Centers for Disease Control and Prevention
Blood Culture Contamination: An Overview for Infection Control and Antibiotic Stewardship Programs Working with the Clinical Laboratory
In offering guidance, the CDC references a study by Doern et al which identifies ways to address blood culture contamination. Among the preventive actions, the authors call for the use of diversion devices saying, “There are devices that are commercially available that have shown promise in further reducing blood culture contamination rates. These devices initially divert a small amount of potentially contaminated blood and then collect blood for the blood culture.”
Read the full guidance: Blood Culture Contamination: An Overview for Infection Control and Antibiotic Stewardship Programs Working with the Clinical Laboratory
Blood Culture Contamination and Diagnostic Stewardship: From a Clinical Laboratory Quality Monitor to a National Patient Safety Measure
Jake D Bunn and Nancy E Cornish. J Appl Lab Med. 2025 Jan 3;10(1):162-170. doi: 10.1093/jalm/jfae132.
Laboratory analysis of blood cultures is vital to the accurate and timely diagnosis of bloodstream infections. However, the reliability of the test depends on clinical compliance with standard operating procedures that limit the risk of inconclusive or incorrect results. False-negative blood culture results due to inadequate volumes of blood can result in misdiagnosis, delay therapy, and increase patients’ risk of developing or dying from bloodstream infections. Likewise, commonly occurring bacteria or fungi on human skin (i.e., commensal organisms) can contaminate the blood culture during collection and increase the risk of false positives, compromising care and leading to unnecessary antibiotic therapy and prolonged hospitalization. In December 2022, a Centers for Medicare & Medicaid Services (CMS) consensus-based entity (CBE) endorsed the Centers for Disease Control and Prevention’s (CDC) proposal for a new patient safety measure to address these concerns. CDC developed this quality measure to promote the standardization of blood culture best practices and improve laboratory diagnosis of bloodstream infections nationally. This special report will emphasize the importance of standardizing blood culture collection and describe the need for a national patient safety measure, new quality tools, and next steps.
Abstract (AACC membership required to access full text.)
Centers for Medicare and Medicaid (CMS)
Published a final rule 42 C.F.R § 482.42
Since early 2020, the CMS Conditions of Participation has required hospitals to “demonstrate adherence to nationally recognized infection prevention and control guidelines for reducing the transmission of infections, as well as best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms.”
CMS Compliance will require:
- A hospital’s infection prevention and control and antibiotic stewardship programs be active and hospital-wide for the surveillance, prevention, and control of [hospital acquired infections] and other infectious diseases.
- Optimization of antibiotic use through stewardship.
Clinical and Laboratory Standards Institute (CLSI®)
Wilson, ML. Principles and Procedures for Blood Cultures, 2nd Edition.
CLSI Document M47Ed2E (ISBN Number: 978-1-68440-149-9) 2022
Infusion Nursing Society
Infusion Therapy Standards of Practice, 9th Edition
Nickel B, Gorski L; Kleidon T, et al. Journal of Infusion Nursing. 47(1S):S1-S285, January/February 2024.
Section 41. Blood Sampling. Practice Recommendations. Section I, Comment G, Part C, recommends: Consider the costs and benefits in implementing a consistent process to divert and discard the initial blood sample when drawing blood cultures. Studies have demonstrated reduction in blood culture contamination with use of a diversion device.”
Infectious Diseases Society of America (IDSA)
Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM).
BLOODSTREAM INFECTIONS AND INFECTIONS OF THE CARDIOVASCULAR SYSTEM (pg 6)
To minimize the risk of contamination of the blood culture with commensal skin microbiota, meticulous care should be taken in skin preparation prior to venipuncture. In addition, products are available that allow diversion and discard of the first few milliliters of blood that are most likely to contain skin contaminant.
American Society for Microbiology
Sautter RL, Parrott JS, Nachamkin I, et al. American Society for Microbiology evidence-based laboratory medicine practice guidelines to reduce blood culture contamination rates: a systematic review and meta-analysis. Clin Microbiol Rev. Published online November 4, 2024. doi:10.1128/cmr.00087-24
[Relevant Excerpt]
Key action statement: institutions (facilities) that draw BCs should consider implementing a diversion device as part of the procedure for drawing peripheral BCs (evidence quality: II, recommendation strength: moderate).
Aggregate evidence quality: II
Benefits: diversion devices reduce BCC by an average of 64% and may lead to more appropriate therapy for bloodstream infections.
Risk, harm, and cost: there is a potential to contribute to iatrogenic anemia in patients with prolonged hospital stays with frequent phlebotomy to obtain BCs if large amounts of blood are discarded. Diversion tubes must be labeled with patient information as with any other specimen tube to avoid unlabeled or mislabeled tubes being processed for other lab studies. The cost of using a non-commercial diversion tube should keep additional costs to a minimum.
Benefit–harm assessment: preponderance of benefit.
Elizabeth L Palavecino, Victoria L Campodónico, Rosemary C She.
This mini-review provides practical recommendations on elaborating BCC rate reports, the parameters to define for the pre-set criteria, how to collect and interpret the data, and additional analysis to include in a BCC report.
[Relevant excerpt]
Recent attention has been given to lowering the acceptable threshold to ≤1%, as it has been noted that this rate is achievable even without blood diversion devices. In large studies, high-performing (90th percentile and above) laboratories have reported contamination rates of ≤1%. Therefore, this threshold may be considered aspirational by some. Conversely, a BCC rate of ≤1% may not always be achievable due to an expected baseline of transient bacteremia and true bacteremia that qualify as contamination based on laboratory criteria. Some investigators have reported that even with the use of initial blood diversion devices, rates lower than 1% may not be attained in some environments. In any case, institutions may choose to lower the acceptable threshold from the standard ≤3% to a level that is practically achievable while ensuring the highest quality BC collections.
Emergency Nurses Association (ENA)
ENA Emergency Nursing Resources Development Committee. Clinical practice guideline: prevention of blood culture contamination. Emergency Nurses Association; 2012 Dec.
Recommendation 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.)
College of American Pathologists (CAP)
CAP 2018 Q-Tracks: MIC.22630
“It is recommended that blood culture statistics, including number of contaminated cultures, be maintained and reviewed regularly by the laboratory director. The laboratory should establish a threshold for an acceptable rate of contamination. Tracking the contamination rate and providing feedback to phlebotomists or other persons drawing cultures has been shown to reduce contamination rates.”
International Guidelines
National Institute for Health and Care Excellence (NICE), United Kingdom
Kurin Lock for blood culture collection
Medical technologies guidance
Reference number: MTG77
Published: 03 April 2024
1 Recommendations
1.1 Kurin Lock can be used in the NHS to reduce contamination in blood culture collection in emergency departments with high blood culture contamination rates while more evidence is generated.
NICE has made this recommendation because although there is uncertainty around the evidence of cost effectiveness for Kurin Lock, antimicrobial resistance is an area of high unmet need in the NHS.
Adopting Kurin Lock would need no change to standard practice. Clinical experts report that it is easy to use and needs minimal training compared with other methods to reduce contamination.
Evidence generation alongside using Kurin Lock in the NHS should give an opportunity to collect resource impact data to inform the economic modelling.
These recommendations will be reviewed within 3 years, or sooner if new evidence becomes available. Take this and the uncertainty around pricing into account when negotiating lengths of contracts.
ML-019 Rev H