Clinical practice guideline: prevention of blood culture contamination

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

An implementation strategy was not provided.

Prevention of blood culture contamination in the pre-analytic phase will aid in the accurate and timely identification of the causative organism in patients with bacteremia, will decrease unnecessary antibiotics and additional tests to identify the reason for the positive blood culture, will reduce costs and length of hospital stay, and will increase patient survival.

Not stated

All articles relevant to the topic were identified via a comprehensive literature search. The following databases were searched: PubMed, Google Scholar, Cumulative Index to Nursing and Allied Health (CINAHL), eTBlast, Ovid, Cochrane Library, Agency for Healthcare Research and Quality (AHRQ; www.ahrq.gov), Specimen Care (www.specimencare.com), and the National Guideline Clearinghouse (www.guideline.gov). Searches were conducted using various combinations of key words including blood culture contamination, blood culture collection, hand preparation, phlebotomy technique, and blood samples. Initial searches were limited to English language articles from January 2002 to October 2012. This search limit was found to be inadequate and, therefore, the time frame was extended to begin with January 1990. In addition, the reference lists in the selected articles were scanned for pertinent research articles. Research articles from emergency department settings, non-emergency department settings, position statements and guidelines from other sources were also reviewed.

Articles that met the following criteria were chosen to formulate the clinical practice guideline (CPG): research studies, meta-analyses, systematic reviews, and existing guidelines relevant to the topic of blood culture contamination. Articles included in meta-analyses or systematic reviews were not considered independently unless there were factors not addressed in the meta-analysis/systematic review. Other types of reference articles and textbooks were also reviewed and used to provide additional information.

38 documents were included in the evidence tables.

Grading the Levels of Evidence*

1. Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of RCTs
2. Evidence obtained from at least one properly designed RCT
3. Evidence obtained from well-designed controlled trials without randomization
4. Evidence obtained from well-designed case control and cohort studies
5. Evidence from systematic reviews of descriptive and qualitative studies
6. Evidence from a single descriptive or qualitative study
7. Evidence from opinion of authorities and/or reports of expert committees

Grading the Quality of the Evidence 

1. Acceptable Quality: No Concerns
2. Limitations in Quality: Minor flaws or inconsistencies in the evidence
3. Major Limitations in Quality: Many flaws and inconsistencies in the evidence
4. Not Acceptable: Major flaws in the evidence

*Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, & Wilkins.

The clinical practice guideline (CPG) authors used a standardized reference table to collect information and assist with preparation of tables of evidence, ranking each article in terms of the level of evidence, quality of evidence, and relevance and applicability to practice. Clinical findings and levels of recommendations regarding patient management were then made by the Emergency Nurses Association (ENA) 2012 Emergency Nursing Resources Development Committee according to ENA's classification of levels of recommendation for practice, which include: Level A High, Level B Moderate, Level C Weak or Not recommended for practice (see the "Rating Scheme for the Strength of the Recommendations" field).

This clinical practice guideline (CPG) was created based on a thorough review and critical analysis of the literature following Emergency Nurses Association (ENA)'s Guidelines for the Development of Clinical Practice Guidelines (see the "Availability of Companion Documents" field).

Conference calls with Subcommittee members and staff are held as necessary to discuss progress and facilitate the Subcommittee's work. All members of the Subcommittee independently complete an exhaustive review of all identified literature, complete a separate evidence table for each topic (if possible), and then reconvene to reach consensus. Each Subcommittee prepares a description of the topic, definition, background, significance, and evidence table. All articles and documents are uploaded to the CPG Development website for easy retrieval by everyone involved with the development process. The Subcommittee identifies and assigns preliminary scores for quality and strength of evidence, and describes conclusions based on the review of the body of evidence. Each Subcommittee also serves as "second readers" for another topic; this assures an in-depth look at the literature by two Subcommittees. The entire Committee reads the articles and reviews the evidence-appraisal tables for each topic and then finalizes implications for practice and the level of recommendation.

A formal cost analysis was not performed and published cost analyses were not reviewed.

