Blood Culture

Definition
Purpose
Description
Preparation
Aftercare
Normal results
Abnormal results
Morbidity and mortality rates
Precautions
Side effects

Definition

A blood culture is done when a person has symptoms of a blood infection, also called bacteremia. Blood is drawn from the person one or more times and is tested in a laboratory to find and identify any microorganism present and growing in the blood. If a microorganism is found, more testing is done to determine the antibiotics that will be effective in treating the infection.

Purpose

Bacteremia is a serious clinical condition and can lead to death . To give the best chance for effective treatment and survival, a blood culture is done as soon as an infection is suspected.

Symptoms of bacteremia are fever, chills, mental confusion, anxiety, rapid heart beat, hyperventilation, blood clotting problems, and shock. These symptoms are especially significant in a person who already has another illness or infection, is hospitalized, or has trouble fighting infections because of a weak immune system. Often, the blood infection results from an infection somewhere else in the body that has spread.

Additionally, blood cultures are done to find the causes of other infections. These include bacterial pneumonia (an infection of the lung), and infectious endocarditis (an infection of the inner layer of the heart). Both of these infections leak bacteria into the blood.

After a blood infection has been diagnosed, confirmed by culture, and treated, an additional blood culture may be done to make sure the infection is gone.

Description

Culture strategies

There are many variables involved in performing a blood culture. Before the person’s blood is drawn, the physician must make several decisions based on a knowledge of infections and the person’s clinical condition and medical history.

Several groups of microorganisms, including bacteria, viruses, mold, and yeast, can cause blood infections. The bacteria group can be further broken down into aerobes and anaerobes. Most microbes do not need oxygen to live. They can grow with oxygen (aerobic microbes) or without oxygen (anaerobic microbes).

Based on the clinical condition of the patient, the physician determines what group of microorganisms is likely to be causing the infection and then orders one or more specific types of blood culture, including aerobic, anaerobic, viral, or fungal (for yeasts and molds). Each specific type of culture is handled differently by the laboratory. Most blood cultures test for both aerobic and anaerobic microbes. Fungal, viral, and mycobacterial blood cultures can also be done, but are less common.

The physician must also decide how many blood cultures should be done. One culture is rarely enough; two to three are usually adequate. Four cultures are occasionally required. Some factors influencing this decision are the specific microorganisms the physician expects to find based on the person’s symptoms or previous culture results, and whether or not the person has had recent antibiotic therapy.

The time at which the cultures are to be drawn is another decision made by the physician. During most blood infections (called intermittent bacteremia) microorganisms enter the blood at various time intervals. Blood drawn randomly may miss the microorganisms. Since microorganisms enter the blood 30-90 minutes before the person’s fever spikes, collecting the culture just after the fever spike offers the best likelihood of finding the microorganism. The second and third cultures may be collected at the same time, but from different places on the person, or spaced at 30-minute or one-hour intervals, as the physician chooses. During continuous bacteremia, such as infective endocarditis, microorganisms are always in the blood and the timing of culture collection is less important. Blood cultures should always be collected before antibiotic treatment has begun.

Laboratory analysis

Bacteria are the most common microorganisms found in blood infections. Laboratory analysis of a bacterial blood culture differs slightly from that of a fungal culture and significantly from that of a viral culture.

Blood is drawn from a person and put directly into a blood culture bottle containing a nutritional broth. After the laboratory receives the blood culture bottle, several processes must be completed:

• provide an environment for the bacteria to grow;
• detect the growth when it occurs;
• identify the bacteria that grow; and
• test the bacteria against certain antibiotics to determine which antibiotic will be effective.

There are several types of systems, both manuaand automated, available to laboratories to carry outhese processes.

The broth in the blood culture bottle is the first step in creating an environment in which bacteria will grow. It contains all the nutrients that bacteria need to grow. If the physician expects anaerobic bacteria to grow, oxygen will be kept out of the blood culture bottle; if aerobes are expected, oxygen will be allowed in the bottle.

The bottles are placed in an incubator and kept at body temperature. They are watched daily for signs of growth, including cloudiness or a color change in the broth, gas bubbles, or clumps of bacteria. When there is evidence of growth, the laboratory does a gram stain and a subculture. To do the gram stain, a drop of blood is removed from the bottle and placed on a microscope slide. The blood is allowed to dry and then is stained with purple and red stains and examined under the microscope. If bacteria are seen, the color of stain they picked up (purple or red), their shape (such as round or rectangular), and their size provide valuable clues as to what type of microorganism they are and what antibiotics might work best. To do the subculture, a drop of blood is placed on a culture plate, spread over the surface, and placed in an incubator.

If there is no immediate visible evidence of growth in the bottles, the laboratory looks for bacteria by doing gram stains and subcultures. These steps are repeated daily for the first several days and periodically after that.

When bacteria grows, the laboratory identifies it using biochemical tests and the gram stain. Sensitivity testing, also called antibiotic susceptibility testing, is also done. The bacteria are tested against many different antibiotics to see which antibiotics can effectively kill it.

All information is passed on to the physician as soon as it is known. An early report, known as a preliminary report, is usually available after one day. This report will tell if any bacteria have been found yet and, if so, the results of the gram stain. The next preliminary report may include a description of the bacteria growing on the subculture. The laboratory notifies the physician immediately when an organism is found and as soon as sensitivity tests are complete. Sensitivity tests may be complete before the bacteria is completely identified. The final report may not be available for five to seven days. If bacteria was found, the report will include its complete identification and a list of the antibiotics to which the bacteria is sensitive.

