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PEDIATRIC BLOOD CULTURE GUIDE

DOCUMENT TYPE: GUIDELINESite Applicability

This guideline applies to all healthcare providers, including physicians, providing care for pediatric patients for whom blood cultures are required at BC Children’s and BC Women’s Hospital.

PurposeThis guideline is designed to provide guidance to healthcare providers in the appropriate collection of blood culture samples from children.

BackgroundBlood cultures are among the most frequently submitted samples to the Microbiology laboratory and are used in the diagnosis and management of many potentially life threatening infections. They are generally collected in patients who require admission to hospital but may be collected from outpatients in certain circumstances (e.g. to investigate for possible infective endocarditis). Blood volume collected correlates closely with the likelihood of recovering the causative pathogen and also with a shorter time to detection.

GuidelineWeight based recommendations for volumes collected and blood culture collection bottles to be used are shown for routine pediatric blood cultures (Table 1) and for anaerobic blood cultures (Table 2) below.

Table 1: Routine patients‡ Pediatric Blood Culture Order

Child’s weight (kg) Collect: Inoculate following bottles:<1 0.5-1 mL 0.5 – 1 mL to Peds Plus

1 to 1.9 1 mL 1 mL to Peds Plus



4-5.9 5 mL 5 mL to Aerobic

6 to 7.9 7 mL 7 mL to Aerobic

8 to 11.9 10 mL 10 mL to Aerobic

12 to 17.9 15 mL Divide equally into 2 Aerobic



40 or greater20 mL site 1 10 mL to Aerobic #1

10 mL to Anaerobic #1

20 mL site 2* 10 mL to Aerobic #210 mL to Anaerobic #2

C-05-07-60031 Published Date: 25-Feb-2019 of 10 Review Date: 25-Feb-2022

This is a controlled document for BCCH& BCW internal use. Refer to online version. Print copy may not be current. See Disclaimer at the end of the document.


DOCUMENT TYPE: GUIDELINE

Table2: Anaerobic† (including Oncology) Pediatric Blood Culture Order

Child’s weight (kg) Collect (ml): Inoculate the following bottles‡:<1 0.75 – 1 mL 0.5 mL to Peds

Plus 0.25 mL – 0.5 mL to Anaerobic

1 to 1.9 1.5 mL 1 mL to Peds Plus 0.5 mL to Anaerobic

2 to 2.9 2 mL 1 mL to Peds Plus 1 mL to Anaerobic

3 to 3.9 3 mL 1.5 mL to Peds Plus 1.5 mL to Anaerobic

4-5.9 5 mL 2.5 mL to Peds Plus 2.5 mL to Anaerobic

6 to 7.9 7 mL 3.5 mL to Peds Plus 3.5 mL to Anaerobic

8 to 11.9 10 mL 5 mL to aerobic 5 mL to Anaerobic

12 to 17.9 15 mL 10 mL to Aerobic 5 mL to Anaerobic

18 to 29.9 20 mL 10 mL to Aerobic 10 mL to Anaerobic

30 to 39.9 30 mL 20 mL divided into 2 Aerobic 10 mL to Anaerobic

40 or greater20 mL site 1

10 mL into Aerobic #110 mL to Anaerobic #1

20 mL site 2* 10 mL to Aerobic #210 mL to Anaerobic #2

† Indications for Anaerobic cultures include:• intraabdominal or pelvic infection, necrotizing enterocolitis in neonates• mouth/neck infection, including septic thrombophlebitis (e.g. Lemierre’s)• necrotizing soft tissue infection• infected bite wounds• immunosuppressed host• prolonged fever of unknown origin with negative aerobic cultures• All children >40 kg

‡ If patient has Central Venous Line (CVL), divide total aerobic volume by number of lumens and collect this volume from each lumen and place each in separate aerobic bottle(s). If the volume going into each aerobic bottle is < 5 mL Peds Plus bottles should be used; if it is ≥ 5mL aerobic bottles should be used.

* Site 2 can be from either a peripheral site or from another lumen of a CVL.

