Journal of Clinical Microbiology & Infectious Disease

JCMID. Volume 1, Number 1, January-April 2015: 6-10

Print-ISSN: 2355-1909, E-ISSN: 2355-1984.

ANALYSIS OF BLOOD CULTURE PROCESSING IN PEDIATRIC PATIENTS

AT DR. KARIADI GENERAL HOSPITAL: WHAT WE CAN LEARN

Leonardus Widyatmoko, Desvita Sari, Subakir, Hendro Wahyono

Department of Clinical Microbiology, Dr. Kariadi Hospital, Diponegoro University Faculty of

Medicine, Semarang, Indonesia

ABSTRACT
Purpose: Blood culture is the most important tool for detecting bacteremia in children with fever.
Many problems arise during blood culturing procedures such as relatively high cost, difficulty in
sampling, high contamination rate, low sensitivity, misleading interpretation results. Therefore,
this study was performed to analyze blood culture processing of our pediatric patients from
handling specimen until result interpretation in order to find its correlation with the real situation
in the ward.

Methods: During the period of June 9, 2014 untilAugust 2, 2014, we conducted a retrospective
chart review of blood cultures obtained from children who hospitalized at non Intensive Ward at
Dr. Kariadi Hospital. Positive blood cultures were labeled as true bacteremia or contamination,
according to an adaptation of CDC/NHSN definitions for laboratory-confirmed bloodstream
infection. Data were analyzed using percentage analysis.

Results: During the study period, we obtained 100 blood culture isolates. Only 44% (N=44) were
taken from 2 peripherally sites, of which 86% (N=38) were coming from our general floor ward
and none from either neonatal unit or emergency room. The overall positivity rate was 21%
(N=21), of which 57% (N=12) were coming from 2 peripherally sites. The overall contamination
rate was 11% (N=11), of which 6 % (N=6) were coming from one site sampling and emergency
room had the highest contamination rate (33%) followed by private floor ward (19%). Gram
negative rods were the most predominant causes for true bacteremia (70%; N=7) while coagulase-
negative Staphylococci were the most predominant causes for contaminant (72%; N=8).

Conclusion: The overall contamination rate in pediatric patients was higher than ASM standard of
maximum 3 %, given the difficulty of performing blood sampling in pediatric patients. The
relatively high contamination rates at emergency ward and private floor ward may be due to lack
of experience of the nurse and minimal monitoring of resident pediatric physicians at private floor
ward. Those results showed that continuing of training and monitoring of performance for blood
culture are mandatory.

Keyword: Blood culture, bacteremia, child, contamination

INTRODUCTION
Fever is a primary complaint of children visiting
the hospital and bacteremia is an important cause
of fever in 1,5% - 2,3% of these children.iBlood
culture has been widely accepted as the most
available method for detection bacteremia and
fungemia thus remain a very important tools in
children presenting with fever.Apart from its
availability, blood culture interpretation remains
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challenging for clinicians. False-negative blood
culture results occur when a low bacteremia load
cannot be detected due to low blood volume
sampling, inappropiate timing of collection,
presence of antibiotic before blood sampling.
False-positive blood culture results occur when a
contaminant organism that is not presented in the
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 Journal of Clinical Microbiology & Infectious Disease
JCMID. Volume 1, Number 1, January-April 2015: 6-10
Print-ISSN: 2355-1909, E-ISSN: 2355-1984.

patients bloodstream is grown in a blood culture In this study, blood culture isolates obtained only
specimen.ii from preexisting central venous catheters were

