BLOOD CULTURE IN SEPSIS

Sanarto Santoso
Department of Microbiology
Faculty of Medicine Brawijaya University/ Saiful Anwar Hospital
2018
Sepsis should be defined as life-
threatening organ dysfunction caused by a
dysregulated host response to infection.
 Blood Culture

• Blood culture is the gold standard for the diagnosis

of sepsis.
• Blood cultures should be drawn prior to the
institution of antibiotics whenever possible.
• If empiric treatment is an emergency, blood
cultures should still be drawn as soon as possible
after institution of antibiotics.
• There is a direct relationship between the volume
of blood obtained and the yield of a blood culture
set.
 Blood Culture workflow
Microbiology
Bed Site Lab

Preliminary
Stain Report
+ Final
Specimen Subculture ID/AST
BC Culture Report
Order Collection
- (-) after 5 days Final
Report

Nurses
Physicians Med Tech
Phlebotomist
Key Points from CLSI M47-A

Timing of drawing blood cultures

Skin disinfection

Volume of blood to inoculate

Number of blood culture sets

How long to incubate bottles?

Phlebotomy for blood culture

• Aseptic technique 
(alkohol 30 seconds,
povidone iodine 2
minutes)
• Closed system 
minimizing skin flora
contamination
• 2 botols from 2 sites
• 8-10 ml adult
• 1-2 ml pediatric
• Room temperature for
delay transport to
microbiology lab
 Blood Cultures to Detect Sepsis
• Positivity Rates (%)

Sepsis 15 - 20
Severe Sepsis 25 - 35
Septic Shock 50 – 70

•Therefore, also need to culture other relevant sites

(urine, sputum, wound, etc)
 100
90
80
Hours to Days
70
60

% Mortality 50
40
30
20
10
0
SIRS Sepsis Severe Septic Shock
Sepsis
%+ 17 25 69
Blood
Cultures

*Rangel-Frausta, 1995 JAMA 273:117-23

Reasons for Negative BC in Sepsis
Patients
Infection is contained locally
Cellular products and/or cytokines

Poor Timing of collection

Too low blood volume collected

Patient on antibiotics
“How much blood should I draw from the
patient?”
 Effect of Volume

100
90
80
70
60
% Relative 50
Yield 40
30
20
10
0
5 10 15 20 25 30 35 40 45 50 55 60
Overall/Mayo ml
What is the best time to draw blood cultures?

• Answer:
Draw blood cultures as close as possible to the
episode of chills or fever. Do NOT delay, as recovery
of microorganisms diminishes with time after the
fever spike.
Volume of blood to be collected for pediatrics

Weight Total Volume to

kg (lb) Collect
< 1.5 (3.3) 1.0
< 4.0 (8.8) 1.0
4-13 (8.8-28.6) 3.0
13-25 (28.6-55.0) 10.0
> 25.0 (55) 20.0
 Volume of Blood Sample
Patient wt (lb) Recommended Total blood vol Vol of blood
blood vol/culture for 2 cultures equal to 1% of
(ml) (ml) patient's total
blood vol (ml)
<19 1 2 2
18-30 3 6 6 -10
30-60 5 10 10-20
60-90 10 20 20-30
90-120 15 30 30-40
>120 20 40 >40

Kaditis, A.G.,et. al. 1996. Yield of positive blood cultures in pediatric oncology patients
by a new method of blood culture collection. Pediatr. Infect. Dis. J. 15:615-620
“How many blood culture sets do I need to draw?”
 100
90
80
70
60
50
Blood Culture Set
40
30
20
10
0
1 2 3 4

Cockerill, CID 2004

 TOP 10 CLINICALLY-SIGNIFICANT MICROORGANISMS
OF SEPSIS
MICROORGANISM %
TRUE CONTAMINANT UNKNOWN

Staph. aureus 87.2 6.4 6.4

E. coli 99.3 0.0 0.7
Coag-neg Staph 12.4 81.9 5.8
Kleb. pneumoniae 100.0 0.0 0.0
Enterococcus spp. 69.9 16.1 14.0
Ps. aeruginosa 96.4 1.8 1.8
S. pneumoniae 100.0 0.0 0.0
C. albicans 90.0 0.0 10.0
Viridans Strep 38.0 49.3 12.7
Entero. cloacae 100.0 0.0 0.0
 Blood Culture in dr.Saiful Anwar Hospital
2017

