Resources

Blood Culture Definitions

Blood Culture Series vs. blood Culture Set

A blood culture series requires the collection of two (2) blood culture sets comprised of four (4) culture bottles from two (2) different collection sites:

Blood culture set #1: Two (2) culture bottles (one aerobic and one anaerobic) from one site
Blood culture set #2: Two (2) culture bottles (one aerobic and one anaerobic) from a separate site

Therefore, a blood culture series requires the use of Two (2) collection devices (one per collection site.)

Best Practice Guideline: It is advised that at least two blood cultures series be collected at separate times to positively identify bacteremia.

Total Blood Cultures

The denominator for calculating a facility’s contamination rate, total blood cultures, is the count of every blood culture series collected, NOT multiples of four (4) specimens or two (2) sets per series.

A Contaminated Blood Culture

According to the College of American Pathologists (CAP), blood culture contamination should be tracked at the blood culture series level:

“The identification of one or more of the following organisms in only one of a series of blood culture specimens: Coagulase-negative Staphylococcus; Micrococcus; Alpha-hemolytic viridans group streptococci; Propionibacterium acnes; Corynebacterium sp. (diptheroids); or Bacillus sp.” (CAP Checklist statement note MIC.22630)

Thus, a contaminated culture bottle is counted as one (1) contaminated blood culture series (1:1), NOT as 1:4 specimens or 1:2 sets collected.

What is the cost of a contaminated culture?

Identifying an institution’s specific cost per false positive blood culture is challenging.
There are three approaches to calculating cost:
literature review, internal financial review, and adjusted patient length of stay (LOS).

Numerous peer-reviewed studies have sought to assess the increased cost of care associated with contaminated blood cultures. For example:

Garcia, et al. ($4,500-$10,078)
Rupp, et al. ($4,580)
Alahmadi, et al.* ($10,078)
Gander, et al. (~$3,500)
Allain ($5,200)
Sutton ($7,200)

For facility-specific costs, one methodology is offered by Allain:

Work with the finance department to evaluate patient records.
Identify patients with similar DRGs and like co-morbidities.
Then compare patients for whom the only notable difference was the presence or absence of a false positive blood culture.

Read Allain, Clin Nurs Specialist 2018

An approximation of costs can be derived by assessing the LOS for each patient with a contaminated culture as well as the average cost the hospital bears for caring for each patient per day. Literature suggests the extended LOS is anywhere from 2-5 days. If the estimated cost to provide care is $2000 per day, then a contamination might add $4000-10,000 to the total cost of care.

Whether one relies on the published literature or employs their own methodology, it is clear false positive blood cultures have a significant financial impact on a hospital.

Fast Facts

Over the past 30 years, strategies to decrease blood culture contamination rates in US hospitals have included the use of specific disinfection materials, educational interventions, collection from separate venipuncture sites, a double-needle technique, employing a discard tube, and reliance on specially-trained staff or dedicated phlebotomists. But, because wide spread and sustainable reductions have been illusive, hospitals have come to accept a 3% contamination rate as the standard of care.

Read the highlights from published clinical studies to better understand the incidence of contamination that leads to false positive blood cultures, the associated costs of contamination, and the on-going measures to reduce contaminated blood cultures.

Click on category heading to view facts.

Incidence

Standards published by the American Society for Microbiology state that acceptable contamination rates should be no higher than 2 to 3%.
(Dunne, WM et al. ASM Press, Washington, DC. 1997.)

Estimated up to 50% of all blood cultures originate in ED. Increasing crowding in EDs is correlated with higher rates.
(Garcia RA et al. AJIC. 2015)

Contaminated blood culture rates vary widely from 0.6% to over 6% and rates have been on the increase.
(Hall and Lyman. Clin Microbiol Rev. 2006)

Contamination rates among individual clinicians range widely (0% to 21%)
(Murillo TA. Pediatr Emerg Care. 2011)

Previous studies have demonstrated that blood culture contamination rates are usually higher at teaching hospitals, sometimes exceeding 7%.
(Schifman RB et.al. Arch. Pathol. Lab. Med. 1998.)

