1. Blood Culture

2. Aim of the test :-  An etiological diagnosis of bacteremia by aerobic and anaerobic cultivation of the blood, with identification and susceptibility test of the isolated organism(s).  Blood culture should be made for cases with suspected septicemia, endocarditis, and bacteremia secondary to localized infections (pneumonia, intra abdominal abscesses, pyelonephritis, epiglottitis, meningitis). In this case the blood culture may provide an etiological diagnosis of the localized infection. Types of specimen:-  Whole blood. Aim of the test :-  An etiological diagnosis of bacteremia by aerobic and anaerobic cultivation of the blood, with identification and susceptibility test of the isolated organism(s).  Blood culture should be made for cases with suspected septicemia, endocarditis, and bacteremia secondary to localized infections (pneumonia, intra abdominal abscesses, pyelonephritis, epiglottitis, meningitis). In this case the blood culture may provide an etiological diagnosis of the localized infection. Types of specimen:-  Whole blood. Introduction:-

3. Criteria of specimen rejection :-  Blood collected in tubes or bottles other than aerobic and anaerobic blood culture bottles.  If the information on the label does not match that of the request form.  Specimens for anaerobic blood culture received in aerobic bottles or vice versa.

4. Common pathogens Streptococcus sppBacteroides fragilis and other anaerobic bacteria Staphylococcus aureusCoagulase negative staphylococci Listeria monocytogenesEnteric gram negative bacilli Corynebacterium jeikeiumNeisseria meningitides Haemophilus influenzaNon fermenter gram negative bacilli Salmonella typhiPseudomonas aeruginosa Parasitic infection Parasite can be found as transiently in the blood stream for example tachyzoites of Toxoplasma gondii Viruses Epstein barr virusHIV virus CytomegalovirusOther human Retroviruses Fungi Candida albicansCryptococcus neoformans Other candida sppCoccidoides immitis Histoplasma capsulatum

5. Types of Bacteremia:-  Bacteremia maybe transient, continuous, or intermittent.  The two major categories of blood stream infections are intravascular those that originate within the cardiovascular system and extravascular those that originate from bacteria entering the blood circulation through the lymphatic system from another site of infection.  Bacteremia maybe transient, continuous, or intermittent.  The two major categories of blood stream infections are intravascular those that originate within the cardiovascular system and extravascular those that originate from bacteria entering the blood circulation through the lymphatic system from another site of infection.

6. Specimen Collection:-  Blood cultures should be drown prior to initiation of antimicrobial therapy, if more than one culture is ordered the specimens should be drawn separately at no less than 30 minutes apart to rule out the possibility of transient bacteremia by self- manipulation by the patient of mucous membrane in the mouth or by local irritation caused by scratching of the skin.  The numbers of bacteria are generally higher in the acute, initial stage than at a later stage of the disease, and small children usually have higher numbers of bacteria in the blood than adults. The number is also higher when the fever rises than when it is falling.  For patients expected to seed bacteria intermittently into the blood 80% of these are detected with the first culture and 99% within the three cultures.  Blood cultures should be drown prior to initiation of antimicrobial therapy, if more than one culture is ordered the specimens should be drawn separately at no less than 30 minutes apart to rule out the possibility of transient bacteremia by self- manipulation by the patient of mucous membrane in the mouth or by local irritation caused by scratching of the skin.  The numbers of bacteria are generally higher in the acute, initial stage than at a later stage of the disease, and small children usually have higher numbers of bacteria in the blood than adults. The number is also higher when the fever rises than when it is falling.  For patients expected to seed bacteria intermittently into the blood 80% of these are detected with the first culture and 99% within the three cultures.

7. Collection Time:-  Before starting antibiotics therapy if time permits, its generally recommended that the first two sets of blood cultures be taken one hour apart and the third set after 3-6 hours.  Obtaining the blood culture one half hour before a temperature spike is ideal because the highest concentration of organisms are circulating at that time, because the temperature spike is usually un predictable an educated guess must suffice in most cases when timing blood cultures.  Before starting antibiotics therapy if time permits, its generally recommended that the first two sets of blood cultures be taken one hour apart and the third set after 3-6 hours.  Obtaining the blood culture one half hour before a temperature spike is ideal because the highest concentration of organisms are circulating at that time, because the temperature spike is usually un predictable an educated guess must suffice in most cases when timing blood cultures.

