)

also obtained at the same time to facilitate interpretation of BC results and diagnosis of
CLABSI (5, 12).
In contrast to organisms considered contaminants, microorganisms that almost
always represent true bacteremia or fungemia when isolated from a BC include, but
are not limited to, the following: Staphylococcus aureus, Streptococcus pneumoniae,
Streptococcus pyogenes, Streptococcus agalactiae, Listeria monocytogenes, Escherichia
coli, and other members of the Enterobacterales, Pseudomonas aeruginosa, Neisseria
meningitidis, Neisseria gonorrhoeae, Haemophilus influenzae, anaerobic Gram-negative
rods (e.g., Bacteroides spp. and Fusobacterium spp.), Campylobacter spp., Cryptococcus
neoformans/gattii, and Candida species (1, 2, 5).
With the use of matrix-assisted laser desorption/ionization-time of flight mass
spectrometry (MALDI-TOF MS), gram-positive bacilli that were identified as Corynebac­
terium spp. or as diphtheroids by previous methods can now be identified to the
genus or species level as Arthrobacter spp., Brevibacterium spp., Microbacterium spp.,
and other Corynebacterium-related genera. Because of the prior inability to accurately
identify these organisms, their association with either true bacteremia or contamination

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is not completely known. A study evaluating the clinical significance of commensal
gram-positive rods isolated from different specimen types found that, although the
majority of Corynebacterium-related species are thought to be contaminants, there is
significant evidence that many are opportunistic pathogens in immunocompromised
hosts, patients with prosthetic devices, and individuals with prolonged hospital stays.
The authors concluded that two or more BC sets should be positive yielding the same
bacterial species to be suggestive of true infection rather than BCC (20).
Microbiology laboratory personnel should consult with IP, infectious diseases (ID), and
AS teams and other stakeholders to decide if microorganisms other than the standard
species described in Table 2 should be included in the estimation of the BCC rate at
their institution. The BCC rate may vary significantly based on the selection of organisms
classified as skin commensals by pre-set laboratory criteria.
Though organism identification is the main parameter used by clinical laboratories
to differentiate true bacteremia from contamination, it cannot be the sole parameter for
clinical interpretation as the organisms most commonly found as contaminants such as
CoNS, Corynebacterium jeikeium, and C. acnes are known to be the cause of infections
such as CLABSI, prosthetic joint infection, endocarditis involving prosthetic valves, and
infection of implantable cardiac stimulators and other implanted foreign devices.

Other parameters
Additional parameters that the laboratory should select include the number of BC sets in
a BC series and the duration of a BC series that will be used for determining the BCC rate.

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The laboratory should also assess whether mixed cultures (e.g., BC growing a pathogen
and a commensal organism) will be counted as a contaminated BC when determining
the BCC rate.

Pros and cons of selecting the number of BC sets and time frame for BC series
In a large Q-tracks study, the CAP defined a contaminated BC as a single BC out of one
or more BCs serially drawn from the same patient in a 24-hour period that yielded one
or more contaminant microorganism(s) as described above. Note that in this definition,
there is no requirement for more than one BC to be collected from a patient for a BC to
be classified as contaminated. The advantages of using this definition are the simplicity of
BCC tabulation and the existence of BCC benchmarks from national studies based on this
definition, against which an institution can compare their BCC rate. A disadvantage is the
potential for overestimating BCC rates with the inclusion of all BC contaminants regardless
of the number of sets drawn. More recently, CLSI guidelines recommended excluding
single BC sets that are positive for possible contaminants from calculation of BCC rates (4).
This recommendation is based on the premise that it is not possible to assess BCC when
only one BC set is drawn in a 24-hour period without a second set for comparison. BCC is
more accurately determined when a single BC set grows a skin commensal organism out
of two or more sets collected within a 24-hour period. The CLSI approach is potentially
more accurate for calculating BCC rates, as long as single BC draws are not the prevailing
institutional practice. On the downside, it requires additional data analysis, which may
pose difficulties for institutions without dedicated resources and expertise. The above
definitions may be applied to monitoring BCs of adult and pediatric patients, but for
pediatric populations in which collection of single BC sets is the predominant practice,
application of the CAP Q-tracks study definition of BCC would be more appropriate (21).
As regards the duration of the BC series, some earlier studies on BCC rates that defined
BCC based on ID specialist interpretations have defined a BC series as the BC sets drawn
over a 48 rather than 24-hour period (22, 23). The 24-hour timeframe discussed above
is reasonable and sufficient if the prevailing practice at an institution is to draw 2–3 BC.
BC sets for BSI work-up followed by start of empiric antibiotic therapy. Use of a 48-hour
period may be more relevant when initial blood cultures are often followed by additional
sets the next day, typically to work up a single clinical episode. It also aligns with the
CDC definition of laboratory-confirmed bloodstream infection which considers all BCs