Costs

There is an increased length of stay of 3.2 days associated with false positive blood cultures.
(Allain M. Clin Nurs Specialist 2018)

Care for a patient with a false-positive in 2009 cost $8,720 more than care for a patient with a negative blood culture results.
(Gander RM et al. J Clin Microbiol. 2009)

About 60% report that hospitals likely submit CLABSI data to NHSN attributable to blood culture contamination, needlessly exposing the hospital to reduced funding.
(Garcia RA. Am J Infect Control. 2017)

Although only 6% of the blood cultures represented contaminants, their associated cost was more than twice that associated with the 87% that were true negatives.
(Zwang O, et al. J Hosp Med. 2006)

The percent increase in patient charges associated with contaminated blood cultures is approximately 50%.
(Bates DW. Et al. JAMA 1991.)

A 50% reduction in false positives would save approximately twice as much as a 50% reduction in false negatives.
(Zwang O, et al. J Hosp Med. 2006)

False positives increase laboratory costs by approximately 20%.
(Gander RM et al. J Clin Microbiol. 2009)

False positives increase the need for additional cultures and other tests.
(Norberg A. JAMA. 2003.)

False positives are treated with antimicrobials up to one half of the time and associated with a nearly 40% increase in antibiotic charges.
(Madeo M et al. 2005. Emerg. Med. J. 22:810-811.)

False positives increase the workload of technologists and other staff.
(Schifman RB. Arch. Pathol. Lab. Med. 1998.)

Prevention

Skin, however, cannot be sterilized during antisepsis procedures because approximately 20% of bacteria are imbedded within deep layers of the epidermis and dermis.
(Garcia RA. Am J Infect Control. 2015)

Respondents in a national survey reported that 90% of hospital protocols emphasize direct venipuncture.
(Garcia RA. Am J Infect Control. 2017)

About half of blood culture contamination results are shared with the unit where it was collected.
(Garcia RA. Am J Infect Control. 2017)

More than 96% of bacteremias are detected with two or three blood culture sets.
(Cockerill FR et al. Clin. Infect. Dis. 2004. Link)

Direct venipuncture results in fewer contaminated blood cultures.
(Snyder SR. Clin Biochem. 2012)

False positive blood culture rates among phlebotomists (3.1) are lower than among non-phlebotomists (5.6 – 7.4).
(Gander RM et al. J Clin Microbiol. 2009)

The rates of contaminated blood cultures among the various antiseptic agents used to prepare the venipuncture site are not statistically different.
(Story-Roller E, et al. J Clin Microbiol. 2016) (Washer LL, et al. Infect Control Hosp Epidemiol. 2013)

Venipuncture needles soil blood culture specimens with unsterilized skin fragments and increase blood culture contamination rate. Initial specimen diversion technology significantly reduces the rates from venipuncture-obtained blood culture specimens.
(Patton RG, Schmitt T. J Clin Microbiol. 2010)

Only 6% of respondents in a national survey said they discard the initial aliquot of blood prior to inoculating the blood culture bottle for peripheral draws and 54% did for central draws.
(Garcia RA. Am J Infect Control. 2017)

Diversion is credited with having reduced contamination of blood components by 40 to 90% between 1995 and 2007.
(Liumbruno GM, Blood Transfus. 2009)

Reductions in contamination of blood cultures may be realized with diversion volume <1ml, as a 21-gauge culture needle (bore, 0.514 mm) captures a minute plug of skin contaminants. (Patton RG, Schmitt T. J Clin Mic)

Annotated Bibliography

In the past two decades, a significant amount of research has been conducted to identify the limitations of blood culture testing and evaluate potential improvements in education, clinical process, and technology.

The following annotated bibliography includes select studies published in the US from 2006 to present day.

Click on category heading to view studies.

Key Articles

Doern GV, Carroll KC, Diekema DJ, Garey KW, Rupp ME, Weinstein MP, Sexton DJ. A Comprehensive Update on the Problem of Blood Culture Contamination and a Discussion of Methods for Addressing the Problem. Clin Microbiol Rev. 2019 Oct 30;33(1).
University of Iowa Carver College of Medicine, Iowa City, Iowa.

Multiple studies show an increased use of unnecessary antibiotics with Blood Culture Contamination (BCCs) (34-41% of patients) for approximately ~7 days after the contamination.
BCCs result in delays in obtaining the correct diagnosis and initiating appropriate therapy.
All six of the cohort studies evaluated demonstrate consistently increased hospital costs or charges associated with blood culture contamination.

The authors conclude, “It is our opinion, however, that overall institutional rates of <1% are now achievable, and therefore, consideration should be given to the establishment of a new universal threshold value of <1%.” Full text is not available without subscription.

