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Which Of The Following Antiseptics Is Most Effective When Drawing Blood Cultures?

Written By Friday, March 25, 2022 Add Comment Edit

Abstract

We aimed to determine whether puncture sites for blood sampling and topical disinfectants are associated with rates of contaminated blood cultures in the emergency department (ED) of a single establishment. This unmarried-center, prospective observational written report of 249 consecutive patients anile ≥ 20 years proceeded in the ED of a university hospital in Japan during 6 months. Pairs of claret samples were collected for aerobic and anaerobic civilisation from all patients in the ED. Physicians selected puncture sites and topical disinfectants according to their personal preference. Nosotros found fifty (20.1%) patients with potentially contaminated blood cultures. 50-six (22.5%) patients were truthful bacteremia and 143 (57.4%) patients were true negatives. Multivariate analysis associated more frequent contagion when puncture sites were disinfected with povidone-iodine than with alcohol/chlorhexidine (adjusted adventure difference, 12.9%; 95% confidence interval [CI] 8.eight–16.9; P < 0.001). Sites of blood collection were also associated with contamination. Femoral and central venous with other sites were associated with contamination more oftentimes than venous sites (adjusted risk divergence), 13.one% (95% CI 8.ii–17.9; P < 0.001]) vs. 17.3% (95% CI three.vi–31.0; P = 0.013). Rates of contaminated blood cultures were significantly higher when blood was collected from femoral sites and when povidone-iodine was the topical clarified.

Introduction

Claret cultures are indispensable to observe life-threatening bacteremia, which is associated with loftier morbidity and mortality rates. Accurate findings of cultured blood samples play important roles in the diagnosis of potentially fatal infections. Contaminated blood cultures that are really false-positive can result in unnecessary antibiotic use, increased health care costs and most importantly, lead to antimicrobial resistance1,2. Several strategies have been recommended to reduce rates of blood civilization contamination3,4,5. However, a meta-analysis has determined that only sampling from separate venipuncture sites and a well-trained phlebotomy team can achieve this6. Although topical 1.0% booze/chlorhexidine gluconate (ACHX) reduces blood culture contamination more effectively than 10% aqueous povidone-iodine (PVI)7,8, both agents are routinely applied at our establishment as topical disinfectants before blood sampling. The rates of faux-positive cultures are significantly reduced when blood is sampled from various venipuncture sites compared with intravenous or cardinal venous catheters9,10. Yet, physicians at our institution may sample blood from various sites, such equally intravenous and central venous catheters, as well as femoral arteries and veins according to personal preference. Those in our emergency section (ED) tend to sample claret from femoral arteries or veins, yet little is understood nearly associations between puncture sites for claret sampling and imitation-positive blood cultures.

Thus, nosotros aimed to determine whether puncture sites for claret sampling and topical antiseptics are associated with claret culture contamination in a unmarried ED.

Methods

Study design

This single eye, prospective observational study proceeded at the ED of a university hospital in Nippon between August 1, 2018 and January 31, 2019. The hospital is an 882-bed university teaching hospital with 8,000 adults presenting at the ED annually. Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were used to design and report the results of this report. The Institutional Review Board at Osaka Medical College approved the study protocol (675(2476)) and waived the need for written, informed consent.

Patients

This study included 249 consecutive patients aged ≥ 20 years from whom blood was sampled in the ED. The exclusion criteria comprised blood sampled elsewhere and age < xx years. If 1 pair of blood samples was nerveless at our ED and some other was nerveless elsewhere or non nerveless, and then only the pair nerveless at our ED was analyzed. I or more of the following comorbidities of the patients were recorded: malignancy, diabetes mellitus, hypertension, prior stroke, dementia, chronic renal insufficiency, liver cirrhosis and coronary avenue disease11,12,13,14.

Blood cultures

Nurses and other medical staff at our institution are not permitted to collect blood culture samples. Only physicians, especially first- or 2d-yr interns, are permitted to collect blood samples in the ED.

Claret (xiv–20 mL) from peripheral veins or arteries was sampled for aerobic and anaerobic culture (seven–10 mL each) in BacT/Warning FA Plus and FN Plus resin bottles (bioMérieux Inc., Durham, NC, USA). Physicians selected the topical disinfectant such as ACHX, PVI, alcohol and others available in the ED, co-ordinate to their personal preferences. A blood culture was considered contaminated if 1 or more of the following organisms were identified in one of two blood cultures: coagulase-negative Staphylococci (CoNS), Propionibacterium acnes, Micrococci, Corynebacteria, Bacillus species other than Bacillus anthracis, or Clostridium perfringens ten,15,16. Viridans streptococci are regarded as contaminants based on the described criteriaten,15, but they are not considered as contaminants at our constitute because they were common causative agents of infective endocarditis. Polymicrobial cultures with a mixture of contaminant and true pathogens were regarded equally contaminatedxiv. A culture was defined as "negative" when bacterial growth was absent or when a bacterium was regarded by the attending microbiologist as having low pathogenicity.

