1. APIC Greater NY Chapter 13 Journal Club Session November 18, 2015 by Steven Bock RN BSN CIC Infection Prevention and Control Department 212-263-5454 / 212-598-6767

2. AJIC – November 2015

3. Blood Cx Best Practices – AJIC Nov 2015 Article Goals 1.clarify standards for blood culture collection - help reduce cultures that are considered contaminants. 2.establish standard blood culture collection practices to reduce false positive results that get counted as CLABSIs. Extensive literature review used to determine best evidence- based practices. Reviewed clinical interpretation of positive and negative blood cultures; what are true positives, false positives, true negatives, and false negatives. Study done by large multi-disciplinary team at 600+ bed suburban academic medical center in Suffolk Co., NY

4. Blood Cx Best Practices – AJIC Nov 2015 Indication for Blood Cultures (BCs) Fever (temp >38C) Hypothermia (temp <36C) Leukocytosis, and/or an absolute granulocytopenia, Various suspected/known clinical infections, including sepsis, meningitis, catheter-related bacteremia, infectious endocarditis/arthritis/osteomyelitis, and FUO BCs may be performed selectively in patients with pneumonia or skin-soft tissue infections

5. Blood Cx Best Practices – AJIC Nov 2015 How many BCs should be collected? How often? One set = one draw site filling two bottles (aerobic and anaerobic) Anaerobes only rarely cause sepsis and can often be recovered from aerobic bottles For adults, always draw at least 2 sets of cultures from separate venipuncture sites For peds, article is silent Timing doesn’t matter; just draw adequate volume with good technique Cultures should be held only at room temperature, taken to the lab within 2 hours of collection 30-60% of all BCs are drawn when pt is on Abx – the resin at the bottom of the bottles is designed to absorb abx. Who knew?!

6. Blood Cx Best Practices – AJIC Nov 2015 BCs by venipuncture vs. intravascular catheter Peripheral generally better; lower contaminated result rates Avoid extremity draws where IVs/CVLs are placed Draw opposite side from mastectomy/lymph node dissection/site of radiation therapy, or hemiperesis IDSA guidelines cited for suspected catheter-related BSI: draw paired blood samples, one from peripheral draw and one from the catheter (net, four bottles) For neutropenic fever (adults and peds), draw one peripheral set and if no CVL, a second peripheral set. If CVL is present, draw one set from each lumen in addition to the single peripheral set. Pop Quiz: Pt with a TLC = ? sets

7. Blood Cx Best Practices – AJIC Nov 2015 BC Collection Site Preparation Apply antiseptic using back and forth motion rather than circular, regardless of product used; better to scrub antiseptic into skin to reach resident bacteria Scrub for 30 seconds (or longer depending on IFU) Allow to dry for 30 sec (CHG-IPA), 1.5 - 2 min if using P-I IPA and CHG-IPA associated with lower contamination rates than P-I. Avoid tincture of iodine (needs to be removed, extra step, allergy issues) CHG-IPA acceptable for pts of all ages, including neonates No guideline consensus on site prep for central line draws. INS guidelines call for needleless access device change before BC collection but the CDC & IDSA are silent on the issue. What do you think and do? Use IPA? CHG-IPA? Other? Change hubs before BC?

8. Blood Cx Best Practices – AJIC Nov 2015 BC Volume, Waste Draws, and Which Bottles to Fill First Volumes are dependent on type of blood culture bottles used (my knowledge). Authors suggest 20-30 ml for adults, less for peds (use published tables based on peds pt weight). Under-filled bottles associated with higher contamination rates Fill bottles in vertical position (can see fill volume line properly) Article describes discard volume method (DVM) to reduce dilution consequences and to reduce contamination risk Peripheral draws - discarding waste reduces contamination rates (why?) Central line draws - no effect on contamination rates (why?) No discussion about dilution impact on results (logic says…) Filling aerobic vs. anaerobic first – controversial; authors favor aerobic first to assure adequate volume. But…

9. Blood Cx Best Practices – AJIC Nov 2015 Preparing BC Bottle Tops BC Culture bottle tops are not sterile Disinfect bottle tops with IPA (or CHG-IPA); avoid P-I as it can degrade the stopper (though how long does that take???) Clinical and Laboratory Standards Institute (CLSI) guideline recommends 70% IPA; no mention if separate swab should be used for skin site and bottle top Steps should be taken to prevent contamination of bottle top during collection

10. Blood Cx Best Practices – AJIC Nov 2015 What PPE should clinician wear? Widely accepted that most BC contamination occurs during specimen collection (not in lab processing of Cx), so does PPE matter? Gloves – sterile vs. non-sterile? One study showed lower contamination rates in peripheral draws using sterile gloves (why?) No standard recommends sterile gloves; unresolved issue Masks? No standards call for clinicians to wear a mask during BC collection. NHSN reviews of contaminated BC results do not show evidence of oral organisms dominating contaminated cultures, so masks are not needed. (What do you do?)

11. Blood Cx Best Practices – AJIC Nov 2015 Other Practice Issues / Considerations Surveying staff compliance with policy may help reduce BC contamination rates (perform gap analysis) Using dedicated phlebotomy teams to collect BCs results in lower contamination rates (for peripheral draws) (why?) Bundling products needed for BCs helps create sustained lower rates of contamination Using checklists for all BCs helps optimize technique and reduce contamination rates Specific BC collection training and periodic retraining with a competency process helps produce sustained reductions in contamination rates

13. TY APIC Greater NY Chapter 13 Awarded me Professional Development Award for 2015 Used funds to buy CIC exam review book – now actively reviewing for my Dec. 8, 2015 CIC exam recertification; sharing book with our dept at NYU Used funds to buy APIC’s lab review book - The Infection Preventionist's Guide to the Lab; sharing with our dept at NYU Used funds to help pay for APIC 2015 conference attendance (what was not covered by APIC as a speaker)