The Centers for Disease Control and Prevention. 2019 AR Threats Report

More than 2.8M antibiotic resistant infections occur in the US each year, and more than 35,000 people die as a result. This means, on average, someone gets an antibiotic resistant infection every 11 seconds and someone dies of this infection every 15 minutes.
One of the three important measures cited is: Slowing the development of resistance through improved antibiotic use.
C. diff is related to antibiotic use and antibiotic resistance, and contributes 224,000 cases and 12,800 deaths each year.

Garcia RA, Spitzer ED, Beaudry J, Beck C, Diblasi R, Gilleeny-Blabac M, Haugaard C, Heuschneider S, Kranz BP, McLean K, Morales KL, Owens S, Paciella ME, Torregrosa E. Multidisciplinary team review of best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremia, reducing contamination, and eliminating false-positive central line-associated bloodstream infections. Am J Infect Control. 2015 Nov 1;43(11):1222-37.
Stony Brook University Hospital, Stony Brook, NY

Skin, however, cannot be sterilized during antisepsis procedures because approximately 20% of bacteria are imbedded within deep layers of the epidermis and dermis.
Blood cultures should be obtained prior to starting antibiotic therapy to optimize the recovery of pathogens.
Estimated up to 50% of all blood cultures originate in the ED. Crowding in EDs is correlated with higher rates.
Improper collection of blood cultures is associated with suboptimal treatment of patients, increased financial burdens, and potential over-reporting of CLABSI.
Costs of a false positive blood culture range from $4500-$10,000.

Full text is not available without subscription.

Gander RM, Byrd L, DeCrescenzo M, Hirany S, Bowen M, Baughman J. Impact of blood cultures drawn by phlebotomy on contamination rates and health care costs in a hospital emergency department. J Clin Microbiol. 2009 Apr;47(4):1021-4.
University of Texas Southwestern Medical Center, Dallas, Texas

Demonstrated the value of phlebotomists in reducing rates of false positive blood cultures.
Phlebotomists had a false positive blood cultures rate of 3.1 which was better than the non-phlebotomists (5.6 and 7.4).
Comparison of median patient charges between negative and false-positive episodes ($18,752 versus $27,472) showed a $8,720 difference while the median length of stay increased from 4 to 5 days.
By utilizing phlebotomists to collect blood cultures in the ED, contamination rates were lowered to recommended levels, with projected reductions in patient charges of approximately $4.1 million per year

Garcia RA, Spitzer ED, Kranz B, Barnes S. A national survey of interventions and practices in the prevention of blood culture contamination and associated adverse health care events. Am J Infect Control. 2018 May;46(5):571-576. Epub 2017 Feb 1.
Stony Brook University Hospital, Stony Brook, NY

80% of respondents report a blood culture contamination rate less than 3%.
90% of hospital protocols emphasize direct venipuncture.
About 60% report that hospitals likely submit CLABSI data to NHSN attributable to blood culture contamination.

Full text is not available without subscription.

Makam AN, Auerbach AD, Steinman MA. Blood culture use in the emergency department in patients hospitalized for community-acquired pneumonia. JAMA Intern Med. 2014 May;174(5):803-6.
University of Texas Southwestern Medical Center, Dallas, Texas

The proportion of cultures collected in the ED during these visits increased from 10% in 2002 to 20% in 2010.
The proportion of cultures collected in patients hospitalized with community-acquired pneumonia (CAP) increased from 29% in 2002 to 51% in 2010, a 76% relative increase.
One potential explanation for increasing culture rates is that the JCAHO/CMS core measure (PN-3b) announced in 2002 mandated that if a culture is collected in the ED, it should be collected prior to antibiotic administration. This encouraged providers to reflexively order cultures in all patients admitted with CAP for whom antibiotic administration is anticipated.

Hall and Lyman. Updated Review of Blood Culture Contamination. Clin Microbiol Rev. 2006 Oct; 19(4): 788–802.
University of Virginia School of Medicine, Charlottesville, Virginia

Rates vary widely from 0.6% to over 6%.
Rates have been on the increase.
Not everyone follows the recommendation of having two samples.
Positive predictive value goes up if two of two blood cultures were positive and both taken from the vein.
Skin antisepsis cannot entirely prevent the contamination of blood cultures

Zwang O, Albert RK. Analysis of strategies to improve cost effectiveness of blood cultures. J Hosp Med. 2006 Sep;1(5):272-6.
Denver Health Med Center, Denver CO

Positive predictive value of a positive blood culture was only 53%.
A 50% reduction in false positives would save approximately twice as much as a 50% reduction in false negatives.
Although only 6% of the blood cultures represented contaminants, their associated cost was more than twice that associated with the 87% that were true negatives.