The Institute for Emergency Nursing Research (IENR) Advisory Council reviews the final document for overall validity and provides feedback as appropriate using the Clinical Practice Guidelines (CPGs) Evaluation Worksheet. Reviews and feedback are sent to the Subcommittee to evaluate and incorporate, as appropriate. Emergency Nurses Association (ENA) staff creates the final products for publication with input from the Committee.

Not applicable: The guideline was not adapted from another source.

Emergency Nurses Association

2012 ENA Emergency Nursing Resources Development Committee

Committee Members: Jean A. Proehl, MN, RN, CEN, CPEN, FAEN; Sherry Leviner, MSN, RN, CEN; Judith Young Bradford, DNS, RN, FAEN; Andrew Storer, DNP, RN, ACNP, CRNP, FNP; Susan Barnason, PhD, RN, APRN-CNS, CEN, CCRN, FAAN; Carla Brim, MN, RN, CEN, CNS; Judith Halpern, MS, RN, APRN; Cathleen Lindauer, MSN, RN, CEN; Vicki C. Patrick, MS, RN, SRPN, ACNP, CEN, FAEN; Jennifer Williams, MSN, RN, CEN, CCRN, CNS

Not stated

This is the current release of the guideline.

Electronic copies: Available in Portable Document Format (PDF) from the Emergency Nurses Association Web site.

The following are available:

• Requirements for the development of: clinical practice guidelines, clinical practice guidelines synopsis, and translation into practice (TIP) recommendations. Des Plaines (IL): Emergency Nurses Association; 2013 Dec. 40 p. Electronic copies: Available in Portable Document Format (PDF) from the Emergency Nurses Association Web site.
• Clinical practice guideline: prevention of blood culture contamination. Synopsis. Des Plaines (IL): Emergency Nurses Association; 2012 Dec. 1 p. Electronic copies: Available in PDF from the Emergency Nurses Association Web site.
• CPG evidence table: prevention of blood culture contamination. Des Plaines (IL): Emergency Nurses Association; 2012 Dec. 21 p. Electronic copies: Available in PDF from the Emergency Nurses Association Web site.
• CPG other resources table: prevention of blood culture contamination. Des Plaines (IL): Emergency Nurses Association; 2012 Dec. 2 p. Electronic copies: Available in PDF from the Emergency Nurses Association Web site.

None available

This NGC summary was completed by ECRI Institute on February 13, 2014. The information was verified by the guideline developer on March 27, 2014.

This summary is based on the original guideline, which is subject to the guideline developer's restrictions.

Bacteremia requiring blood culture

To evaluate which pre-analytic variables related to peripheral venous specimen collection and transportation decrease blood culture contamination

Hospitalized patients with bacteremia requiring blood cultures

The grades of recommendations (A–C, Not Recommended, I/E), levels of evidence (I–VII), and quality of evidence (I–IV) are defined at the end of the "Major Recommendations" field.

Description of Decision Options/Interventions and the Level of Recommendation

Please note that the references listed after each recommendation represent the evidence considered when making the recommendation. This does not mean that the evidence in each individual reference supports the recommendation.