•From 9005 blood cultures  2444 (27%)

positive cultures
 TOP 10 MICROORGANISMS ENCOUNTERED FROM
BLOOD CULTURE in Dr. SAIFUL ANWAR HOSPITAL MALANG 2017
Microorganism ∑ isolates %
Staphylococcus, coagulase negative 416 17
Staphylococcus aureus 233 10
– MRSA = 93 (40%)
Klebsiella pneumoniae 207 8
– ESBL = 132 (64%)
Escherichia coli 190 8
– ESBL = 150 (79%)
Enterococcus faecalis 87 4
Acinetobacter baumannii 79 3
Carbapenem resistant = 73%
Pseudomonas aeruginosa 56 2
Enterobacter cloacae 49 2
Corynebacterium striatum 18 1
Serratia marcescens 18 1
Antibiogram of blood culture in Dr.Saiful Anwar
hospital, Malang (2017)
%Susceptible
Gram positive N OXA CZO GEN CIP LIN VAN
microorganisms
Staphylococcus aureus 233 60 60 60 53 100 100
Coagulase neg Staph 416 10 10 59 26 100 100
Enterococcus faecalis 87 AMP NT NT 49 100 100
84
OXA=oxacillin; CZO=cefazolin (representing 1st generation of
cephalosporins); CIP=ciprofloxacin; LIN=linezolid; VAN=vancomycin;
AMP=ampicillin; NT=not tested in panel.
Note: CLSI 2018  for staphylococci that test susceptible, gentamicin is
used only in combination with other active agents that test susceptible.
Antibiogram of blood culture in Dr.Saiful Anwar
hospital, Malang (2017)
% Susceptible
Gram negative N AMP CRO GEN AK CIP MEM SXT
microorganism
Klebsiella pneumoniae 207 0 36 28 92 64 82 40
Escherichia coli 190 0 21 60 95 30 94 37
Acinetobacter baumannii 79 0 13 11 55 19 27 40

AMP= ampicillin; CRO=ceftriaxone; GEN=gentamicin; AK=amikacin;

CIP=ciprofloxacin; MEM=meropenem; SXT=trimethoprim-sulfamethoxazole
Coagulase Negative Staphylococci

• 90% resistant against Cefoxitin  MR coagulase negative

Staphylococci  no need infection prevention and control
measures as MRSA
Consider as a pathogen when…
• 2 or more positive blood cultures from different sites
• Clinical findings of infection especially in immunocompromised
patient
• Similar genotype from different time points
• Staphylococcus epidermidis isolated from a sterile site—joint, CSF
especially if prosthetic device present (shunt, artificial joint)
Treatment :
doc for methicillin-resistant strains  Vancomycin
 Methicillin-Resistant Staphylococcus aureus
(MRSA)
• 40% resistant against cefoxitin  MRSA
• These are organisms that are not sensitive to common
penicillin based drugs such as methicillin, amoxicillin, penicillin,
oxacillin
• Normal flora- lives on human skin, noses, vaginal tract
• May cause infections if enters the body
• Contagious- through person to person contact  need
infection prevention and control measures
• MRSA is not more virulent than MSSA, but it is not easy to be
treated
• Treatment  Vancomycin
 ESBL
• Klebsiella pneumoniae (64%), E.coli (79%), resistant against
Ceftriaxone  ESBL (Extended Spectrum Beta-lactamases) producing
bacteria
• Gram negative producing ESBLs have emerged as problematic
pathogens in hospitals and nursing homes.
• Exhibit resistance to a variety of antimicrobial agents
• The ESBL enzymes are plasmid-mediated enzymes capable of
hydrolyzing and inactivating a wide variety of ß-Lactams, including
third-generation cephalosporins, penicillins, and aztreonam.
• Treatment : drug of choice  carbapenem (meropenem,imipenem)
12% resistant against Meropenem  KPC?
AST  still sensitive against Amikacin
Summary
• Blood culture is the gold standard for the diagnosis of sepsis
• From 9005 blood cultures in Saiful Anwar Hospital year
2017, 27% positive cultures
• Bacteria isolated from blood cultures : Coag.neg.staph
(17%), Staph.aureus (10%) K.pneumoniae (8%), E.coli (8%),
E.faecalis (4%) A.baumannii (3%), Ps.aeruginosa (2%),
E.cloacae (2%), C.striatum (1%), S.marcescens (1%)
• 90% of Coag.neg.staph resistant against Cefoxitin,
considered as MR coag neg staph phenotypically
• 40 % Staph.aureus resistant against Cefoxitin  MRSA
• Klebsiella pneumoniae (64%), E.coli (79%), resistant against
Ceftriaxone  ESBL (Extended Spectrum Beta-lactamases)
producing bacteria
THANK YOU