Self WH, Speroff T, Grijalva CG, McNaughton CD, Ashburn J, Liu D, Arbogast PG, Russ S, Storrow AB, Talbot TR. Reducing blood culture contamination in the emergency department: an interrupted time series quality improvement study. Acad Emerg Med. 2013 Jan;20(1):89-97.
Vanderbilt University School of Medicine, Nashville, TN

The study objective was to develop and evaluate the effectiveness of a quality improvement (QI) intervention for reducing blood culture contamination in an ED.
The QI intervention involved changing the technique of blood culture specimen collection from the traditional clean procedure, to a new sterile procedure, with standardized use of sterile gloves and a new materials kit containing a 2% CHG skin antisepsis device, a sterile fenestrated drape, a sterile needle, and a procedural checklist.
During the baseline period, (4.3%) cultures were contaminated, compared to (1.7%) during the intervention period.

Hall RT, Domenico HJ, Self WH, Hain PD. Reducing the blood culture contamination rate in a pediatric emergency department and subsequent cost savings. Pediatrics. 2013 Jan;131(1):e292-7.
Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, Tennessee

Introduced a standardized sterile collection process to reduce peripheral blood culture contamination rate and unnecessary use of resources.
The peripheral blood culture contamination rate was reduced from 3.9% during the baseline period to 1.6% during the intervention period.
There was a yearly estimated savings of ~$250,000 in hospital charges.

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Technology

Arenas M, Boseman GM, Coppin JD, Lukey J, Jinadatha C, Navarathna DH. Asynchronous Testing of 2 Specimen-Diversion Devices to Reduce Blood Culture Contamination: A Single-site Product Supply Quality Improvement Project. J Emerg Nurs. 2021 Jan 8:S0099-1767(20)30383-4.

Central Texas Veterans Health Care System

This is the first study that has examined successful applications of 2 main commercial devices used to reduce BC contamination, demonstrating that these devices “drastically reduced the blood culture contamination rates (BCCR), irrespective of the volume of initial diversion.”
The facility’s emergency department averaged 250 BC collections per month, with BCCR rates at 3% to 4.7%.
Various QI methods were employed to reduce the ED BCCRs to below 2.5%. Using a transfer device, discarding initial blood by aspiration, and cleaning the site—were unsuccessful as were repeated attempts to use existing process improvement procedures.
The facility decided to compare two devices: Device A (Steripath) is a “a manually triggered vein-to-bottle closed system that isolates the first 1 mL to 2 mL of blood” and Device B (Kurin) uses technology that “passively diverts passively diverts less than 0.15 mL of blood.”
Device A was available to staff for 5 months (664 samples). Kurin was available on the unit for 10 months (1312 samples.)
The mean rate of contamination for Device A was 45% to 86% lower than that for the control and that the mean rate of contamination for Kurin was 63% to 87% lower than that for the control.
The authors note that the findings corroborate the results of the recent publication by O’Sullivan and Steere, who reported that Kurin significantly lowered the BCCR compared with the standard method.

O’Sullivan DM and Steere L. Reducing False-Positive Blood Cultures: Using a Blood Diversion Device. Connecticut Medicine. February 2019; Vol 83(2): Page 53-56.

Hartford Hospital, Hartford CT

Despite having a relatively low 1.7% FPBC rate in their ED, Hartford Hospital significantly reduced the rate an additional 74% to 0.44% with Kurin use.
Using a conservative estimate of $5,000 as the cost of a FPBC, the hospital estimated annual savings of $750,000.
The authors comment that diversion can be accomplished in various ways, but “anything that requires a change in behavior will result in poorer compliance and less effective outcomes.”

Baxter M, Cook C and James A. Passive Engineering Controls Result in Sustained 66% Reduction in Blood Culture Contamination. The Sixth Decennial International Conference on Healthcare-Associated Infections. Abstracts, March 2020: Global Solutions to Antibiotic Resistance in Healthcare. Infection Control & Hospital Epidemiology Volume 41, Issue S1: October 2020, pp.s342-s343.

St. Mary’s Regional Medical Center, Russellville AR

St. Mary’s struggled with contamination rates with a historical average above 6%, which was reduced to ~5% with education.
With Kurin, contamination rates fell from 4.93% to 1.66%, a 66% reduction.
St. Mary’s reported that compliance with Kurin use was 70-75%.
Kurin use prevented over 140 patients from enduring the potential complications of a blood culture contamination.
St. Mary’s estimated that patients with a contaminated culture had an extended stay of almost 4 days compared to those with true negatives.
Using an estimated cost of a contamination at $4,000, the hospital estimates annual savings at >$500,000.

