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Blood Culture Dilemmas

Blood Culture Dilemmas. Dr Peter Cowling Chair Bacteriology SMI Committee. UK Standards for Microbiological Investigations (SMIs). Steering Committee Syndromic Algorithm Committee Virology/ Serology SMI Committee Bacteriology SMI Committee. Our responsibility.

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Blood Culture Dilemmas

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  1. Blood Culture Dilemmas Dr Peter Cowling Chair Bacteriology SMI Committee

  2. UK Standards for Microbiological Investigations (SMIs) • Steering Committee • Syndromic Algorithm Committee • Virology/ Serology SMI Committee • Bacteriology SMI Committee

  3. Our responsibility ..does not start at the laboratory door Starts at the point the clinician considers the differential diagnosis

  4. Our involvement in specimen pathway • From start • To finish

  5. Partnership Working • Equal partners • Nominated representatives • Regular two way reporting • Optimal consultation processes • Increased joint ownership • Increased authority

  6. NICE Accreditation • NHS Evidence accredited processes for SMIs • Follows AGREE protocol • Sets the UK standard for diagnostic microbiology • Covers whole specimen pathway • Also certified to ISO 9001:2008

  7. SMI B 37Investigation of Blood Cultures • Issued 27 March 2013 • Issue number 7

  8. Acknowledgements 1 • Dr Shabnam Iyer • Dr Mike Weinbren • Mr Ian Sturgess

  9. Consultation • Consultation through usual process • Additional parallel consultation through BIA • Total responses 59 • Accepted 23 • Partially accepted 6 • Rejected 7 • No action 23

  10. B37 Amendments • Standards for TaTs • Inclusion of SIRS and neonatal sepsis • Removal of differential quantitative culture • Direct sensitivity testing • Inclusion of molecular methodologies • Contamination target <3% • Pre-incubation advice • Lab management of transportation

  11. Dilemmas • TaTs and Transforming Pathology agenda • Meeting the needs and expectations of users (e.g paediatricians) • Pre-loading handling of bottles (requesting/ transportation/ off site incubators/ off site culture) • Empirical blind antimicrobial treatment • Existing plate-based methodologies

  12. Turnaround times (TaTs)

  13. Proposals for improvement • Mike Weinbren, Shabnam Iyer, Ian Sturgess • Set standards for TaTs • Collection to loading • Initial positive reports and sens testing • Endorse rapid tests on positive bottles • Set standards for satellite/peripheral labs • Request CPA to formally include b.c audits • Request BSAC to recommend direct sens testing

  14. Mike Weinbren’s audits • Load delay average 7h (max 20h) • Unload delay average 5h (max 14h) • On site laboratory • Worst out of hours and weekends • 2nd audit of transport delays showed little delay on site • 60% loaded within 2h of receipt but long tail on graph (n=191). Bottles rec’d 24h but loaded only 08.00-19.00 • Potential for saving up to 2 days of TaT if loading/unloading delays are reduced + rapid testing

  15. Kavi, Weinbren & Sturgess survey • Telephone survey of blood culture methods in UK • 43 respondents across UK • 4/16 off site blood cultures stored in incubator • 0/43 load during night • 21/43 pre-incubate overnight, 22/43 at RT • 31/43 have 24h on site shift systems (blood sciences) • 1/43 rapid sens on GNBs, 41/43 do direct sens discs

  16. User expectations

  17. Neonatal blood cultures • NICE guideline CG 149 Aug 2012 • Requirement for 36h reporting of a negative culture • Allows cessation of antimicrobials, 2nd gentamicin dose • Allows timely discharge • Is cost effective

  18. Duration of antibiotic treatment: early-onset neonatal infection without meningitis Positive blood culture or strong suspicion of infection • Usual antibiotic duration should be 7 days. Consider longer if baby has not recovered or if advised. Negative blood culture • Consider stopping antibiotics at 36 hours. • If continuing beyond 36 hours, review the baby at least once every 24 hours to consider whether antibiotics can be stopped. NICE (CG 149) Aug 2012

  19. Duration of antibiotics treatment:decisions 36 hours after starting antibiotic treatment • To fully implement the guideline, hospital systems to provide real time blood culture results at 36 hours are needed. • Consider stopping antibiotics at 36 hours: if • blood culture is negative and • initial suspicion of infection was not strong and • baby’s clinical condition reassuring (no clinical indicators) and • levels and trends of C-reactive protein are reassuring. NICE (CG 149) Aug 2012

  20. Rationale for 36h decision “Since the health economic analysis conducted for the guideline showed that stopping antibiotic treatment at 36 hours in the babies listed above will be cost saving, and one of the criteria for stopping treatment depends on the result of blood culture, the cost savings can be realised only if the blood culture results are available within 36 hours.” NICE (CG 149) Aug 2012

  21. Antibiotics for suspected infection in the baby • Use intravenous benzylpenicillin with gentamicin as first-choice. • Benzylpenicillin 25 mg/kg every 12 hours. • Gentamicin, starting dosage of 5 mg/kg. • If a second gentamicin dose is required, give 36 hours after the first (interval may be shortened based on clinical judgment). (My emphasis)NICE (CG 149) Aug 2012

  22. Therapeutic monitoring for gentamicin Trough concentrations • Measure trough immediately before second dose. • Concentrations should be available in time to inform the next dose (If not, do not withhold dose unless renal dysfunction is evident). • Consider repeating measurement of trough concentrations at least before every third dose. NICE (CG 149) Aug 2012

  23. Neonatal blood cultures 36h rule:UK experience • 4/31 significant isolates >36h incl. 1 baby discharged home • 11/119 +ve cultures >36h post loading (9 contaminants, 2 CNS infections already on treatment). 23/119 >36h post collection (4 significant but on antibiotics pre b.c. and clinically septic) • 92% 4410 cultures +ve <36h (100% of paediatric) • 18/76 +ve cultures post collection (16 contaminants, 2 significant, 1 on treatment) • “nearly all signalled within 18h, never mind 36!”

  24. Acknowledgments 2 • Dr Tom Lewis • Dr Sarah Abu Hassan • Dr John Cheesbrough • Dr Alaric Colville • Dr J Kavi • Dr Martin Sheppard

  25. Future dilemmas • Emergence of multi-resistance • Less effective & more toxic blind treatment • Need for replacement of 19th Century Microbiology • Rapid, molecular methodology for whole specimen pathway (“Star Trek” vision) • Near patient testing

  26. The Embarrassing Truth? • Blood Sciences • Microbiology

  27. Laissez faire • Long TaTs generally accepted as the norm by laboratories, users and patients • Technology available to revolutionise Microbiology • Insufficient challenge to status quo

  28. Wrong focus • Laboratory accreditation-focussed • Not patient-focussed • ISO standards are an improvement

  29. Purchaser Provider Model

  30. Voice of the Customer • Purchaser - Provider (adversarial) • Customer involvement and joint ownership (partnership)

  31. Acknowledgements 3 • The Standards Unit, PHE • Ruhi Siddiqui, Head of Unit • Clare Harris, Standards Microbiologist • Ayuen Lual, Standards Microbiologist • Ijeoma Ezeajughi, Research Scientist • Nicola Day, Technical Support Officer • Caroline Lawson, Information Office • Shirley Boland, Administrative Assistant • and……….Val Bevan and Brian Duerden

  32. Thank you

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