Infection Control & Hospital Epidemiology (2019), 40, 457–459 doi:10.1017/ice.2019.37
Commentary
Drawing blood cultures through intravascular catheters: Controversy and update
Leonard A. Mermel DO, ScM1,2,3 1Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, 2Division of Infectious Diseases, Rhode Island Hospital, Providence, Rhode Island and 3Department of Epidemiology and Infection Control, Rhode Island Hospital, Providence, Rhode Island
Abstract
Studies published between 1999 and 2011 demonstrated increased blood culture contamination with catheter-drawn cultures compared with percutaneously-drawn cultures. Studies published between 2012 and 2015 reported that use of antiseptic barrier caps on central venous catheter hubs significantly reduces the incidence of catheter-drawn blood culture contamination. Local guidelines regarding sites for blood culture collection should reflect institution-level blood culture contamination rates for percutaneously-drawn and catheter-drawn cultures using currently available technologies that reduce contamination at both sites.
(Received 8 January 2019; accepted 5 February 2019)
A recommendation in the 2009 Infectious Disease Society of America (IDSA) guidelines for diagnosing and managing intravas- cular catheter infections suggests obtaining blood cultures through a catheter lumen and percutaneously.1 This has led to concern that the recommendation promotes false-positive, catheter-drawn blood cultures, resulting in unnecessary antibiotic use, inflated rates of central-line–associated bloodstream infections reported to Center for Disease Control and Prevention (CDC)’s National Healthcare Safety Network, and higher Hospital-Associated Condition scores reported to the Centers for Medicare andMedicaid (CMS).Arecent survey found that 90%of responding hospitals had protocols recom- mending that blood cultures should be obtained percutaneously rather than through central venous catheters,2 ameasure that reflects diagnostic stewardship efforts.3 Concern about increased risk of blood culture contaminationwhen blood is obtained through a cath- eter is primarily based on studies published several years ago, prior to use of antiseptic barrier caps (so-called ‘port protectors’), which passively disinfect the surface of needleless connectors used on cath- eter hubs, thereby reducing the surface bioburden and risk of intra- luminal microbial ingress. What was the evidence then and what is it now? A meta-analysis of studies published between 1999 and 2011
found increased blood culture contamination with catheter-drawn cultures compared with percutaneously-drawncultures (odds ratio [OR], 2.69; 95% CI, 2.03–3.57) with moderate study heterogeneity (Q=19.5; P=.012).4 Some of these studies were done before wide- spread use of needleless connectors on catheter hubs; none were conducted in the era of antiseptic barrier cap use5 nor with technologies that divert an initial aliquot of blood.6,7Amultimodal infection prevention program involved use of (1) a blood culture collection kit, (2) a 2-nurse protocol for blood culture collection,
Author for correspondence: Leonard A. Mermel, Email:
lmermel@lifespan.org Cite this article: Mermel LA. (2019). Drawing blood cultures through intravascular
catheters: Controversy and update. Infection Control & Hospital Epidemiology, 40: 457–459,
https://doi.org/10.1017/ice.2019.37
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
and/or (3) limiting catheter-drawn cultures (if such cultures were needed, the needleless connector was removed and the catheter hub was scrubbed before obtaining samples for blood cultures).8 In the first 6 months of 2010 (baseline), 2011, and 2012, contami- nation rates of percutaneously-drawn blood cultures were 0.9% (40 of 4,353), 0.8% (39 of 4,733), and 0.5% (21 of 4,206), respectively. For the same periods for catheter-drawn cultures, contamination rates were 4.8% (84 of 5,274), 1.3% (3 of 227), and 0% (0 of 39), respectively. That is, contamination rates combining 2011 and 2012 data of 0.67% and 1.1%, respectively, for percutaneously- drawn and catheter-drawn blood cultures [RR, 1.7; 95% CI, 0.5–5.3]). Notably, antiseptic barrier caps were not used. Lack of compliance with routine scrubbing of catheter needle-
less connectors before accessing for any purpose, such as obtaining blood cultures, has led to a recommendation to change the needle- less connector before blood culture collection (
https://www.ins1. org/Store/
ProductDetails.aspx?productId=113266). The evidence for this recommendation comes from a single publication.9 The investigators found greater concordance with percutaneously- drawn blood cultures if blood was obtained using a new needleless connector rather than an old connector. However, a recent survey found that 48% of hospitals simply remove old connectors and draw blood directly from catheter hubs rather than through a nee- dleless connector.2 This practice is supported by a study that dem- onstrated colonization of 12% and 6.7% of central venous catheter needleless connectors and hubs after removal of the connectors, respectively.10 In this study, antiseptic barrier caps were not used, and the higher colonization rate of the connectors may, in part, reflect a more sensitive laboratory method used for the needleless connector culture. A meta-analysis that excluded low-quality methodology
studies revealed that antiseptic barrier caps reduce central-line– associated bloodstream infections (incidence rate ratio [IRR], 0.66; 95%confidence interval [CI], 0.53–0.83).5 Cluster-randomized trials involving hemodialysis catheters have also demonstrated
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122