Ostwald C and Whitsell K. Reduction of False Positive Blood Culture Rates using a Passive Blood Diversion Device in an Urban Academic Pediatric Emergency Department. Association for Professionals in Infection Control, June 2021.

John R. Oishei Children’s Hospital

The first study on a device to reduce BCCs in the pediatric population and the first study to use the peripheral IV (PIV) Kurin product line.
Zero BCCs in 1175 cultures using Kurin, compared to 6 BCCs in 65 cultures without the device.
Statistically significant at P=.0001.

Rhew D, Childress W. Decreasing Blood Culture Contamination Rates When Using an Initial Peripheral IV: Implementing the 5s P’s and Using a Closed System Device. Nur Primary Care. 2021; 5(3): 1-6.

Cone Health- Greensboro, NC

Before implementation, 4 of their 5 EDs were above the 3% benchmark.
After a successful pilot, they expanded to 3 more EDs.
Rates went from 3.1% to 1.3% to 0% when using Kurin. Blended rates dropped to 2.1%.

Burnie J and Vining S. Impact on Emergency Department Blood Culture Contamination. Clinical Nurse Specialist: Nov/Dec 2021.

TriHealth, Cincinnati, Ohio

BCCs were reduced 51% in the original facility and over 70% in the second hospital, which was added because of these initial significant results. These lower rates have been sustained for over two years.
An internal study estimated an average cost of a BCC at $5863, with an average extended length of stay of 2.65 days.
Savings were estimated at almost $2M during this period.
Nearly 250 patients benefited from the introduction of Kurin.

Hodson J, Stebbing J, Graham C and O’ Donnell S. Reducing False-Positive Blood Cultures in Adult A&E using a Initial Specimen Diversion Device. Infection Prevention Society Conference, Liverpool, England, September 2021.

Guy’s and St. Thomas’ NHS Foundation Trust, London, England

A trial took place at Guy’s and St. Thomas’ NHS Foundation Trust, a prestigious hospital in London, among emergency patients (referred to as A&E in the UK).
Over 500 samples were collected with blood culture contamination rates being reduced from 6% to “under 2%”—a 66% reduction.
The authors concluded that Kurin can save the hospitals money and have a positive impact on their patients.

Arnaout S, Ellison III RT, Greenough TC, Wedig A, Mitchell MJ, St. John L and Stock S. Prospective Trial of Passive Diversion Device to Reduce Blood Culture Contamination. ID Week, Sept/Oct 2021.

UMass Memorial Medical Center, Worcester, MA

UMass Memorial Medical Center summarized Kurin trial data in two ways: when the product was intended to be used and when it was actually used.
Two ED sites were involved in the trial, with one ED using Kurin for ten weeks, while the other used their standard technique. After a wash out period, the two EDs switched roles.
~5600 cultures were collected during the trial, about half of which were drawn with Kurin.
The “observed” contamination rate, when Kurin was used, showed a reduction from 3% to 1.1%, a 63% decrease.
There was no change in true positive rates.
UMass used a cost of $7,000 per contaminated culture, yielding a cost savings calculation of $1.8M in the “observed” rate.
They reported an increased LOS of 1.3 days for contaminated cultures, which translates to 343 avoided hospital days per year.
Compliance averaged 50-60%.

Sutton J, Fritsch P, MoodyM, Dinaro K, Holder C. Preventing Blood Culture Contamination using a Novel Engineered Passive Blood Diversion Device. Association for Professionals in Infection Control, June 2018 Minneapolis, MN [Abstract: EI – 101]

Bayfront Health St. Petersburg, St. Petersburg, FL

The reduction in the contamination rate of 0.025 to 0.012 was statistically significant.
During the post-intervention period, the diversion device was not used in 8 out of 9 contaminated cultures.
The diversion device was utilized in only 50% of blood draws during the post-intervention period.
The hospital estimates that each false positive blood culture adds $7,500 in costs, so implementing Kurin would save the hospital over $500,000 annually, after the cost of the product.

