 Show Although prompt antibiotic treatment of patients with sepsis improves outcomes, treatment before blood cultures are obtained may reduce the accuracy and utility of microbiological data. This prospective investigation evaluated whether the sensitivity of blood cultures was altered when they were obtained after antibiotic administration. </TOC Summary>
Background:Administering antimicrobial agents before obtaining blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear how this strategy affects diagnostic sensitivity. Objective:To determine the sensitivity of blood cultures obtained shortly after initiation of antimicrobial therapy in patients with severe manifestations of sepsis. Design:Patient-level, single-group, diagnostic study. (ClinicalTrials.gov: NCT01867905) Setting:7 emergency departments in North America. Participants:Adults with severe manifestations of sepsis, including systolic blood pressure less than 90 mm Hg or a serum lactate level of 4 mmol/L or more. Intervention:Blood cultures were obtained before and within 120 minutes after initiation of antimicrobial treatment. Measurements:Sensitivity of blood cultures obtained after initiation of antimicrobial therapy. Results:Of 3164 participants screened, 325 were included in the study (mean age, 65.6 years; 62.8% men) and had repeated blood cultures drawn after initiation of antimicrobial therapy (median time, 70 minutes [interquartile range, 50 to 110 minutes]). Preantimicrobial blood cultures were positive for 1 or more microbial pathogens in 102 of 325 (31.4%) patients. Postantimicrobial blood cultures were positive for 1 or more microbial pathogens in 63 of 325 (19.4%) patients. The absolute difference in the proportion of positive blood cultures between pre- and postantimicrobial testing was 12.0% (95% CI, 5.4% to 18.6%; P < 0.001). Sensitivity of postantimicrobial culture was 52.9% (CI, 42.8% to 62.9%). When the results of other microbiological cultures were included, microbial pathogens were found in 69 of 102 (67.6% [CI, 57.7% to 76.6%]) patients. Limitation:Only a proportion of screened patients were recruited. Conclusion:Among patients with severe manifestations of sepsis, initiation of empirical antimicrobial therapy significantly reduces the sensitivity of blood cultures drawn shortly after treatment initiation. Primary Funding Source:Vancouver Coastal Health, St. Paul's Hospital Foundation Emergency Department Support Fund, the Fonds de recherche Santé–Québec, and the Maricopa Medical Foundation. References
Affiliations: Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (M.P.C.) University of British Columbia, St. Paul's Hospital, and the Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada (R.S.) Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada (K.P.) Surrey Memorial Hospital, University of British Columbia, Surrey, British Columbia, Canada (S.N.S.) University of Arizona College of Medicine, Phoenix, Arizona (M.A.) University of British Columbia and Lion's Gate Hospital, Vancouver, British Columbia, Canada (A.C.D.) University of British Columbia, Vancouver, British Columbia, Canada (M.G., R.J., K.H., C.S.) McGill University Health Centre, McGill University, Montreal, Quebec, Canada (A.L., K.D., C.C., J.T., G.C., C.P.Y.) Banner University Medical Center, Phoenix, Arizona (Z.S.) London Health Sciences Centre, London, Ontario, Canada (A.M.) University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada (D.S.) Financial Support: By Vancouver Coastal Health, St. Paul's Hospital Foundation Emergency Department Support Fund, the Fonds de Recherche Santé–Québec, and the Maricopa Medical Foundation. Disclosures: Dr. Akhter reports grants from Maricopa Medical Foundation during the conduct of the study. Dr. Yansouni reports grants from bioMérieux outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-1696. Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose. Data Sharing Statement: The following data and supporting documents will be made available with publication: deidentified participant data, data dictionary, and statistical/analytic code (contact Matthew P. Cheng; e-mail, [email protected]harvard.edu). These data will be made available to researchers whose proposed use of the data has been approved, for a specified purpose, with investigator support and with a signed data access agreement (restrictions: none). Corresponding Author: Matthew P. Cheng, MD, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, PBB-A4, Boston, MA 02115; e-mail, [email protected]harvard.edu. Current Author Addresses: Dr. Cheng: Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, PBB-A4, Boston, MA 