One automated system is considered one of the most important technical advances in blood cultures. It is called continuous-monitoring blood culture systems (CMBCS). The instruments automatically monitor the bottles containing the patient blood for evidence of microorganisms, usually every 10 minutes. Many data points are collected daily for each bottle, and fed into a computer for analysis. Sophisticated mathematical calculations can determine when microorganisms have grown. This, combined with more frequent blood tests, make it possible to detect microbial growth earlier. In addition, all CMBCS instruments have the detection system, incubator, and agitation device in one unit.

Preparation

Ten ml (milliliter) of blood is usually needed for each blood culture bottle. First a healthcare worker locates a vein in the inner elbow region. The area of skin where the blood will be drawn must be disinfected to prevent any microorganisms on a person’s skin from entering the blood culture bottle and contaminating it. The area is disinfected by wiping the area with alcohol in a circular fashion, starting with tiny circles at the spot where the needle will puncture the skin and enlarging the size of the circles while wiping away from the puncture site. The same pattern of wiping is repeated using an iodine or iodophor solution. The top of the bottle is disinfected using alcohol. After the person’s skin has been disinfected, the healthcare worker draws the blood and about 10 ml of blood is injected into each blood culture bottle. The type of bottles used will vary based on whether the physician is looking for bacteria (aerobes or anaerobes), yeast, mold, or viruses.

Aftercare

Discomfort or bruising may occur at the puncture site or the person may feel dizzy or faint. Pressure to the puncture site until the bleeding stops reduces bruising. Warm packs relieve discomfort.

Normal results

Normal results will be negative. A single negative culture does not rule out a blood infection. False negatives can occur if the person was started on antibiotics before the blood was drawn, if the environment for growth was not right, the timing was off, or for some unknown reason the microorganism just didn’t grow. Three negative cultures may be enough to rule out bacteremia in the case of endocarditis.

Abnormal results

The physician’s skill in interpreting the culture results and assessing the person’s clinical condition is essential in distinguishing a blood culture that is truly positive from a culture that is positive because it became contaminated. In true bacteremia, the patient’s clinical condition should be consistent with a blood infection caused by the microorganism that was found. The microorganism is usually found in more than one culture, it usually grows soon after the bottles are incubated, and it is often the cause of an infection somewhere else in the person’s body.

When the culture is positive because of contamination, the patient’s clinical condition usually is not consistent with an infection from the identified microorganism. In addition, the microorganism is often one commonly found on skin, it rarely causes infection, it is found in only one bottle, and it may appear after several days of incubation. More than one microorganism often grow in contaminated cultures.

Morbidity and mortality rates

Morbidity rates are miniscule. The most common problems are minor bleeding and bruising. Since neither are reportable events, morbidity can only be estimated. Mortality is essentially zero.

Precautions

The only precaution needed is to clean the venipuncture site with alcohol.

Side effects

The most common side effects of a blood culture are minor bleeding and bruising.

Resources

BOOKS

Fischbach, F. T. and M. B. Dunning. A Manual of Laboratory and Diagnostic Tests, 8th ed. Philadelphia: Lippincott Williams & Wilkins, 2008.

McGhee, M. A Guide to Laboratory Investigations, 5th ed. Oxford, UK: Radcliffe Publishing Ltd., 2008.

Price, C. P. Evidence-Based Laboratory Medicine: Principles, Practice, and Outcomes, 2nd ed. Washington, DC: AACC Press, 2007.

Scott, M. G., A. M. Gronowski, and C. S. Eby. Tietz’s Applied Laboratory Medicine, 2nd ed. New York: Wiley-Liss, 2007.

Springhouse Corp. Diagnostic Tests Made Incredibly Easy!, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2008.

PERIODICALS

Dagogo-Jack, S., M. M. Funnell, and J. Davidson. “Barriers to achieving optimal glycemic control in a multi-ethnic society: a US focus.” Current Diabetes Reviews 2, no. 3 (August 2006): 285–293.

Dosanjh, D. P., T. S. Hinks, J. A. Innes, et al. “Improved diagnostic evaluation of suspected tuberculosis.” Annals of Internal Medicine 148, no. 5 (March 2008): 325–336.

Haylock, D. N., and S. K. Nilsson. “Expansion of umbilical cord blood for clinical transplantation.” Current Stem Cell Research and Therapy 2, no. 4 (December 2007): 324–335.

Tavil, B., Y. I. Balci, I. Yildirim, G. Secmeer, M. Ceyhan, and M. Turncer. “Linezolid-induced reversible bicyto-penia in a 4-year-old boy with methicillin-resistant Staphylococcus aureus bacteremia.” Pediatric Hematology and Oncology 25, no. 1 (January 2008): 67–71.

OTHER

American Clinical Laboratory Association. Information about clinical chemistry. http://www.clinical-labs.org/ (February 24, 2008).

Clinical Laboratory Management Association. Information about clinical chemistry. http://www.clma.org/ (February 22 2008).

Lab Tests Online. Information about lab tests. http://www.labtestsonline.org/ (February 24, 2008).

National Accreditation Agency for Clinical Laboratory Sciences. Information about laboratory tests. http://www.naacls.org/ (February 25, 2008).

ORGANIZATIONS

American Association for Clinical Chemistry, 1850 K Street, NW, Suite 625, Washington, DC, 20006, (800) 892-1400, http://www.aacc.org/AACC/.

American Society for Clinical Laboratory Science, 6701 Democracy Blvd., Suite 300, Bethesda, MD, 20817, (301) 657-2768, http://www.ascls.org/.

American Society for Clinical Pathology, 1225 New York Ave., NW, Suite 250, Washington, DC, 20005, (202) 347-4450, http://www.ascp.org/.

College of American Pathologists, 325 Waukegan Rd., Northfield, IL, 60093-2750, (800) 323-4040, http://www.cap.org/apps/cap.portal.

L. Fleming Fallon, Jr., M.D., Dr.P.H.