8. Collection of Blood for Culturing:-  During blood culture collection all percussion should be taken to minimize the percentage of contaminated blood culture, to reduce the chance of contaminating organisms from the skin the vein puncture site should ideally be prepared as follows; 1. Wash with soap, rinse with sterile water or saline. 2. Apply 1-2 % tincture of iodine or povidone –iodine and allow drying for 1-2 minutes. 3. Remove the iodine with 70 % alcohol wash, if the site again be palpated after the iodine – alcohol preparation the finger must be disinfected or sterile gloves worn.  A tourniquet is applied to the upper arm above the vein puncture site to distend the anticubital veins.  During blood culture collection all percussion should be taken to minimize the percentage of contaminated blood culture, to reduce the chance of contaminating organisms from the skin the vein puncture site should ideally be prepared as follows; 1. Wash with soap, rinse with sterile water or saline. 2. Apply 1-2 % tincture of iodine or povidone –iodine and allow drying for 1-2 minutes. 3. Remove the iodine with 70 % alcohol wash, if the site again be palpated after the iodine – alcohol preparation the finger must be disinfected or sterile gloves worn.  A tourniquet is applied to the upper arm above the vein puncture site to distend the anticubital veins.

9. Collection of Blood for Culturing:-  Remove Flip Caps from the tops of the selected culture bottles. Disinfect the septa of the bottles with alcohol or iodine preparation and allow to dry.  Perform venipuncture with syringe and collect the desired amount of blood. If the vein is missed a new needle should be used.  Transfer the recommended amount of blood into the culture bottles using aseptic technique if desired. First fill the aerobic bottle. Do not overfill the bottles! Any remaining blood may be used for additional tests.  Label the bottles according to the routine procedure. When using a sticker do not cover the tear-off section of the barcode label.  Note: 1:5 to 1:10 blood/broth ratio is the appropriate ratio to achieved, this dilution minimizes the effects of microbial inhibitors present in blood and dilutes any antimicrobial agents.  Remove Flip Caps from the tops of the selected culture bottles. Disinfect the septa of the bottles with alcohol or iodine preparation and allow to dry.  Perform venipuncture with syringe and collect the desired amount of blood. If the vein is missed a new needle should be used.  Transfer the recommended amount of blood into the culture bottles using aseptic technique if desired. First fill the aerobic bottle. Do not overfill the bottles! Any remaining blood may be used for additional tests.  Label the bottles according to the routine procedure. When using a sticker do not cover the tear-off section of the barcode label.  Note: 1:5 to 1:10 blood/broth ratio is the appropriate ratio to achieved, this dilution minimizes the effects of microbial inhibitors present in blood and dilutes any antimicrobial agents.

10. Specimen processing:-  The bottle incubated for 24 hour before plating to enhance the growth of bacteria, aerobic bottle plate on blood agar, MacConky, and chocolate in CO2 incubator for 24 hour, anaerobic incubate anaerobically on blood agar for 48 hour, and the negative bottle should be reincubated and tested after 10 days before discarded as negative culture. If slow growing organisms are suspected as Brucella spp. its should be clearly indicated on the requisition form and the culture bottles should be further incubated for 2-4 weeks before being reported out as negative.

13. Sodium polyanethol sulphonate (SPS):-  The anticoagulant in blood culture medium must not harm the bacteria and must prevent clotting of the blood, which entrap bacteria and prevent their detection.  The most commonly used preparation in blood media is 0.025% to 0.05% SPS.  In addition to it’s anticoagulant properities, SPS is also anticomplementary, antiphagocytic, and interferes with the activity of some antimicrobial agents.  The anticoagulant in blood culture medium must not harm the bacteria and must prevent clotting of the blood, which entrap bacteria and prevent their detection.  The most commonly used preparation in blood media is 0.025% to 0.05% SPS.  In addition to it’s anticoagulant properities, SPS is also anticomplementary, antiphagocytic, and interferes with the activity of some antimicrobial agents.