Allain, M. Top Scoring Abstracts From the 2018 National Association of Clinical Nurse Specialists Annual Conference: Not Your ‘‘Average’’ ED: A CNS-Led Project That Reduced Blood Culture Contaminations in One Emergency Department to Below Expected Levels. Clin Nurs Specialist 2018 May/June; E1-2

Crouse Hospital, Syracuse, NY

Baseline rates varied between 1.6 and 2.1%.
While using Kurin, rates fell to 0.8%, 50% below their best performance and 57% below their mean performance.
7 of 9 contaminations during the study period occurred when Kurin was not used.
Using cost of contaminated cultures of $5200, Allain calculated that the hospital would save more than $185,000 per year.
There was an increased length of stay of 3.2 days associated with false positive blood cultures.

Bell M, Bogar C, Plante J, Rasmussen K, Winters S. Effectiveness of a Novel Specimen Collection System in Reducing Blood Culture Contamination Rates. J Emerg Nurs. 2018 Apr 20. pii: S0099-1767(17)30148-4.

Lee Health Fort Meyers, FL; Cape Coral, FL.

Study data was limited to only those blood cultures collected with the device. It does not reflect the impact on the overall blood culture contamination rate.
The data showed an 82.8% reduction in false positives.
Based on the historical 3.52% rate of blood-culture contamination for the health facilities, 2.92 false positives were prevented for every 100 blood cultures drawn.

Full text is not available without subscription.

Rupp ME, Cavalieri RJ, Marolf C, Lyden E. Reduction in Blood Culture Contamination Through Use of Initial Specimen Diversion Device. Clin Infect Dis. 2017 Jul 15;65(2):201-205.

University of Nebraska Medical Center, Omaha, NE

Study data was limited to only those blood cultures collected with the device. It does not reflect the impact on the overall blood culture contamination rate.
False positives increase laboratory costs by approximately 20%, are associated with a nearly 40% increase in antibiotic charges and can extend the length of hospital stay by up to 5 days.
False positive blood culture rate decreased from 1.78% to 0.22% with use of an Initial Specimen Diversion Device (ISDD).

Patton RG, Schmitt T. Innovation for Reducing Blood Culture Contamination: Initial Specimen Diversion Technique. J Clin Microbiol. 2010 Dec;48(12):4501-3.

Northwest Hospital and Medical, Seattle, WA.

>0.5ml and <2ml is adequate diversion to significantly reduce contamination.
Initial specimen diversion technology reduced contamination of blood cultures by excluding contaminants from the first portion of the venipuncture-obtained culture specimen.

Behavioral Change/Education/Protocols

Moeller D. Eliminating Blood Culture False Positives: Harnessing the Power of Nursing Shared Governance. J Emerg Nurs. 2017 Mar;43(2):126-132.
Advocate Health, Illinois

A new process decreased the blood culture contamination rate from a baseline rate of 5.37% to 1.76%.
The chief recommendation is to engage staff through clinical leadership.

Full text is not available without subscription.

Bowen CM, Coleman T, Cunningham D. Reducing Blood Culture Contaminations in the Emergency Department: It Takes a Team. J Emerg Nurs. 2016 Jul;42(4):306-11.
Kennedy Health, Cherry Hill, NJ.

The plan targeted environmental and skin contaminates, teamwork, education, and feedback.
During the 8-week pilot, the monthly contamination rates were 1.96% and 0.3%, respectively. Subsequent data over 1 year revealed the contamination rates ranged from 0.2% to 1.51%, with a mean of 0.87%.

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Sinnott PL, Breckenridge JS, Helgerson P, Asch S. Using lean management to reduce blood culture contamination. Jt Comm J Qual Patient Saf. 2015 Jan;41(1):26-2.
Palo Alto Health Care System, Menlo Park, California, USA

Reduce the blood culture contamination rate using Lean management quality improvement methods, including a rapid process improvement workshop to identify root causes of variation in blood culture procedures and countermeasures (potential improvement strategies) to address each problem.
The blood culture contamination rate decreased significantly from 4.2% in the 19-month baseline period to 2.8% in the last 12 months of follow-up.
An estimated 261 contaminated blood culture were avoided in the follow-up period.

Full text is not available without subscription.

Self WH, Talbot TR, Paul BR, Collins SP, Ward MJ. Cost analysis of strategies to reduce blood culture contamination in the emergency department: sterile collection kits and phlebotomy teams. Infect Control Hosp Epidemiol. 2014 Aug;35(8):1021-8.
Vanderbilt University School of Medicine, Nashville, TN

Compared hospital costs associated with three collection strategies: usual care, sterile kits, and phlebotomy teams.
Baseline contamination rates associated with usual care, sterile kits, and phlebotomy teams were 4.34%, 1.68%, and 1.10%, respectively.
Compared to usual care, annual net savings using the sterile kit and phlebotomy team strategies were $483,219 and $288,980, respectively.