02115. Dr. Stenstrom: St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V1S1Y1, Canada. Dr. Paquette: Montreal Children's Hospital, 1001 boul Décarie, B05.2043, Montreal, Quebec H4A 3J1, Canada. Dr. Stabler: Surrey Memorial Hospital, 13750 96th Avenue, Surrey, British Columbia V3V 1Z2, Canada. Dr. Akhter: Maricopa Integrated Health System, 2601 East Roosevelt Street, Phoenix, AZ 85008. Dr. Davidson: Lions Gate Hospital, 231 East 15th Street, North Vancouver, British Columbia V7L-2L7, Canada. Mr. Gavric: 1908 Scotia Street, Vancouver, British Columbia V5T0E8, Canada. Drs. Lawandi, Demir, and Yansouni and Ms. Caya: McGill University Health Centre, 1001 boul Décarie, Glen Site Block E, Montreal, Quebec H4A 3J1, Canada. Drs. Jinah and Sweet: Vancouver General Hospital, 899 West 12th Avenue, Intensive Care Unit JPN2, Room 2438, Vancouver, British Columbia V5Z 1M9, Canada. Dr. Saeed: Banner University Medical Center, 1111 East McDowell Road, Phoenix, AZ 85006. Dr. Huang: Vancouver General Hospital, 899 West 12th Avenue, Vancouver, British Columbia V5Z 1M9, Canada. Dr. Mahpour: London Health Sciences Centre, 1151 Richmond Street, London, Ontario N6A4V2, Canada. Mr. Shamatutu: University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, British Columbia V6T 1Z3, Canada. Dr. Troquet: McGill University Health Centre, 1001 boul Décarie, CS1.6143, Montreal, Quebec H4A 3J1, Canada. Dr. Clark: McGill University Health Centre, 1001 boul Décarie, CS1.6224, Montreal, Quebec H4A 3J1, Canada. Author Contributions: Conception and design: M.P. Cheng, R. Stenstrom, K. Paquette, A. Mahpour, J.-M. Troquet, C. Yansouni, D. Sweet. Analysis and interpretation of the data: M.P. Cheng, R. Stenstrom, K. Paquette, Z. Saeed, C. Caya, C. Yansouni, D. Sweet. Drafting of the article: M.P. Cheng, R. Stenstrom, K. Paquette, R. Jinah, Z. Saeed, C. Yansouni, D. Sweet. Critical revision of the article for important intellectual content: M.P. Cheng, R. Stenstrom, K. Paquette, S.N. Stabler, M. Akhter, A. Lawandi, C. Caya, J.-M. Troquet, C. Yansouni, D. Sweet. Final approval of the article: M.P. Cheng, R. Stenstrom, K. Paquette, S.N. Stabler, M. Akhter, A.C. Davidson, M. Gavric, A. Lawandi, R. Jinah, Z. Saeed, K. Demir, K. Huang, A. Mahpour, C. Shamatutu, C. Caya, J.-M. Troquet, G. Clark, C. Yansouni, D. Sweet. Provision of study materials or patients: R. Stenstrom, S.N. Stabler, M. Akhter, A.C. Davidson, R. Jinah, K. Huang, A. Mahpour, C. Shamatutu, C. Caya, J.-M. Troquet, G. Clark, C. Yansouni, D. Sweet. Statistical expertise: R. Stenstrom, K. Paquette, C. Caya, D. Sweet. Obtaining of funding: R. Stenstrom, M. Akhter, Z. Saeed, C. Yansouni, D. Sweet. Administrative, technical, or logistic support: R. Stenstrom, A.C. Davidson, R. Jinah, Z. Saeed, K. Huang, C. Shamatutu, C. Caya, J.-M. Troquet, G. Clark, D. Sweet. Collection and assembly of data: M.P. Cheng, R. Stenstrom, S.N. Stabler, M. Akhter, A.C. Davidson, M. Gavric, A. Lawandi, R. Jinah, Z. Saeed, K. Demir, K. Huang, A. Mahpour, C. Shamatutu, G. Clark, C. Yansouni, D. Sweet. This article was published at Annals.org on 17 September 2019. * For members of the FABLED Investigators, see the Appendix. Why is it important to collect cultures before antibiotic administration?Obtaining cultures before antibiotic use improves the chances of identifying the offending microorganism, which improves patient care. Inappropriate antibiotic use can result in prolonged hospital stays and increased costs, but it can also have adverse consequences on the patient's prognosis.
What is the purpose of culture and sensitivity when administering antibiotic therapy?A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection.
When Should blood cultures be drawn in relation to antibiotic administration?The Surviving Sepsis Campaign guidelines recommend that blood cultures be drawn before starting antimicrobial therapy, with 45-minute delays considered acceptable to achieve this goal (12). However, prompt initiation of effective antimicrobial therapy is a critical determinant of survival (13).
What do you need to assess before beginning antibiotic therapy?Culture/sensitivity must be done before first dose (may give before results are obtained). Assess WBC results, temperature, pulse, respiration. Interven- tion/Evaluation: Monitor lab results, particularly WBC and culture/sensitivity reports. Assess for adverse reactions.
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What is the purpose of obtaining a culture prior to the administration of an antibiotic?
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