1. Provide education and training for personnel who collect blood cultures. Level C – Weak (Bamber et al., 2009; Dhillon, Clark, & Azadian, 2009; Eskira et al., 2006; McLellan, Townsend, & Parsons, 2008; Roth et al., 2010; College of American Pathologists [CAP], 2008; Weddle, Jackson, & Selvarangan, 2011)
2. Have blood cultures drawn by dedicated phlebotomy staff. Level B – Moderate (Bekeris et al., 2005; Mermel et al., 2009; Mtunthama et al., 2008; Roth et al., 2010; Schifman et al., 1998; Snyder et al., 2012; CAP, 2008)
3. Draw blood cultures from a dedicated peripheral venipuncture site, not an intravenous catheter. Level B – Moderate (Baron et al., 2005; Mermel et al., 2009; Snyder et al., 2012; Stohl et al., 2011)
4. Routine sterile gloving during venipuncture may decrease blood culture contamination. Level C – Weak (Kim et al., 2011)
5. Use pre-assembled blood culture collection packs. Level C – Weak (Bamber et al., 2009; Dhillon, Clark, & Azadian, 2009; Madeo, Jackson, & Williams, 2005; Snyder et al., 2012; Thomas et al., 2011)
6. Clean culture bottle tops with antiseptic prior to blood culture bottle inoculation. Level B – Moderate (Bekeris et al., 2005; Schifman et al., 1998)
7. Clean culture bottle tops with 70% isopropyl alcohol and air dry prior to blood culture bottle inoculation. Level C – Weak (Clinical and Laboratory Standards Institute [CLSI], 2007)
8. Use products containing alcohol to cleanse the skin prior to collecting blood cultures. Level A – High (Baron et al., 2005; CLSI, 2007; McLellan, Townsend, & Parsons, 2008; Mermel et al., 2009; Qamruddin, Khanna, & Orr, 2008; Schifman et al., 1998; Shahar, Wohl-Gottesman, & Shenkman, 1990; Snyder et al., 2012; Strand, Wajsbort, & Sturmann, 1993)
9. Use alcoholic chlorhexidine to clean the skin before drawing blood cultures in patients over 2 months of age. Level A – High (Baron et al., 2005; Benjamin et al., 2011; Caldeira, David, & Sampaio, 2011; CLSI, 2007; Madeo & Barlow, 2008; Marlowe et al., 2010; Mermel et al., 2009; Tepus et al., 2008)
10. Use alcohol to clean the skin before drawing blood cultures in children under 2 months of age. Level C – Weak (CLSI, 2007)
11. Apply alcohol containing solutions with 30 seconds of vigorous back and forth scrubbing. If povidone-iodine is used, it should be applied in concentric circles. Level C – Weak (Baron et al., 2005)
12. Allow the skin cleansing agent to air dry before venipuncture when drawing blood cultures. Level A – High (Baron et al., 2005; CLSI, 2007; Mermel et al., 2009)
13. Divert the initial 1–2 ml of blood into a sterile receptacle when drawing blood culture specimens via peripheral venipuncture. Level B – Moderate (Patton & Schmitt, 2010) (Note: New evidence is pending. When it is available, this recommendation will be updated if indicated.)
14. Inadequate evidence exists to make a recommendation regarding blood sample volume and prevention of contamination of blood cultures. (Note: Manufacturers' recommendations for the blood specimen volume per culture bottle should be followed). Level – I/E (Bekeris et al., 2005; CLSI, 2007; Schifman et al., 1998)
15. Inoculate the blood culture bottle with a different needle than that used for venipuncture. (Note: Changing needles is not recommended due to the risk of blood exposure). Level B – Moderate (Spitalnic, Wollard, & Mermel, 1995; Bekeris et al., 2005; Baron et al., 2005)
16. Monitor contamination rates and provide performance feedback to personnel who draw blood cultures. Level B – Moderate (Bekeris et al., 2005; Gibb et al., 1997; Thomas et al., 2011; CAP, 2008)

Definitions:

Levels of Recommendation for Practice

Grading the Levels of Evidence*

1. Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of RCTs
2. Evidence obtained from at least one properly designed RCT
3. Evidence obtained from well-designed controlled trials without randomization
4. Evidence obtained from well-designed case control and cohort studies
5. Evidence from systematic reviews of descriptive and qualitative studies
6. Evidence from a single descriptive or qualitative study
7. Evidence from opinion of authorities and/or reports of expert committees

Grading the Quality of the Evidence

1. Acceptable Quality: No concerns
2. Limitations in Quality: Minor flaws or inconsistencies in the evidence
3. Major Limitations in Quality: Many flaws and inconsistencies in the evidence
4. Not Acceptable: Major flaws in the evidence

*Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, & Wilkins.

None provided

The Food and Drug Administration warns that use of chlorhexidine in premature infants or children under 2 months of age may cause excessive skin irritation and chemical burns. Chlorhexidine is not currently recommended in infants less than 2 months of age.