Taking into account both problems above excluded, due to difficulties in differentiating
respectively, and other problems such as between colonization, contamination and true
relatively high cost, difficulty in sampling for bloodstream infection. The remaining blood
pediatric patients, high contamination rate, low culture results were divided into true bacteremia
sensitivity, there are probabilitiesformisleading and contamination, according to an adaptation of
interpretation in differentiating true bloodstream the Centers for Disease Control and Prevention
pathogens from contaminations.Nevertheless, (CDC) National Healthcare Safety Network
several indicators can be used such as the species (NHSN) definitionsiv for laboratory-confirmed
of organism detected, number of positive culture bloodstream infection, in combination with the
sets, time for growth, the patients clinical clinical manifestations such as fever, leukocytosis
manifestation, laboratory abnormalities and the or leukopenia and elevated inflammatory markers
presence of indwelling catheters.2 (see Figure 1). The CDC definition of laboratory
confirmed bloodstream infection (not central line
American Society of Microbiology (ASM) has
related) is either 1 positive blood culture with a
set standard for contamination rate of maximum
recognized pathogen from a venipuncture or for
3% in adults.iii In febrile children, hypotethically it
skin organisms more than 2 blood cultures drawn
will be higher due to the predominant use of
on separate occasions positive for the same
blood culture to detect occult bacteremia. Given
organism plus clinical manifestations. According
the high risk of occult bacteremia in children and
to the College of American Pathologists v, the
the increasing rates of blood collection for culture,
definition of contamination is a positive blood
it is important to determine the current state of
culture with the presence of one or more of the
blood culture contamination in children.
following organisms in only one of a series of
Therefore, the aim of this study wasto analyze
blood culture specimens such as: Staphylococcus,
blood culture processing of our pediatric patients
Micrococcus, viridans streptococci, Propionibacterium
from handling specimen until result
acnes, Corynebacterium sp., Bacillus spp. The
interpretation in order to find its correlation with
contamination rate was defined as the percentage
the real situation in the ward.
of contaminated culture isolates in total blood
culture bottles. Data were analyzed using
MATERIALS AND METHODS
percentage analysis.
Study site and period
This study took place at the Dr. Kariadi General
Figure 1. Adaptation of the Centers for Disease
Hospital, Semarang, Central Java Indonesia. This
Control and Prevention (CDC) National
institution is a tertiary hospital and teaching
hospital. During the period of June 9, 2014 until
August 2, 2014, we conducted a retrospective
chart review of blood cultures obtained from
children below 18 years old from non Intensive
Ward.

Blood Sample Collection

Blood specimen taken by nurses from the non
intensive ward was collected in bacterial culture
media (BACTEC Peds Plus, BD, USA) and
incubated at 37oC for up to 5 days. For positive
blood cultures, microorganisms were identified
by semi-automated methods (VITEK2,
bioMrieux, Marcy-l'Etoile, France) in the clinical Healthcare Safety Network (NHSN) definitions
microbiology laboratory. for laboratory-confirmed bloodstream infection4

Classification of blood culture and data analysis

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 Journal of Clinical Microbiology & Infectious Disease
JCMID. Volume 1, Number 1, January-April 2015: 6-10
Print-ISSN: 2355-1909, E-ISSN: 2355-1984.

RESULTS AND DISCUSSIONS Table 2. Contamination Rate according to Ward

During the study period, we obtained 100 Type
blood culture isolates (including sterile one) from
144blood culture bottles.Only 44% (N=44) were Ward Total Total Contami
taken from 2 peripherally sites, of which 86% Blood Contaminated nation
(N=38) were coming from our general floor ward Culture
and none from either neonatal unit or emergency
room (see table 1). Further, 21 isolates (21%) were
positive for bacterial growth, of which 57% Bottle Isolates Rate(%) *
(N=12) were coming from 2 peripherally sites (see Private 21 4 19,05
figure 2).The overall contamination rate was 11% floor
(N=11), of which 6% (N=6) were coming from one
General 78 3 3,85
site sampling and emergency room had the
floor
highest contamination rate (33%) followed by
private floor ward (19%) (see table 2). Gram Neonatal 42 3 7,14
negative rods were the most predominant causes unit
for true bacteremia (70%; N=7) while coagulase- Emergenc 3 1 33,33
negative Staphylococci were the most y room
predominant causes for contaminant (72%; N=8) *Contamination Rate(%) = the percentage of
(see table 3). contaminated culture isolates in total blood
culture bottles
The mean age of patients who had blood
samples taken for culture was 1,75 years and the
mean age of patients who had contamination was Table 3. List of Microorganisms in Positive
1,67 years (see table 4). Isolates