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obtained over two consecutive calendar days (10). It is difficult to predict the impact of
confounders with use of prolonged time windows, such as intervening use of antibiotics,
baseline rate of BCC, case mix, and inclusion of additional qualifying BC series, as they can
lead to either an increase or decrease in BCC counts. The decision should ultimately be
based on a timeframe that best fits institutional practices. To illustrate, a large study by the
Veterans Health Administration detailed successful system-wide application of a BCC rate
monitoring tool that opted for a much longer, 30-day timeframe allowance for a BC series
(24). Finally, the timeframe for BCC calculations is to be differentiated from that used for
limiting frequency of susceptibility testing on repeat isolates from BCs. A timeframe of up
to 5 days is recommended for this purpose as detailed elsewhere (4).
Any exclusion criteria adopted for the numerator should also be adopted for the
denominator and vice versa. In particular, if single-draw BC sets are excluded from the
count of contaminated BCs, they should also be excluded from the count of all BCs
collected.
As outlined above, the definition of BCC may be modified based on the institution’s
practices and patient population. Modifications that have been recommended include
exclusion from analysis of BCs obtained during post-mortem examinations and separate
analysis of BC sets drawn from vascular lines vs from peripheral draws as BCs drawn
from indwelling intravascular lines are prone to higher contamination rates (25). BC sets
drawn on neonatal patients should also be calculated separately from those of other age
groups (3). Investigation into cases of unknown significance, such as single set BCs that
recover a potential contaminating organism, or isolation of viridans group streptococci

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(which could be pathogenic in certain patient populations), may be considered time and
expertise allow in order to increase the robustness of BCC rate monitoring as a quality
tool (22).
Importantly, the calculation of BCC rate by the laboratory is for the purpose of
institutional quality assurance and operator feedback and not for strict clinical interpreta­
tion. The clinical interpretation of BCC is based on clinical judgment as to the likelihood
that the microorganism isolated is the cause of bacteremia in a particular patient.
Applying laboratory criteria, a BC result may be interpreted as contaminated, but the
clinical team may interpret this as true bacteremia based on clinical findings. In most
cases, the laboratory cannot assess with complete certainty the clinical significance of
a BC that yields an organism considered a contaminant, and so the organism isolated
should be reported for the clinical team to make a proper clinical assessment and
determine if further work-up is needed (4). To convey the possibility of BCC on the lab
report, clinical laboratories may choose to include an explanatory comment when one
is recovered from a single set. Commonly used verbiage includes that recovery of such
an organism, e.g., CoNS, from a single blood culture out of two or more sets generally
indicates contamination (5, 26)—for example, “The recovery of this organism from a
single blood culture most likely represent contamination. If further work up is needed,
please contact the Clinical Microbiology Laboratory.” (5).
It bears mentioning that published studies of BCC rates may use different parameters
for the definition of BCC, so published data may not always be generalizable to everyday
practice. Therefore, care should be taken when comparing BCC rates between institu­
tions or in published studies as the parameters for determining BCC rates may differ.
For example, to improve stringency of their BCC definition, some studies have excluded
patients with indwelling lines or catheters or those who are immunocompromised or
else applied in-depth physician review of each patient to interpret positive BC results to
determine contamination (27).

Collection of data
Microbiology laboratory personnel often have the responsibility of calculating BCC
rates at a particular institution. This task can be time-consuming, labor-intensive, and
challenging to interpret. Before starting to collect the data, it is important for laboratories
to familiarize themselves with the different types of reports that may be available to

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obtain the information needed, the different locations in the health care system where
blood cultures are collected and how these locations are identified in their reports,
the personnel obtaining BCs (nursing vs phlebotomy vs other), and if and how the BC
collector is identified in the laboratory information system. Understanding and defining
these parameters is crucial to evaluating the data included in the BCC reports and
for resolving possible discrepancies that may be observed when comparing different
data sources. Below are the main methods used by laboratories to collect the data to
determine BCC rate.

