Standard Operating Procedure

Transcription

1 Subject Blood Culture Collection Index Number Lab-1325 Section Laboratory Subsection Specimen Collection and Processing Category Departmental Contact Regina Collins Last Revised 3/17/2017 References Required document for Laboratory Accreditation by the College of American Pathologists (CAP), Centers for Medicare and Medicaid Services (CMS) and/or COLA. Applicable To Employees of Gundersen Health System laboratories, Gundersen St. Joseph s Hospital laboratories, Gundersen Tri-County Hospital laboratories, Gundersen Boscobel Hospital and Clinics laboratories and Gundersen Palmer Lutheran Hospital and Clinics laboratories that collect blood cultures by venipuncture method for the BD BACTEC. Detail PRINCIPLE: An infection of the blood is called septicemia or bacteremia. This condition is detected by culturing blood. Bacteria, Fungus, and AFB all may be isolated from the blood. The physician needs to clarify which type of culture is required since each class of microorganism requires nutrient media specific to their needs. Blood cultures are usually ordered prior to the start of antimicrobial therapy and usually in a series of 2 or 3 sets. By collecting blood cultures in a series the likelihood of detecting the infectious organism is increased. This policy incorporates the use of the Bactec System for the majority of our blood cultures. The three different types of bottles we use to collect blood cultures in include: 1. BD BacTec Plus Aerobic/F Culture Bottle 2. BD BacTec Lytic/10 Anerobic/F Culture Bottle 3. BD BacTec Peds Plus/F Culture Vials BACTEC Plus Aerobic/F media is an all-purpose enriched soybean-casein digest broth media. The media contains resins for antibiotic neutralization. BD BACTEC Lytic/10 Anaerobic/F medium contains a lysing agent to increase the detection and recovery of organisms partially phagocytized by white blood cells. It is an enriched soybean-casein digest broth. BACTEC Peds Plus/F media are specialized media that accommodate small-volume samples (<3 ml of blood), to optimize detection of common pediatric pathogens. The medium is an enriched soybean-casein digest broth and contains resins for antibiotic neutralization. One set of blood cultures consists of a set of two bottles of nutrient broth. Bottle one (Bactec Plus) is Aerobic; Bottle Two (Bactec Lytic/10) is anaerobic. Lab-1325 Blood Culture Collection Page 1 of 6

2 A single Peds Plus bottle is adequate for pediatric patients. Gundersen Health lab also uses the WAMPOLE ISOSTAT Microbial System (ISOLATOR) for collection of blood to be cultured for AFB, Fungus, and Legionella. These tubes are used as a temporary sterile transport container for the sample. The tubes contain NO nutrient broth at all, and any organism would eventually die if left too long in the tubes. The tubes must be processed by Microbiology ASAP after collection. The Infectious Disease Department recommends that no more than 3 blood cultures be drawn during a 24 hour period, except in special circumstances. If more than 3 are requested, an Infectious Disease provider must grant approval or be involved in the patient s care. However, more than 3 cultures/24 hour period may be needed for the following clinical situations: 1. Bacterial pneumonia 2. Meningitis 3. Fever of unknown origin 4. Acute Infective Endocarditis 5. Sub-acute Infective Endocarditis 6. Any request made by an Infection Disease Provider Request for more than 3 blood cultures in a 24-hour period that do not meet the above criteria require an Infectious Disease consult. CLINICAL SIGNIFICANCE: N/A SPECIMEN: The specimen is aseptically collected whole blood (capillary specimens are not acceptable). The physician designates the time for blood cultures to be drawn. If no time is given, the draws should occur consecutively. Each set of cultures needs to be drawn as a SEPARATE venipuncture procedure. This is done as a check for contamination. Note: It is acceptable for a patient with an indwelling line (art line, hickman, multi-med, etc.) to have one set of blood cultures drawn off the line by IVT or specially trained nurses following guidelines in GL Blood Culture Collection from Catheters/Lines. If two or more sets are ordered, a venipuncture should be performed for at least one set (unless the physician specifically writes an order stating, draw all off line or do not draw off line.) 1. Culture Specifications Occasionally blood cultures will be ordered with special instructions such as Culture for Brucella. Make sure that the special instructions are entered as order comments so Microbiology will be aware. Listed below are the EPIC test codes and bottle/tube requirements for each type of blood culture order: Routine: TEST Code: BC (Blood Culture) Lab-1325 Blood Culture Collection Page 2 of 6