16. How to culture an intravenous catheter tips:-  When colonization of an indwelling catheter is suspected of being the focus for septicemia, the catheter tip may be cultured to determine its status.  After overnight incubation the colonies are counted, A positive culture result with greater than 5 CFU.  When colonization of an indwelling catheter is suspected of being the focus for septicemia, the catheter tip may be cultured to determine its status.  After overnight incubation the colonies are counted, A positive culture result with greater than 5 CFU.

17. Post specimen processing:-  Interfering factors:- Patient on antibiotic therapy  Result reporting:- Any isolated organism will be reported. Antibiotic sensitivity will also be included with the report.  Turn around time:-  Initial blood culture results will be reported as soon as it shows growth.  Final results with sensitivity will be issued after 24- 48 hours of the initial report.  Negative results will be issued after 10 days of culture submission.  Interfering factors:- Patient on antibiotic therapy  Result reporting:- Any isolated organism will be reported. Antibiotic sensitivity will also be included with the report.  Turn around time:-  Initial blood culture results will be reported as soon as it shows growth.  Final results with sensitivity will be issued after 24- 48 hours of the initial report.  Negative results will be issued after 10 days of culture submission.

18. Interpretation of Positive Blood Cultures:-  Virtually any organism, including normal flora, can cause bacteremia.  A negative culture result does not necessarily rule out bacteremia; false-negative results occur when pathogens fail to grow.  A positive culture result does not necessarily indicate bacteremia; false-positive results occur when contaminants grow.  Gram-negative bacilli, anaerobes, and fungi should be considered pathogens until proven otherwise.  The most difficult interpretation problem is to determine whether an organism that is usually considered normal skin flora is a true pathogen.  Virtually any organism, including normal flora, can cause bacteremia.  A negative culture result does not necessarily rule out bacteremia; false-negative results occur when pathogens fail to grow.  A positive culture result does not necessarily indicate bacteremia; false-positive results occur when contaminants grow.  Gram-negative bacilli, anaerobes, and fungi should be considered pathogens until proven otherwise.  The most difficult interpretation problem is to determine whether an organism that is usually considered normal skin flora is a true pathogen.

19. Limitations:-  Three negative sets of blood cultures in the absence of antimicrobial therapy are usually sufficient to exclude the presence of bacteremia.  One set is seldom ever sufficient.  Prior antibiotic therapy may cause negative blood cultures or delayed growth.  Blood cultures from patients suspected of having Brucella or Leptospira must be requested as special cultures, Consultation with the laboratory for special culture procedures for the recovery of these organisms prior to collecting the specimen is recommended.  Yeast often are isolated from routine blood cultures. However, if yeast or other fungi are specifically suspected, a separate fungal blood culture should be drawn along with each of the routine blood culture specimens.  Three negative sets of blood cultures in the absence of antimicrobial therapy are usually sufficient to exclude the presence of bacteremia.  One set is seldom ever sufficient.  Prior antibiotic therapy may cause negative blood cultures or delayed growth.  Blood cultures from patients suspected of having Brucella or Leptospira must be requested as special cultures, Consultation with the laboratory for special culture procedures for the recovery of these organisms prior to collecting the specimen is recommended.  Yeast often are isolated from routine blood cultures. However, if yeast or other fungi are specifically suspected, a separate fungal blood culture should be drawn along with each of the routine blood culture specimens.

20.  Mycobacterium avium complex (MAC) is frequently recovered from blood of immunocompromised patients, particularly those with acquired immunodeficiency syndrome, AIDS. Special procedures are required for the recovery of these organisms.  Observed that performance of biphasic system to be superior in recovering Brusella spp.The bi phasic system is feasible and practical method, it has the advantage of repeated exposure of agar medium to actively proliferating organisms in the liquid broth during sub culturing, which is simply by tilting the bottle.