“Discard” blood can be used from a CVL for blood culture unless there is an indwelling antibiotic or ethanol therapy (i.e. “antibiotic lock” therapy). In this case, the discard volume should not be used for the blood culture.

Fungal blood cultures are generally of little added benefit unless there is concern for certain endemic mycoses (e.g. Histoplasmosis) or Malassezia spp. infection. Routine aerobic blood culture bottles are




DOCUMENT TYPE: GUIDELINEadequate for recovery of yeasts such as Candida spp. If fungal-specific or mycobacterial cultures are required contact Medical Microbiologist on call.

Equipment For Central Venous Line Collection Requisitions and computerized or addressograph labels for patient

- note that each “site” requires its own requisition Hospital grade surface disinfectant wipes Chlorhexidine 2% in 70% alcohol swabs x 6 Gloves, non-sterile One 10 mL pre-filled Normal Saline syringe per lumen (x2 if implanted port) Blood culture collection containers (ensure to check expiry date on bottles) Appropriate blood collection tubes if collecting further blood work from CVL (ensure to

check expiry date on tubes) Blood transfer vacutainer device (one per lumen) Sterile dead-end cap if interrupting IV infusion (one per lumen) Empty sterile 10 mL syringe (amount of syringes dependent on number of lumens and

volume of blood to be collected) - NOTE: the use of vacutainer is not recommend for blood collections due to importance regarding accuracy of blood volume to be drawn- NOTE: larger syringes may be used on cuffed CVCs, short term CVCs and Implanted ports however ONLY 10mL syringes may be used on PICC lines for blood collection

If Heparin locking post blood collection (see “Heparin Locking Central Venous Lines” Procedure Document):

10 mL pre-filled syringe with heparin 10units/mL (one per lumen) SwabcapTM (one per lumen)

Procedure for Central Venous Line CollectionSTEPS RATIONALE




DOCUMENT TYPE: GUIDELINE1. REVIEW physician orders for blood cultures and determine if anaerobic cultures are to be collected. Oncology patients will routinely require anaerobic cultures and other patients will have anaerobic cultures only if specifically ordered by the physician.

Indications for Anaerobic cultures include:• intraabdominal or pelvic infection, necrotizing

enterocolitis in neonates• mouth/neck infection, including septic

thrombophlebitis (e.g. Lemierre’s)• necrotizing soft tissue infection• infected bite wounds• immunosuppressed host• prolonged fever of unknown origin with

negative aerobic cultures• All children >40 kg

2. IDENTIFY patient by comparing name on requisition and labels to patient ID band or hospital approved photo ID. Please refer to Patient identification Policy.

NOTE: Paper requisitions can be brought into patient room even if on isolation.

Failure to correctly identify patients prior to procedures may result in errors and/or recollection.

3. EXPLAIN the procedure to the patient and family Evaluates and reinforces understanding of previously taught information and confirms consent for procedure.May help to reduce anxiety/concern about current clinical situation patient is in.

4. CLEAN non-porous work surface with hospital grade disinfectant wipe

Routine infection control practices. Reduces transmission of microorganisms.

5. PERFORM hand hygiene for one minute using soap and water. Routine infection control practices prior to CVL care.

6. PREPARE equipment using aseptic technique at the bedside of the patient.

Routine infection control practices.

7. REMOVE the protective cover on the blood culture collection bottle and SCRUB the top of the culture bottle with Chlorhexidine 2% in 70% alcohol swabs for 30-60 seconds using good friction. Allow to dry for 1 minute.

Decrease risk of blood culture contamination.

8. CLAMP CVL Catheter. If second lumen infusing, CLAMP second lumen.

NOTE: If high risk infusion running in second lumen, it may not be appropriate to clamp second lumen or draw blood from this lumen. In these scenarios, please consult with physician prior to clamping second lumen.

Both lumens must remain clamped during blood sampling to ensure no contamination or dilution of blood samples.

It may not be clinically appropriate for patients dependent on a high risk infusion to clamp second lumen (i.e. inotropes, insulin infusion etc.)