Manual entry and review

In this case, patient BC results are reviewed at specific time intervals and based on
parameters set by the laboratory. Both negative and positive cultures are first evaluated
for inclusion in the analysis (see eligibility criteria, above). Then, the reviewer categorizes
each positive result as a pathogen or contaminant and then summarizes the findings
for the report. The advantage of this method is that it is readily available as it does not
need equipment or software for analysis. The main disadvantages are that is very labor
intensive and more suitable for laboratories with small numbers of BCs.

Laboratory information system

A report would need to be built based on the pre-set criteria selected by the laboratory.
In some cases, at the time of culture work-up, the technologist determines whether
a BC should be considered contaminated and documents that determination in the

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laboratory information system (LIS). Then, the data can be retrieved and an automated
report obtained at specific time intervals, usually monthly or quarterly, to estimate the
BCC rate. Additionally, laboratories may retrieve statistical data from the LIS by develop­
ing an automated report with several rules dictating inclusion or exclusion of cultures.
Such a report may also include automated rules that categorize “contaminated” cultures
according to the organism’s name or the inclusion report can be manually filtered for
organism names of potential contaminants in blood cultures. The data may be further
refined either manually or through the LIS based on additional institution- or population-
specific rules to determine which of these positive BCs meet the definition of BCC. The
main advantage of this method is that there is no need to acquire additional software
systems and all the information needed to prepare the BCC report (organism isolated,
number of sets collected, and number of positive sets) is accessible and searchable. The
disadvantages include the need for development of the program by an experienced
team.

BC instrument software
The manufacturers of BC systems offer software which can be used to calculate the BCC
rate according to the parameters set by the laboratory. The use of this tool will depend
on whether the data are bi-directional—meaning the organism identification will be
known by the system so the culture results can be interpreted—or only unidirectional,
meaning the organism identification for each culture will need to be added manually in
order to interpret the results. Advantages include software with flexible and easy-to-gen­
erate reports. Among the disadvantages are cost of software, limited customization, and
interfacing connectivity mostly being available to instruments of the same manufacturer,
restricting access to information.
Quality assurance should be done for each type of BCC report prepared to ensure
that the appropriate data have been obtained, that patient locations and collector
identification are properly assigned, and that the overall numbers for BCs collected and
BCC rates derived from the data are accurate. For example, use a different type of report
or source of data to assess the number of BCs collected at one specific location and
compare this to the number obtained in the BCC report. The collector identification
for a specific location in the LIS report can be compared to the list of collectors from
nursing/management for that specific location.

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Preparation of reports, interventions to reduce BCC, and monitoring
compliance
Each laboratory should have protocols for regularly reviewing BCC rates, accepta­
ble limits, appropriate interventions for reducing high contamination rates and for
monitoring compliance (4). As described above, a few documents, such as from CLSI or
CAP, can assist with setting metrics. Prevention of BCC should be pursued by a multidisci­
plinary team, including the microbiology laboratory, nursing, the vascular access team,
AS team, infection control, patient care unit directors, information technology specialists
and administrative leaders. The AS and IP teams can help with the implementation
of mitigation strategies such us hand hygiene and diagnostic stewardship, and with
monitoring compliance (9). Frequent review of BCC rates with team-specific discussion
and communication has been associated with reductions in BCC at a minimal cost
(14), which can help identify improvement opportunities and monitor the effectiveness
of changes implemented over time. Additionally, the BCC reports can help determine
the BC utilization rate and whether interventions for reducing the use of unnecessary
BCs should be considered (11). Laboratory stewardship efforts should involve educat­
ing clinical providers about the specific circumstances that necessitate repeat blood
cultures. The decision to repeat blood cultures depends on several factors, including
the identification of the organism growing (always indicated for S. aureus bacteremia
and candidemia, due to the common occurrence of persistent infection, which may
change the duration of therapy and management, but not recommended in patients