Statistical analysis

Chiselled variables are described as frequencies and percentages (%) and continuous variables are shown equally ways with standard deviation (SD). Data were compared using one-manner analyses of variance (ANOVA), χ2 and Fisher exact tests as appropriate. Differences in run a risk and robust 95% conviction intervals (CI) of contagion co-ordinate to sites and topical disinfectants were estimated using univariate and multivariate analyses with modified least squares regression17. The same patients were considered every bit a random effect in the above model. Historic period, sex and disease status were adjusted as confounders in multivariate analyses. Because blood can exist sampled from few sites, we too included in the category CV Other, blood sampled from recently inserted primal venous (CV) catheter, venous and arterial catheters as well as implanted ports. Because nosotros did not have many topical antiseptics to assess, we included only PVI or ACHX in analyses. We did non impute for missing values. Significance for all statistical findings was taken at P < 0.05. All data were statistically analyzed using SPSS version 25.0 software (IBM Corp., Armonk, NY, Usa) or SAS software, version 9.4 (SAS Institute, Cary, NC, United states of america).

Results

Baseline characteristics

We analyzed 249 patients who were prospectively included in this study between Baronial i, 2018 and January 31, 2019. Thus, information from 249 patients and 483 pairs of blood cultures were analyzed. A total of fifty (twenty.i%) patients with potential contaminants were institute in blood cultures, the about common of which was Staphylococcus epidermidis in 12 (24.0%), followed by Staphylococcus hominis in iv (eight.0%). Two (0.eight%) patients had a mixture of truthful bacteremia and contaminating isolates. L-six (22.five%) patients had true bacteremia with Escherichia coli beingness the virtually prevalent microorganism in 17 (thirty.4%). Cultured blood samples from 143 (57.iv%) patients were identified as true negative. The most common source of infection in 22 (39.3%) patients with true bacteremia was the urinary tract, whereas pulmonary disease was the virtually prevalent in 17 (34.0%) and 52 (36.4%) patients with contaminated and truthful negative cultures, respectively. These ii sources significantly differed among the iii groups (pulmonary disease and urinary tract; both P = 0.001). Only one pair of claret samples was cultured from 15 patients. Table one shows other baseline characteristics of the three groups of patients.

Table 1 Characteristics of patients with blood cultures in emergency department.

Total size table

Sites and topical antiseptics

Femoral arteries and veins tended to be sampled in most patients in all three groups, but at unlike ratios (Tables 1 and 2). Over lx% of blood samples from patients with contaminants was collected from femoral sites (mostly the femoral artery), whereas < fifty% of blood samples from patients with negative cultures was collected from these sites. Blood sampled from a recently inserted central venous catheter conferred the greatest adventure for contamination when taken as an independent factor. Even so, the number of samples was small-scale (n = fifteen); thus, we classified this as "CV Other".

Table ii Claret civilisation sites and topical antiseptics.

Full size table

Topical antiseptics too significantly differed amid the three groups (Table 2). The sites of > 90% of patients with contaminated blood cultures were disinfected with PVI, compared with < 75% of the patients in the other 2 groups. Other topical antiseptics comprising booze or benzalkonium were not included in the analysis because of small numbers (Table 2) and the possibility of confounding the results.

Proportion of contamination by sites and topical antiseptics

With reference to ACHX, univariate assay using modified least squares regression associated PVI with contamination (proportions of contamination associated with PVI and ACHX: 16.2% vs. 0.8%; adventure divergence, xv.iv%; 95% CI 11.2–19.6; P < 0.001). With reference to blood collected from venous venipuncture sites, univariate analysis using modified least squares regression associated femoral sites or CV Other with contamination (Tabular array 3).

Tabular array three Univariate analysis using modified least squares regression.

Total size table

Multivariate analysis showed that the proportion of contamination was college for PVI than ACHX (adapted risk divergence, 12.ix%; 95% CI 8.8–xvi.nine; P < 0.001). Sites of blood sampling were also associated with contamination. The proportion of contamination was higher at femoral sites and CV Other, than at venous at sites (adjusted take a chance differences: 13.1% [95% CI 8.ii–17.9; P < 0.001] and 17.iii% [95% CI 3.6–31.0; P = 0.013], respectively. Sex was non significantly associated with contagion, however historic period was associated with contamination (Table 4).

Table 4 Multivariate analysis using modified least squares regression.

Full size tabular array

We also assessed associations between sites and topical antiseptics with contagion. With reference to femoral sites and ACHX, PVI and femoral sites, and PVI and CV Other were significantly associated with contamination, whereas PVI and venous, ACHX and CV Other and ACHX and venous sites were not (Table four).

Discussion

This single center, prospective observational written report found that blood samples collected from femoral areas disinfected with PVI were significantly associated with contaminated claret cultures. The most common source of infection among patients with true bacteremia was the urinary tract, and most of such patients had pyelonephritis. In contrast, the most prevalent source of infection among patients with contaminated blood cultures was pulmonary disease, with most of such patients having aspiration pneumonia.