9. PAUSE or DELAY infusion on IV pump. If CVL is heparin locked, skip to step 11.10. PERFORM hand hygiene (may use alcohol-based hand sanitizer at bedside) and DON non-sterile gloves

Routine infection control practices

11. REMOVE IV tubing and attach sterile dead-end cap to open end of IV line to keep covered.

Routine infection control practices. Gloves to protect health care provider.

12. SCRUB the needleless connector (cap) for 30 second with Chlorhexidine 2% in 70% alcohol swab and allow to dry for one minute. Repeat with a second swab and clean up the line from the cap towards the clamp, including the clamp. Allow to dry for one minute.

NOTE: If CVL has had a SwabcapTM on the needleless connector for >5minutes you may remove the SwabcapTM and proceed to the next step without cleaning if you know the SwabcapTM has not been compromised.

Routine infection control practices. Decreases risk of contamination. Chlorhexidine is active against Gram-positive and Gram-negative organisms, facultative anaerobes, aerobes, and yeast. Must allow for full dry time to be effective.

13. ATTACH empty sterile sample syringe to needleless connector using aseptic technique.



https://en.wikipedia.org/wiki/Aerobes

https://en.wikipedia.org/wiki/Facultative_anaerobes

https://en.wikipedia.org/wiki/Gram-negative_bacteria

https://en.wikipedia.org/wiki/Gram-positive_bacteria


DOCUMENT TYPE: GUIDELINE14. UNCLAMP catheter and WITHDRAW appropriate amount of blood required by pulling back on the plunger of syringe gently. Refer to Table 1 or 2 at the beginning of the guideline to determine appropriate amount of blood required for culture bottle(s) based on patient’s weight.

NOTE: “Discard” blood can be used from a CVL for blood culture unless there is an indwelling antibiotic or ethanol therapy (i.e. “antibiotic lock” therapy) in the CVL. In this case, the discard volume should not be used for the blood culture. If this is the case, remove the appropriate amount of blood for discard into sample syringe and CLAMP catheter. REMOVE syringe from needless connector and immediately dispose of the discarded blood. The appropriate volume of discard is depending on the patient’s weight and line type:

Type of CVL AMOUNT of DISCARDCuffed CVC < 10 kgs 1.5 mLCuffed CVC > 10 kgs 3 mLShort-term CVC 1.5 mLImplanted Port 3 mLCuffed/uncuffed PICC < 10 kgs 1.5 mL

Cuffed/uncuffed PICC > 10kgs 3 mL

Hemodialysis/Apheresis 3 mL

Repeat Step 14 with new sterile sample syringe if first was used for discard.

Ensuring the appropriate amount of blood volume will result in an accurate blood culture test. Low volumes may lead to false negative reports.

If you pull back to quickly, the blood may rush into the syringe too quickly causing lysis or hemolysis of the cells.

Removes antibiotic solution from catheter to ensure uncontaminated blood specimen is places in blood culture bottle.

15. If discard not required, CLAMP catheter. REMOVE syringe from needless connector and attach blood transfer vacutainer device.

To keep end of CVL clean, you may ATTACH the next empty sterile sample syringe to needless connector (if further blood sampling is required) or, if no further bloodwork required, ATTACH sterile NS pre-filled syringe and allow line to rest, clamped, with syringe attached.

To ensure tip of syringe is not contaminate before blood is transferred into blood culture bottle.

16. IMMEDIATELY TRANSFER blood from sterile sample syringe to appropriate blood culture collection bottles and/or blood tubes using the blood transfer vacutainer device.

GENTLY invert each tube/bottle after blood is added. Please refer to Order of Draw reference tool to ensure appropriate transfer order and appropriate number of inversions per blood tube.DO NOT invert blood while in sterile sample syringes.

Once in tubes, inverting ensures blood cells are all mixed with additives in tubes.

DO NOT SHAKE or will cause cell lysis.