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with uncomplicated Gram-negative bacteremia), the origin of the infection (always

recommended for endovascular infections, but usually not in patients with mild skin
and soft tissue infections, community-acquired pneumonia, or pyelonephritis), and the
clinical response (11, 28). A multidisciplinary team can facilitate communication between
departments and make sure that the BC quality metrics monitored by the microbiology
laboratory reach bedside providers so they can improve their practices and implement
changes appropriately (11).
It is recommended that monthly reports are prepared for patient care units with more
than 50 BCs per month (29). Some laboratories prepare quarterly reports for units with
less than 50 BCs per month. The primary data that should be included in the reports
is shown in Table 3. BCC reports should include the rate for each patient care unit and
comparison with their rate in previous months and the overall hospital rate. Comparison
of rates between units can increase the satisfaction of the teams with lower rates and
improve ownership and awareness of the need for improvement for those with higher
rates. Variation in rates between departments can also help identify the units with the
most barriers to achieving acceptable BCC rates and guide interventions towards them
(29). Additionally, BCC rate reports should include true-positive BC rates. The American
Society for Microbiology (ASM) notes that optimal true-positive BC rates should be in the
6%–12% range (5). If it is too low, it can indicate that too many BCs have been drawn and,
as described previously, interventions to reduce unnecessary BC testing should be put in
place. On the other hand, if the true-positive BC rate is too high, it can reflect that not
enough BCs have been collected (5).
As discussed above, when calculating the BCC rate, the microbiology laboratory may
exclude single sets that yield potential contaminants from the calculation. However,
the inclusion of the single draw percentage rate and their positivity rate for suspected
contaminants can be helpful, to emphasize the importance of drawing more than one
set of BCs. Additionally, if a unit has a high rate of single BC sets, interventions to avoid
unnecessary testing in patients with low pretest probability of BSI may be developed.
Accurate tracking of BCC rates by units with confidential employee identifiers to
designated managers allows direct feedback to individuals who performed phlebot­
omy and an assessment of compliance with microbiological sampling procedures (30).
Subsequent retraining has been shown to reduce BCC rates (2, 13, 31, 32). The use of
trained phlebotomists for blood culture collection has been linked to a reduction in the

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occurrence of BCC, therefore, calculating the BCC rate for cultures collected by phlebot­
omists vs non-phlebotomists may also be considered. The use of bundled preventive

TABLE 3 Data to be included in BCC reports for feedback to the appropriate stakeholders

Data to collect Comments

Primary data BCC rate for each patient care unit and a comparison of their rate
in previous months and the overall hospital rate
Number of blood cultures/1,000 patient days
The true-positivity BC rate
Single draw percentage rate
Confidential list of employees per unit who performed
phlebotomy, phlebotomy vs nursing or other non-phlebotomy
personnel, and their individual BCC metrics.
a
Optional data BCC rate in peripheral and central line draws
Identity of organisms isolated as contaminants
Percent of cultures with less than the optimal volume of blood stated
by the manufacturer
a
Optionality of this data refers to its inclusion in the external report. However, this data is important for the laboratory to collect and monitor internally.
Each laboratory should have protocols for acceptable limits, appropriate
interventions for reducing high contamination rates and for monitoring
compliance
As a measure of appropriate utilization of BC
An acceptable true-positive blood culture rate should be in the 6%–12% range (5)
May indicate the need for education about the importance of collecting more than
one set of BCs
Separate calculations of BCC rate based on collector type may identify group-
specific opportunities for feedback.
Retraining of employees and/or departments with higher than usual BCC can
decrease contamination rates
May indicate the need for further education on improved line draw sterility and to
promote peripheral draws over line draws
Training for collection and disinfection practices
Identify issue for educational efforts to reduce the rate of false-negative BCs

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practices, procedural checklists, establishing a monitoring compliance program, and