3 1 BACTEC Plus Aerobic/F Blue 1 BACTEC Lytic/10 Anaerobic/F Purple OR BACTEC Peds Plus/F Pink Fungal: TEST Code: BCF (Blood Culture Fungal) 1 ISOLATOR Tube* AFB: TEST Code: BCA (Blood Culture AFB) 1 ISOLATOR Tube* Legionella: TEST Code: BCL (Blood Culture Legionella) 1 ISOLATOR Tube* Note: If patient has Fungal and AFB blood culture orders, only 1 isolator tube per set needs to be drawn. 2. Patient Preparation: See Procedure Section. 3. Amount: Ideally, the optimum amount of blood should be drawn to enhance the recovery of organisms. For recommendations from the Microbiology department, see the tables below: BACTEC BOTTLES AMOUNT COLLECTED BACTEC Plus Aerobic/F (BLUE) BACTEC Lytic/10 Anaerobic/F (PURPLE) BACTEC Peds Plus (PINK) 20 ml 10 ml 10 ml ml *Maximum amount in the Pediatric bottle for Pediatric patients is 3 ml, depending on the child s weight. Guidelines for difficult draws on adults: NOTE: If 3 ml or less is obtained on an adult patient, a peds bottle should be used and the reason should be documented (e.g. very difficult draw). If less than the optimal amount (10 cc) in each bottle) is obtained, the distribution of blood collected should be as follows: Venipuncture Amount in BACTEC Plus Aerobic Vial (Silver Label) ml Split equally between aerobic and anaerobic vials ml 8 ml 5-8 ml ml 5-7 ml 5- ml 5-9 ml Entire blood amount 0 ml Amount in BACTEC Lytic/10 Anaerobic Vial (Purple label) Lab-1325 Blood Culture Collection Page 3 of 6

4 The amount that was collected should be written on the label along with the site that was drawn from (i.e. LA9 would mean that 9 cc was placed in this bottle from the left arm). Abbreviations for Locations LA left arm LH left hand LF left foot Color of port (blue, red, etc.) RA right arm RH right hand RF right foot WAMPOLE ISOLATOR TUBES Wampole ISOLATOR 10 Microbial Tube *Wampole ISOLATOR 1.5 Microbial Tube Optimal Amount 10 mls 1.5 mls Minimum Amount 2 mls 1.0 ml NOTE: The optimal amount of blood needed for an ISOLATOR 10 Microbial tube is 10 mls. Microbiology will process any amount of blood obtained, but organism recovery is decreased. It is preferred that if a small amount of blood is obtained and you feel it is possible to obtain the optimal amount of blood with a redraw, that the redraw is performed. Only send less than 10 mls of blood if the patient is extremely hard to draw. Please label the tube with the amount of blood placed into the tube. If 1.5 mls or less of blood is obtained, it is acceptable to use the ISOLATOR 1.5 tube. *ISOLATOR 1.5 microbial tubes are reserved for neonatal draws (i.e. NICU) and extremely hard to draw patients. Tubes are located in Microbiology. 4. Handling Conditions: a. BacTec Bottles Store at Room Temperature (15-30 o C until samples can be taken to Microbiology and loaded into the BacTec. DO NOT REFRIGERATE! b. Isolator Tubes Isolator tubes are to be kept at room temperature for up to 16 hours if necessary, but immediate processing is recommended. DO NOT REFRIGERATE OR FREEZE. NOTE: Specimens from patients on antibiotics, short draws, and specimens for quantitative cultures need to be processed immediately. 5. Labeling: Label all specimens according to Lab-1330 Patient Identification. In addition, note the site of draw. This information may be helpful in determining if the patient has a systemic blood infection, or a localized infection of a foreign body (indwelling line). REAGENTS/MATERIALS: Please see manufacturer inserts for specific ingredients in each BACTEC Culture Vial. NOTE: Store bottles between 2-25 o C in a dry location out of direct sunlight. WAMPOLE Isolator Tubes: Lab-1325 Blood Culture Collection Page 4 of 6