Inverting or mixing blood in sample syringe will cause hemolysis and dramatically impact accuracy of results. Blood must be immediately transferred to appropriate tube or collection bottle with the least amount of manipulation as possible.




DOCUMENT TYPE: GUIDELINEIf putting blood into micro-tubes, remove top of micro-tube and gently depress blood filled syringe to add appropriate amount of blood to micro-tube.17. If further blood sampling required, using attached sterile sample syringe, UNCLAMP catheter and WITHDRAW required amount of blood and repeat steps 14-18 until full volume of blood has been collected from lumen and all blood transferred into appropriate collection tubes.

If no further blood sampling required, using attached sterile pre-filled normal saline syringe, UNCLAMP catheter and with thumb on the plunger of the syringe, give two-three quick pushes of the normal saline into the catheter. Then with a continuous fast motion, FLUSH into the needleless connector and catheter with remaining normal saline required:

Type of CVL Minimum NS Flush Required

Cuffed < 10 kgs 3 mLCuffed > 10 kgs 9 mLShort-term CVC 3 mLImplanted Port 18 mL (use x2 pre-filled 10

mL syringes)All PICCs < 10 kgs 3 mLAll PICCs > 10 kgs 9 mLHemodialysis/Apheresis 9 mL

Creates turbulent flow to clear catheter of blood and help maintain patency of the line. Flush must always be done. Do not connect back to line and use IV fluids to flush the line.

18. RECONNECT infusion set and commence infusion or HEPARIN LOCK line as ordered.

NOTE: If second lumen is present, keep lumen #1 clamped or heparin lock lumen #1 and then repeat steps 12-18 on lumen #2. Ensure IV therapy is never running into a lumen while drawing blood out of the second lumen with the exception noted in step #8 regarding high risk infusions.

Resumes therapy as ordered.

Both lumens must remain clamped during blood sampling to ensure no contamination or dilution of blood samples.

It may not be clinically appropriate for patients dependent on a high risk infusion to clamp second lumen for any length of time (ie: inotropes, insulin infusion etc.) consult physician team.

19. COMPLETE site to source safety check of IV infusion system. Site assessment (“TLC”). Ensure fluid running through all CVL lumens. All connections are secure and clamps are in appropriate position.

Decrease risk of infiltration or extravasation. Ensure line remains patent.

20. LABEL blood culture collection bottles and other blood tubes at patient’s bedside. Label must include MRN, first and last name, date of birth, date and time sample drawn and on blood culture bottle must indicate which site (ie: white lumen, medial port, peripheral etc.) and volume of blood placed into the bottle.

Safe blood sampling practices. See “Blood Sampling from Central Venous Lines” procedure for further details including Group and Screen procedure.

21. PLACE specimens into transport bags22. REMOVE gloves and PERFORM hand hygiene. Routine infection control practices.23. COMPLETE appropriate laboratory requisitions for blood cultures, this includes indicating the site where blood sample was obtained, RN initials, date and time and volume of blood collected. Each site of collection must have its own requisition. Ensure patient’s weight is indicated on the blood culture requisition(s).

Signing the requisitions confirms you have correctly identified the patient.

24. ARRANGE for transport to the lab. Blood culture collection bottles may be tubed via the pneumatic tube system.

NOTE: all samples being sent via pneumatic tube system in the Teck ACC building must be put inside appropriate zip and fold bag. If unable C-05-07-60031 Published Date: 25-Feb-2019 of 10 Review Date: 25-Feb-2022



DOCUMENT TYPE: GUIDELINEto locate zip and fold bag, a porter must be called to deliver specimens.

Equipment for Peripheral Blood Culture Collection With Iv Start Requisitions and computerized or addressograph labels for patient

- note that each “site” requires its own requisition Chlorhexidine 2% in 70% alcohol swabs x 6 Gloves, non-sterile Blood culture collection containers Appropriate blood collection tubes if collecting further blood work Blood transfer vacutainer device Empty sterile 10mL syringe (amount of syringes dependent on volume of blood to be

collected) All equipment required for initiating a PIV. See INITIATING A PERIPHERAL

INTRAVENOUS (PIV) policy on ePOPS.