allowing opportunities for employee feedback on the barriers they encounter in
following the appropriate procedures for an aseptic technique and skin preparation
can be used to encourage compliance with standardized protocols for obtaining a
BC specimen (30, 33, 34). Employee feedback can provide valuable insight into the
strengths of the interventions implemented or the areas that still need improvement
(35). Furthermore, the implementation of rewards to units who achieve an institutionally
agreed upon target compliance and BCC rate may serve as additional incentives for
compliance (30).
Additional or optional information that can be included in the BCC report is shown
in Table 3. Comparing the rate of contamination of peripheral and central line draws can
be useful. A large difference in BCC rates between peripheral and central line draws can
point to the need for further education on improved line draw sterility, and identifying
contamination in central line draws can help increase the accuracy of reportable CLABSIs
(33). Reporting the percent of secondary bloodstream infections and the site of the
primary infection can help identify other areas of the hospital where interventions for
infection prevention might be necessary (36). Furthermore, including information about
the organisms isolated as contaminants in the BCC report can help identify the source
of contamination (skin vs environmental contaminants) and guide retraining toward
reducing environmental factors and/or site preparation and disinfection practices (35).
The yield of true pathogens from blood cultures is influenced by the blood volume
that is drawn, and inadequate volumes may also have an effect on contamination
(33) with higher blood collection volumes being associated with significantly lower
contamination rates (3, 37). A possible explanation for this finding is that the low-blood-
volume cultures could be associated with patients with poor peripheral venous access,
potentially leading to difficulties in maintaining sterility during the blood collection
process. Once the contaminant is introduced in the culture, a lower volume of blood
may result in a higher concentration of the contaminant, increasing the probability of
obtaining a positive blood culture growing a contaminant (37).
For adults, the CLSI recommends drawing 10 mL of blood per BC bottle, or collecting
the maximum blood volume recommended by the BC vial manufacturer (4). Including
the percent of cultures with less than the recommended volume of blood in the BCC
report can identify another area for educational efforts that has been shown to be

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successful in reducing BCC and the rate of false-negative BCs (33).
The information provided in BCC reports can be used to identify obstacles to achieve
acceptable BCC rates and opportunities for interventions and to develop collabora­
tive system-wide quality improvement strategies to improve patient care and reduce
unnecessary costs associated with BCC (2).

Acceptable threshold
The acceptable BCC threshold of ≤3% has been widely agreed upon and cited by the
CAP, ASM, CLSI, and other guidelines (2–4, 38–40). This threshold is based on data
gathered from hundreds of clinical laboratories, published in 1998 and 2005, which have
been used to establish benchmarks for BCC rates (3, 38). A wide range of BCC rates were
reported, with median rates falling within the 2%–3% range.
Recent attention has been given to lowering the acceptable threshold to ≤1%, as
it has been noted that this rate is achievable even without blood diversion devices
(2, 4). In large studies, high-performing (90th percentile and above) laboratories have
reported contamination rates of ≤1% (3, 38). Therefore, this threshold may be considered
aspirational by some. Conversely, a BCC rate of ≤1% may not always be achievable due
to an expected baseline of transient bacteremia and true bacteremia that qualify as
contamination based on laboratory criteria. Some investigators have reported that even
with the use of initial blood diversion devices, rates lower than 1% may not be attained
in some environments (41). In any case, institutions may choose to lower the acceptable

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Minireview Journal of Clinical Microbiology

threshold from the standard ≤3% to a level that is practically achievable while ensuring
the highest quality BC collections.

Summary
Laboratory diagnosis of bacteremia depends on blood cultures. However, blood cultures
can be contaminated with skin commensal microorganisms making it difficult to
differentiate true infection from contamination. BCC can have severe consequences and
potentially compromise the quality of patient care. Microbiology laboratory personnel
routinely prepare BCC reports, monitor BCC rates, and provide feedback to the appropriate
committees within their healthcare system. It is important for the laboratory to consult
with their IP and AS teams and reach a consensus on the parameters to use for calculating
the BCC rate (e.g., which microorganisms to include as contaminants) to enhance the
accuracy and utility of the BCC report for the purpose of institutional quality assurance
and operator feedback. These strategies can help in reducing the risk of contaminating
samples collected for blood culture.

AUTHOR AFFILIATIONS
1
Department of Pathology, Wake Forest University School of Medicine, Winston-Salem,
North Carolina, USA
2
Department of Pathology, Division of Medical Microbiology, Johns Hopkins University
School of Medicine, Baltimore, Maryland, USA
3
Department of Pathology, Keck School of Medicine of the University of Southern
California, Los Angeles, California, USA

AUTHOR ORCIDs

Elizabeth L. Palavecino http://orcid.org/0000-0002-4525-6064

Victoria L. Campodónico http://orcid.org/0009-0006-7840-1199

AUTHOR CONTRIBUTIONS

Elizabeth L. Palavecino, Conceptualization, Supervision, Writing – original draft, Writing

– review and editing | Victoria L. Campodónico, Writing – original draft, Writing – review

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and editing | Rosemary C. She, Writing – original draft, Writing – review and editing

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