Nosotros also constitute that femoral puncture sites comprised an independent take a chance factor for blood culture contamination. Physicians tended to collect blood from femoral arteries or veins because it is easier than collecting from other sites. However femoral sites are colonized more often than other sites18 and these are associated with catheter-related bloodstream infection19. Internal jugular sites as well confer gamble for blood culture contamination18,xix. One observational study in an intensive intendance setting identified higher contamination rates in cultures of blood sampled from recently inserted cardinal lines compared with arterial lines and via straight peripheral venipuncturetwenty. The contamination rate in the present written report was the highest (53.three%) in 15 blood samples collected from central catheters that were recently inserted into the internal jugular vein. However, this number was too low to be statistically relevant.

Several reports have described associations betwixt topical antiseptics and blood culture contagion21,22. A meta-analysis has found that blood civilisation contamination is more significantly reduced by ACHX than by PVIvii. Even so physicians tended to disinfect puncture sites with PVI more frequently than ACHX at our infirmary for the post-obit reasons. Firstly, physicians and ED staff are more familiar with PVI than ACHX because it has been applied as a peel disinfectant for many years. Secondly, residents and medical students are not educated nearly blood culture procedures while at academy.

Pneumonia was the near mutual affliction among patients with contaminated and true negative blood cultures. Several studies of patients with community-caused pneumonia (CAP) have plant that claret cultures provide piffling diagnostic benefit23,24,25. One reason for the very high contamination rate at our hospital was due to mishandling of cultured blood samples from adult patients with CAP and isolated leukocytosis or fever. Claret samples should exist cultured from selected immunocompromised patients, those with complicated urinary tract infection who are under antibody therapy at the time of blood drove, and patients with suspected endocarditis24,26.

Several strategies have been advocated to reduce rates of blood culture contamination. Sampling from various venipuncture sites, and reliance on a well-trained phlebotomy team can reduce these rateshalf-dozen. Furthermore, switching from PVI to ACHX or other topical antiseptics and advisory intervention and feedback might reduce rates of blood civilisation contamination, fifty-fifty when physicians conduct phlebotomies27,28.

This report has several limitations. Our patient accomplice was modest and some parameters could not be conclusively determined. Even so, specific injection sites and PVI were associated with significantly increased contamination rates. Some physicians were aware of this study proceeding inside the ED and might have been more attentive when collecting claret than they might take been in wards. Physicians could select their preferred topical disinfectant for claret sampling, which might be a confounder because many studies have associated contamination more oft with PVI than with ACHX. Blood collection sites prepared using the aforementioned disinfectant should exist compared under the same weather.

Conclusions

This prospective observational study found that femoral puncture sites and PVI were independent take chances factors for claret civilization contamination. Other sites and antiseptics should exist selected for skin disinfection before blood sampling to reduce culture contamination. Physicians should utilise ACHX when they collect claret civilisation sample from femoral puncture sites.

Information availability

The datasets used and/or analyzed during the electric current study are available from the corresponding author on reasonable asking.

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Acknowledgements

Nosotros wish to give thanks Dr. Oi for providing information as an infection control dr.. Nosotros also wish to thank all nursing staff working in the emergency section for collecting data about the blood culturing procedure.

Funding

This research did non receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Affiliations

  1. Section of Emergency Medicine, Osaka Medical College, 2-vii Daigaku-machi, Takatsuki City, Osaka, 596-8686, Japan

    Koshi Ota, Masahiro Oka, Kanna Ota & Akira Takasu

  2. Department of Biostatistics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

    Koji Oba

  3. Research and Development Center, Osaka Medical Higher, Osaka, Japan

    Keisuke Fukui & Yuri Ito

  4. Department of Nursing, Osaka Medical College Hospital, Osaka, Nihon

    Emi Hamada & Naomi Mori

  5. Department of Clinical Laboratory, Osaka Medical College Hospital, Osaka, Japan

    Yuriko Shibata

Contributions

One thousand.O. designed the written report, and wrote the initial typhoon of the manuscript. One thousand.O., K.F., and Y.I. contributed to analysis and estimation of information and assisted in the grooming of the manuscript. All other authors have contributed to data collection and interpretation and critically reviewed the manuscript. All authors canonical the final version of the manuscript and agree to be accountable for all aspects of the piece of work in ensuring that questions related to the accuracy or integrity of whatsoever part of the work are accordingly investigated and resolved.

Corresponding author

Correspondence to Koshi Ota.

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The authors declare no competing interests.

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Ota, K., Oba, M., Fukui, K. et al. Sites of blood collection and topical antiseptics associated with contaminated cultures: prospective observational study. Sci Rep eleven, 6211 (2021). https://doi.org/ten.1038/s41598-021-85614-vii

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