Procedure for Peripheral Blood Culture Collection with IV StartSTEPS RATIONALE1. REVIEW physician orders for blood cultures and determine if anaerobic cultures are to be collected

Indications for Anaerobic cultures include:• intraabdominal or pelvic infection, necrotizing

enterocolitis in neonates• mouth/neck infection, including septic

thrombophlebitis (e.g. Lemierre’s)• necrotizing soft tissue infection• infected bite wounds• immunosuppressed host• prolonged fever of unknown origin with negative

aerobic cultures• All children >40 kg

2. IDENTIFY patient by comparing name on requisition and labels to patient ID band or hospital approved photo ID. Please refer to Patient identification Policy.

NOTE: Paper requisitions can be brought into patient room even if on isolation.

Failure to correctly identify patients prior to procedures may result in errors

3. EXPLAIN the procedure to the patient and family. Evaluates and reinforces understanding of previously taught information and confirms consent for procedure.May help to reduce anxiety/concern about current clinical situation patient is in.

4. CLEAN non-porous work surface with hospital grade disinfectant wipe.

Routine infection control practices. Reduces transmission of microorganisms.

5. PERFORM hand hygiene. Routine infection control practices.6. PREPARE equipment using aseptic technique at the bedside of the patient.

Routine infection control practices.

7. REMOVE the protective cover on the blood culture collection bottle and SCRUB the top of the culture bottle with Chlorhexidine 2% in 70% alcohol swabs for 30-60 seconds using good friction. Allow to dry for 1 minute.

Decrease risk of blood culture contamination.

8. INITIATE PIV – review INITIATING A PERIPHERAL INTRAVENOUS (PIV) policy and DON non-Sterile gloves.9. Once PIV insitu, CLAMP PIV extension tubing. REMOVE tip of PIV extension.10. ATTACH sterile syringe to PIV extension tubing using aseptic




DOCUMENT TYPE: GUIDELINEtechnique.11. UNCLAMP catheter and WITHDRAW appropriate amount of blood required by pulling back on the plunger of syringe gently. Refer to Table 1 or 2 at the beginning of the guideline to determine appropriate amount of blood required for culture bottle(s) based on patient’s weight.

Ensuring the appropriate amount of blood volume will result in an accurate blood culture test. Low volumes may lead to false negative reports.

12. CLAMP extension tubing. REMOVE syringe from needless connector and attach blood transfer vacutainer device.

To keep end of PIV extension tubing clean, you may ATTACH the next empty sterile sample syringe to needless connector (if further blood sampling is required) or, if no further bloodwork required, ATTACH sterile NS pre-filled syringe and allow line to rest, clamped, with syringe attached.

NOTE: If discard required, the first syringe is to be discarded immediately into sharps or biohazard and repeat step 10-12 for blood collection for culture bottle.

To ensure tip of syringe is not contaminate before blood is transferred into blood culture bottle.

13. IMMEDIATELY TRANSFER blood from sterile sample syringe to appropriate blood culture collection bottles and/or blood tubes using the blood transfer vacutainer device.

GENTLY invert each tube/bottle after blood is added. Please refer to Order of Draw reference tool to ensure appropriate transfer order and appropriate number of inversions per blood tube.DO NOT invert blood while in sterile sample syringes.

If putting blood into micro-tubes, remove top of micro-tube and gently depress blood filled syringe to add appropriate amount of blood to micro-tube.

Once in tubes, inverting ensures blood cells are all mixed with additives in tubes.

DO NOT SHAKE or will cause cell lysis.

Inverting or mixing blood in sample syringe will cause hemolysis and dramatically impact accuracy of results. Blood must be immediately transferred to appropriate tube or collection bottle with the least amount of manipulation as possible.

14. If further blood sampling required, using new sterile sample syringe, UNCLAMP catheter and WITHDRAW required amount of blood and repeat steps 10-14 until full volume of blood has been collected and all blood transferred into appropriate collection tubes.