Self WH, Mickanin J, Grijalva CG, Grant FH, Henderson MC, Corley G, Blaschke Ii DG, McNaughton CD, Barrett TW, Talbot TR, Paul BR. Reducing blood culture contamination in community hospital emergency departments: a multicenter evaluation of a quality improvement intervention. Acad Emerg Med. 2014 Mar;21(3):274-82.
Vanderbilt University School of Medicine, Nashville, TN.

Measured the effect of implementing a sterile blood culture collection process.
At Hospital A, during the baseline period, 165 of 3,417 (4.83%) cultures were contaminated as compared to 142 of 5,238 (2.71%) during the intervention period. At Hospital B, during the baseline, 63 of 2,509 (2.51%) cultures were contaminated. But with the full sterile process, 51 of 1,865 (2.73%) cultures were contaminated.
Hospital B experienced poor adherence. So, a simplified sterile process used during intervention period 2 was associated with a significant reduction in contamination, with 17 of 1,860 (0.91%) cultures contaminated.
Monitoring the implementation process was important to identify and overcome operational challenges.

Marini MA, Truog AW. Reducing false-positive peripheral blood cultures in a pediatric emergency department. J Emerg Nurs. 2013 Sep;39(5):440-6.
Children’s Hospital Boston, Boston, MA, USA.

Reduced the rate of false-positive peripheral blood cultures using blood culture kits, a dedicated team obtaining peripheral blood cultures, and following up with staff who draw a contaminated peripheral blood cultures.
The rate of false-positive peripheral blood cultures decreased from the baseline rate of 2.1%. to 1.4%.

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Weddle G, Jackson MA, Selvarangan R. Reducing blood culture contamination in a pediatric emergency department.Pediatr Emerg Care. 2011 Mar;27(3):179-81.
Children’s Mercy Hospitals and Clinics, Kansas City, MO

Reduced the rate of false-positive peripheral blood cultures by educating staff about hospital policy, using a blood culture-drawing kit, having a dedicated team obtaining peripheral blood cultures, and following up with staff who draw a contaminated peripheral blood culture.
The false-positive peripheral blood culture rate in the emergency department dropped from 2.1% to 1.4%.
Before intervention, 44 patients were called back to the emergency department, and 25 were admitted because of blood culture contamination. After intervention, a total of 9 patients were called back, and 5 were admitted.

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Harding AD, Bollinger S. Reducing blood culture contamination rates in the emergency department. J Emerg Nurs. 2013 Jan; 39(1): e1-6.
Southcoast Hospitals Group, New Bedford, MA, USA

Developed and implemented a corrective action plan to lower contamination rates including: private conversations with staff members associated with higher numbers of contaminated draws, ensuring availability of necessary blood culture collection supplies, re-education of all staff surrounding blood culture collection best practices, monthly feedback on blood culture contamination rates, and continuing private conversations as necessary.
The average rate of blood culture contamination dropped from 1.82% to 1.01% after the interventions, a 44% decrease in hospital-wide blood culture contamination rates.
Annualized cost avoidance of approximately $614,000.

Boyce JM, Nadeau J, Dumigan D, Miller D, Dubowsky C, Reilly L, Hannon CV. Obtaining blood cultures by venipuncture versus from central lines: impact on blood culture contamination rates and potential effect on central line-associated bloodstream infection reporting. Infect Control Hosp Epidemiol. 2013 Oct;34(10):1042-7.
Yale-New Haven Hospital, New Haven, Connecticut

Evaluated the impact of a new blood culture policy that discouraged drawing blood samples from central lines.
The proportion of blood samples obtained for culture from central lines decreased from 10.9% to 0.4%.
The proportion of blood cultures that were contaminated decreased from 84 (1.6%) of 5,274 to 21 (0.5%) of 4,245.
Based on estimated excess hospital costs of $3,000 per contaminated blood culture, the reduction in CBCs yielded an estimated annualized savings of $378,000 in 2012 when compared to 2010.
In mid-2010, 3 (30%) of 10 reported CLABSIs were suspected contamination compared with none of 6 CLABSIs reported from mid-November 2010 through June 2012.