5 Isolator 10 ml tubes (Polypropylene glycol, SPS & Saponin) Isolator 1.5 ml tubes (Pediatric tubes) (Polypropylene glycol, SPS & Saponin) NOTE: Store Isolator tubes at room temperature (15-30 o C) Materials: Syringe (sterile unopened) BD Safety Needle for syringe or butterfly Sterile Angel wing female adaptor (for blood culture bottles) 2 X 2 gauze All-purpose Sponge Bandage Tourniquet Chlora prep antiseptic skin preps Alcohol preps OR Sterile Angel wing male adaptor (for blood culture bottles) BD Vacutainer Brand Push Button Blood collection set 2 x 2 gauze All-purpose Sponge Bandage Tourniquet Chlora prep antiseptic skin preps Alcohol preps a. Performance Parameters: N/A b. Storage Requirements: All supplies must be stored at room temperature (20-25 o C) Two ear-loop masks (1 for self, 1 for patient) One hair-cover (for phlebotomist, not patient) Greet patient according to Customer Service guidelines Explain procedure to patient. EQUIPMENT/INSTRUMENT: N/A Implementation 1. Verify the expiration date on the blood culture bottles. 2. Phlebotomist must don mask and hair cover (all hair must be covered). Then ask patient to don mask. Patient may refuse to do so, ask patient then to turn face. You may continue without patient cooperation. 3. Cleanse the top of the BACTEC Bottles or Isolator tube with 70% alcohol prep and allow to air dry. 4. Clean the skin surface using chlora prep antiseptic skin prep. Area must be scrubbed for 30 seconds and allowed to air dry. NOTE: For infants <2 months of age, scrub for 30 seconds with an alcohol pad. Then do a circular scrub from the inside out and allow to air dry. 5. Obtain blood by venipuncture being careful not to touch the prepared area. a. If using syringe method, use safety device and discard needle. Attach Angel Wing Female Adaptor and transfer blood to blood culture bottles and/or ISOLATOR Microbial tube. Lab-1325 Blood Culture Collection Page 5 of 6

6 b. For ISOLATOR Microbial Tubes it is VERY IMPORTANT that clotted specimens be redrawn. c. Add appropriate amount of blood to each bottle and/or tube required. d. ISOLATOR Microbial tubes need to be inverted at least 5 times to start cell lysis (ISOLATOR) and prevent clotting in tube. 6. Label the bottles and/or tubes with the patient s name, clinic number, date and time. It is very important to write the site that the blood was drawn from on all labels that you attach to the bottles. PROCEDURE NOTES: N/A CALCULATIONS: N/A INTERPRETATION: N/A LIMITATIONS: 1. False positives from skin contaminants (Coagulase negative staphylococcus or Corynebacterium) may occur. This is attributed to poor sterile technique. 2. False negatives may occur due to inadequate amount of specimen. The volume of blood obtained is directly proportional to the recovery rate of the infectious organism. REVIEW AND CHANGES: This document and all attached forms shall be reviewed optimally on an annual basis, with 2 years as the maximum review date. Review will be done by the technical leader, medical director or designated person. Changes require retyping the document or form and review by the medical director. REFERENCES: 1. BACTEC Bottles, Manufacturer s Insert. 2. Wampole ISOSTAT Microbial System: Manufacturer s Insert (revised February 2003). 3. PHLEBOTOMY Handbook, Blood collection Essentials, Garza & McBride 5 th Edition. 4. Introduction to Phlebotomy, CAP Press 14 th Edition. Lab-1325 Blood Culture Collection Page 6 of 6