Table 1. Distribution of blood samples

Blood Culture Microorganism N
Sites of Ward N Interpretation
Venipuncture True Pseudomonas 2
Bacteremia aeruginosa
2 peripherally sites Private floor 6 Enterobacter spp 2
Salmonella group 1
General floor 38 Klebsiella pneumoniae 1
Neonatal unit 0 Acinetobacter 1
Emergency room 0 baumannii
1 peripherally site Private floor 9 Staphylococci CoNS 3
Contamination Staphylococci CoNS 8
General floor 2 Stenotrophomonas 1
Neonatal unit 42 maltophilia
Emergency room 3 Acinetobacter 1
radioresisten
Figure 2. Study Flow and Results Diagram
Table 4. Mean Distribution of age

Patients N Mean of age

(years)
Contamination 11 1,67
True pathogen 10 1,76
Sterile 79 1,75
Overall 100 1,75

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DISCUSSION
Blood culture has been a main diagnostic tool
for diagnosing bacteremia. The protocol for
obtaining blood samples from at least 2
peripherally sites has been widely accepted. The
purpose of taking from 2 peripherally sites is for
differentiating the results, whether contamination
or true bacteremia.vi In this study, samples from 2
peripherally sites mostly came from general ward
and samples from 1 peripherally sites mostly
came from the neonatal unit. This results showed
us that adherence to protocol was difficult to
achieve in the neonatal unit. According to our
observation, the problem of getting the vascular
access in neonatal patients was the main problem
for 2 sites collection as we observed that the
majority of patients in neonatal unit had low birth
weight.
Contamination of blood culture can compromise
its specificity. Difficulty in discriminating
between contamination and true bacteremia leads
to increased duration of hospital stay,
unnecessary additional laboratory test, and
inappropiate use of antibiotics; the latter may
direct the emergence of multidrug resistant
organisms (MDROs), antibiotic-associated
diarrhea (AAD) and other adverse outcome. vii
The American Society of Microbiology
recommends a target rate of 3% for blood culture
contamination in adults3, meanwhile until now
there are no exact guideline concerning
contamination rate among the pediatric
population. In our study, the contamination rates
in every pediatric ward are above the ASM
standard. This contamination may be caused by
taking the sample from an inappropiate sample
site, an interruption in skin antisepsis protocol,
poor compliance to the standard protocol for
blood sampling, poor blood sampling
technique.The high contamination rate in
emergency unit was difficult to prevent due to
rapid turnover of patients, overcrowding due to
the inadequate inpatient capacity and lack of
ongoing training. Surprisingly, the contamination
rate in neonatal unit was lower than private floor
ward (7,14% vs. 19,05%). According to our
observation, the personnel who collected blood
samples in the neonatal unit was highly
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Journal of Clinical Microbiology & Infectious Disease
JCMID. Volume 1, Number 1, January-April 2015: 6-10
Print-ISSN: 2355-1909, E-ISSN: 2355-1984.
skilledand well trained neonatal nurses compared
with those in the private floor who only regular
nurse with standard skilled in blood sampling.
Besides that, in neonatal unit there were always
pediatric residents whom monitoring patients for
24 hours, meanwhile in private floor ward,
pediatric residents observed only in limited
access.
Younger pediatric patients are more likely to
receive medical attention and be admitted to
hospital.viii Our study showed that the average
age of patients taken blood sampling was 1,75
years and average age of contamination group
was 1,67 years. That results may contribute to our
higher results of contamination compared to
ASM standard due to complex technical skills.
Schifman et al.ix recommended blood culture
collection by a dedicated phlebotomy team, as it
was the most effective method for reducing
culture contamination. Our study showed that
dedicated nurse in the neonatal unit played
significant role in reducing contamination.
Besides that, consistent training, appropiate
feedback and postfeedback observations may be
helpful in reducing rates of contamination. x The
role of closed monitoring of pediatric residents
appear to be helpful in adherence to blood
sampling protocol and reducing contamination
rates.
CONCLUSION
The higher contamination rate in our pediatric
patients than ASM standard may be due to the
difficulty of performing blood sampling in
pediatric patients. The relatively high
contamination rates at emergency ward and
private floor ward may be due to lack of
experience of the nurse and minimal monitoring
of pediatric residentsin private floor ward. Those
results showed that continuing of training and
monitoring of performance for blood culture are
mandatory
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JCMID. Volume 1, Number 1, January-April 2015: 6-10
Print-ISSN: 2355-1909, E-ISSN: 2355-1984.

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