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Snyder SR, Favoretto AM, Baetz RA, Derzon JH, Madison BM, Mass D, Shaw CS, Layfield CD, Christenson RH, Liebow EB. Effectiveness of practices to reduce blood culture contamination: A Laboratory Medicine Best Practices systematic review and meta-analysis. Clin Biochem. 2012 Sep;45(13-14):999-1011.
Battelle Centers for Public Health Research and Evaluation, Associated Laboratory Consultants, Centers for Disease Control and Prevention, University of Maryland, United States

Review the effectiveness of three practices for reducing blood culture contamination rates: venipuncture, phlebotomy teams, and prepackaged preparation/collection (prep) kits.
All studies for venipuncture and phlebotomy teams favored these practices. For prep kits 6 studies’ effect sizes were not statistically significantly different from no effect.

Murillo TA, Beavers-May TK, English D, Plummer V, Stovall SH. Reducing contamination of peripheral blood cultures in a pediatric emergency department. Pediatr Emerg Care. 2011 Oct;27(10):918-21.
Arkansas Children’s Hospital, Little Rock, AR

Determined the ED Contamination rate and evaluate an educational intervention.
Positivity rate during the pre-study phase was 6.8%; 114 were contaminants and 40 were pathogens. Positivity rate during the intervention phase was 6.3%; 124 were contaminants and 33 were pathogens.
Contamination rates of individual practitioners ranged from 0% to 17% (PRE) and from 0% to 21% (POST).
The rate in the ED for peripherally drawn blood cultures is approximately 5% monthly. For each culture positive for organism, the chance of contamination is 75% or higher.

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Skin Antisepsis

Story-Roller E, Weinstein MP. Chlorhexidine versus Tincture of Iodine for Reduction of Blood Culture Contamination Rates: A Prospective Randomized Crossover Study. J Clin Microbiol. 2016 Dec;54(12):3007-3009.
Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

Of the 6,095 total blood culture sets obtained, 667 (10.94%) were positive and 238 (3.90%) were contaminated.
Of the 3,130 blood cultures obtained using IT, 340 (10.86%) were positive and 123 (3.93%) were contaminated. Of the 2,965 blood cultures obtained using CHG, 327 (11.03%) were positive, and 115 (3.88%) were contaminated.
The rates of contaminated blood cultures between the two antiseptic agents were not different statistically.

Septimus EJ, Hayden MK, Kleinman K, Avery TR, Moody J, Weinstein RA, Hickok J, Lankiewicz J, Gombosev A, Haffenreffer K, Kaganov RE, Jernigan JA, Perlin JB, Platt R, Huang SS. Does chlorhexidine bathing in adult intensive care units reduce blood culture contamination? A pragmatic cluster-randomized trial. Infect Control Hosp Epidemiol. 2014 Oct; 35 Suppl 3: S17-22.
Hospital Corporation of America, Nashville, Tennessee.

Universal decolonization with CHG bathing resulted in a significant reduction in blood culture contamination.

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Washer LL, Chenoweth C, Kim HW, Rogers MA, Malani AN, Riddell J 4th, Kuhn L, Noeyack B Jr, Neusius H, Newton DW, Saint S, Flanders SA. Blood culture contamination: a randomized trial evaluating the comparative effectiveness of 3 skin antiseptic interventions. Infect Control Hosp Epidemiol. 2013 Jan;34(1):15-21.
University of Michigan Health System

The overall blood culture contamination rate for the study population was 0.76%.
Intent-to-treat rates of contaminated blood cultures were not significantly different among the 3 antiseptics.

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Marlowe L, Mistry RD, Coffin S, Leckerman KH, McGowan KL, Dai D, Bell LM, Zaoutis T. Blood culture contamination rates after skin antisepsis with chlorhexidine gluconate versus povidone-iodine in a pediatric emergency department. Infect Control Hosp Epidemiol. 2010 Feb;31(2):171-6.
University of Pennsylvania School of Medicine, Philadelphia, USA.

The blood culture contamination rate decreased from 24.81 to 17.19 contaminated cultures per 1,000 cultures after implementation of chlorhexidine, a 30% relative decrease.
Skin antisepsis with chlorhexidine significantly reduces the blood culture contamination rate among young children, as compared with povidone-iodine.

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*Alahmadi YM, Aldeyab MA, McElnay JC, Scott MG, Darwish Elhajji FW, Magee FA, Dowds M, Edwards C, Fullerton L, Tate A, Kearney MP. Clinical and economic impact of contaminated blood cultures within the hospital setting. J Hosp Infect. 2011 Mar;77(3):233-6.

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