If no further blood sampling required, using sterile pre-filled normal saline syringe, UNCLAMP extension tubing and with a thumb on the plunger of the syringe, give two-three quick pushes of the normal saline into the tubing. Then with a continuous fast motion, FLUSH the rest of the normal saline required into the line.

Creates turbulent flow to clear catheter of blood and help maintain patency of the line. Flush must always be done. Do not connect back to line and use IV fluids to flush the line.

15. ATTACH needless connector (microclave clear cap) to end of PIV extension tubing and COMMENCE IV therapy infusion per orders or SALINE LOCK PIV per orders.

Ensures patency of PIV.




DOCUMENT TYPE: GUIDELINE16. COMPLETE site to source safety check of IV infusion system. Site assessment (“TLC”). If IV therapy infusing, ensure all connections are secure and clamps are in appropriate position.

Decrease risk of infiltration or extravasation. Ensure line remains patent.

17. LABEL blood culture collection bottles and other blood tubes at patient’s bedside. Label must include MRN, first and last name, date of birth, date and time sample drawn and on blood culture bottle must indicate which site (aka: peripheral site) and volume of blood placed into the bottle.

Safe blood sampling practices. See transfusion medicine guidelines for appropriate labelling of group and screen samples.

18. ARRANGE for blood samples to be transported to the lab. Blood culture collection bottles may be tubed via the pneumatic tube system.

NOTE: all samples being sent via pneumatic tube system in the Teck ACC building must be put inside appropriate zip and fold bag. If unable to locate zip and fold bag, a porter must be called to deliver specimens.

DocumentationDOCUMENT on appropriate record(s) – Nurses Notes, PIV initiation flowsheet and/or CVL flowsheet if appropriate

Procedure and time Any difficulties with blood return from the CVL Patient’s response to procedure if unusual

References1. JP Buttery. Blood cultures in newborns and children: optimising an everyday test. Arch Dis Child Fetal

Neonatal Ed, 2002, 87: F25-F28.2. TG Connell, M Rele, D Cowley, JP Buttery, and N Curtis. How Reliable Is a Negative Blood Culture

Result? Volume of Blood Submitted for Culture in Routine Practice in a Children's Hospital. Pediatrics, 2007, 119;891.

3. Gaur AH, et al. Optimizing blood culture practices in pediatric immunocompromised patients: evaluation of media types and blood culture volume. Ped Infect. Dis. J. 2003.

4. Gonsalves WI, Cornish N, Moore M, Chen A, Varman M. Effects of volume and site of blood draw on blood culture results. J Clin Microbiol. 2009 Nov;47(11):3482-5.

5. Isaacman DJ, Karasic RB, Reynolds EA, Kost SI. Effect of number of blood cultures and volume of blood on detection of bacteremia in children. J Pediatr. 1996 Feb;128(2):190-5

6. Campigotto A, Richardson SE, et al. Low Utility of Pediatric Isolator Blood Culture System for Detection of Fungemia in Children: a 10-Year Review. J Clin Microbiol. 2016 Sep;54(9):2284-7.

Definitions

Patient: any person receiving services from C&W.

Consent: for the purpose of this guideline, consent is a signed acknowledgment from a patient to permit a specified action in relation to that patient's personal or Sensitive Information. Consent must be retained in either physical form (Signature; paper based record) or electronic form (“I agree”; “yes”; ticked check-box) as part of an electronic health record.

Staff: all officers, directors, employees, contractors, physicians, health care professionals, students and volunteers employed or contracted by C&W.

Health Care Provider: C&W Staff who are providing direct health-related care to a patient.C-05-07-60031 Published Date: 25-Feb-2019 of 10 Review Date: 25-Feb-2022



DOCUMENT TYPE: GUIDELINE

Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN06-Jun-2018 CC.03.48 Pediatric Blood Culture Guide Approved at: BC Children’s Best Practice Committee06-Feb-2019 C-05-07-60031 Pediatric Blood Culture Guide Approved at: BC Children’s Best Practice Committee

DisclaimerThis document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.



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