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201711312

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UWHC,UWMF,

Policies,Clinical,UW Health Clinical,General Care and Procedures,Labs/Specimens

Blood Cultures for Adult Patients (2.5.6)

Blood Cultures for Adult Patients (2.5.6) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Labs/Specimens

2.5.6


UW HEALTH CLINICAL POLICY 1
Policy Title: Blood Cultures for Adult Patients
Policy Number: 2.5.6
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: October 20, 2017

I. PURPOSE

This policy is intended to ensure that blood cultures are only taken in appropriate circumstances using
accepted standard techniques. Compliance with this policy is intended to reduce inappropriate sampling,
reduce the likelihood of blood culture contamination, and optimize the recovery of pathogens by
standardization of practice.

For pediatric patients, please refer to UW Health clinical policy, Blood Cultures for Pediatric Patients.

II. DEFINITIONS

A. “Intravascular lines” include central venous access devices (CVAD), arterial lines, midline intravenous
peripheral catheters, peripheral intravenous catheters (PIV), or any other catheter inserted into an artery or
vein that can be used to collect blood.

III. POLICY ELEMENTS

A. Indications for blood cultures:
i. Collect blood cultures when a patient develops two or more signs of infection, i.e., new fever,
hypothermia, rigors, tachycardia, tachypnea, hypotension, leukocytosis, mental status change,
oliguria, hypoxia, or metabolic acidosis.
a. Drawing blood cultures in patients with none or only one of these signs of infection is
discouraged, as the probability of bacteremia in such patients is very low. A thorough
workup to identify a potential source of infection should be performed prior to drawing
blood cultures in these patients.
B. It is critically important to draw the initial sets of blood cultures before the patient receives antibiotics. If the
patient develops a new fever and/or other signs of sepsis while on antimicrobial agents, draw blood cultures
prior to adding or changing therapeutic agents.
C. Test of cure cultures (i.e., repeat blood cultures after a positive result) are generally not warranted in
patients who are clinically improving.
i. Test of cure cultures may be warranted in specific clinical situations:
a. Culture-proven endocarditis,
b. Bacteremia due to S. aureus, fungemia, or organisms of epidemiological importance (e.g.,
extensively drug resistant gram-negative rods (XDR-GNR), or
c. In patients who continue to show a picture of sepsis despite antimicrobial therapy.
D. A signed order from a physician or advanced practice provider (APP) is required to draw blood cultures.
E. Personnel who may perform blood culture collection
i. Collection by peripheral venipuncture may be performed by phlebotomists, RNs, Emergency
Department Technicians, physicians, and APPs.
ii. Collection of blood cultures from an intravascular line must be performed by an RN. Cultures drawn
from lines should only be done in selected clinical situations. See Section III, G and H.
a. If the collection is performed immediately after central line insertion, a physician or APP
privileged for central line insertion or a GME trainee authorized to insert central lines may
perform the collection.
F. The UW Health standard for adults is to use peripheral venipuncture to collect two blood culture sets
(two bottles each, one aerobic, one anaerobic), drawn from separate sites, for a total of four bottles.
i. Peripheral venipuncture is the strongly preferred method for the collection of blood
cultures. The use of an intravascular line to collect blood for culture is strongly discouraged due to
a two-fold to four-fold greater risk of contamination.
ii. The two sets of blood cultures should be collected as soon as possible one after the other,
preferably within one hour. Blood cultures specimens should be handled at room temperature and
transported to the lab as soon as possible. Send each set of cultures to the lab immediately after
collection; do not delay transport based on collection difficulties of subsequent sets.
iii. Each bottle should contain 8-10 mL of blood each, for a total of approximately 40 mL. This provides



UW HEALTH CLINICAL POLICY 2
Policy Title: Blood Cultures for Adult Patients
Policy Number: 2.5.6

the maximal information needed for interpretation of blood culture results.
a. Do not place more than 10 mL in one bottle.
b. Using volumes less than 8 mL per bottle is strongly discouraged, because lower volumes
adversely affect recovery and detection times. The minimal amount that can be processed
in an adult blood culture bottle (aerobic or anaerobic) is 3 mL. Do not submit adult bottles
with less than 3 mL of blood to the lab.
iv. If it was not possible to collect a minimum of 16 mL from one site (which could be divided into 8 mL
for the aerobic bottle and 8 mL for the anaerobic bottle), fill the aerobic bottle first (to 8 mL) and
place any remaining blood (if 3 mL or over) in the anaerobic bottle. If there is not at least 3 mL
remaining, do not send an anaerobic bottle.
G. Intravascular lines, including CVADs, should not be cultured unless all attempts at peripheral venipuncture
have been exhausted.
i. If an adequate sample cannot be obtained using peripheral venipuncture, it is reasonable to collect
the sample from an intravascular line.
ii. If it is necessary to collect both blood culture sets from lines, use two different lines. If two lines are
not available, blood should be collected from two different lumens of the same line.
iii. Because of potential clinical consequences, a dialysis catheter is generally not used for collection
of blood cultures unless it is the suspected source of infection (i.e., fevers during dialysis,
malfunctioning catheter), or as an absolute last resort.
H. If an intravascular line is the suspected source of infection (i.e., no other obvious source of infection), it is
reasonable to collect one blood culture set by peripheral venipuncture and one set from the suspected line
(one lumen only).
i. Multi-lumen sampling should not be done as part of an initial fever workup per Infectious Disease
recommendations.
a. If cultures remain negative but suspicion remains high for central line-associated
bloodstream infection (CLABSI), it is reasonable to draw blood cultures from every lumen,
in addition to a peripheral venipuncture.
ii. If there is more than one possibly infected line, it is reasonable to obtain one blood culture set by
peripheral venipuncture, and one set from each suspected line (one lumen only from each line).
a. In patients with multiple central venous access lines, if a blood cultures result is positive
for bacteremia and there is question regarding which line is the source, it is reasonable to
culture all the lumens.
iii. In patients with neutropenic fever, it is reasonable to obtain 2 sets of blood cultures at the onset of
fever and redraw them when there is a change in clinical condition (e.g., defervescence followed by
fever or clinical exam/imaging findings suggestive of infection) rather than daily blood cultures.

IV. PROCEDURE FOR BLOOD CULTURE COLLECTION VIA PERIPHERAL VENIPUNCTURE

A. Equipment and site preparation
i. Gather supplies
ii. Prior to use, check the expiration date of each blood culture bottle and examine each bottle for
evidence of damage, contamination or deterioration. Do not use expired bottles or bottles
displaying evidence of damage or contamination such as leakage, cloudiness, discoloration
(darkening), bulging or depressed septum.
iii. Perform hand hygiene per UW Health clinical policy #4.1.13 and don clean gloves.
iv. Apply a tourniquet, locate the site for venipuncture, and remove the tourniquet.
a. Prior to cleansing, an ultrasound probe may be used to locate a venipuncture site. Mark
vein with a surgical marker. Remove ultrasound gel prior to cleansing.
b. If ultrasound must be used during venipuncture, maintain sterility of the puncture site and
ultrasound probe using a sterile cover such as a sterile Tegaderm or sterile ultrasound
probe cover.
v. Cleanse the site for venipuncture with ChloraPrep® One-Step Applicator per the manufacturer’s
directions.
a. Maximal treatment area for one applicator is approximately 4 inches x 5 inches.
b. Remove the ChloraPrep® applicator from packaging without touching the sponge.
Cleanse the site with ChloraPrep®.
c. Use gentle repeated back-and-forth strokes of the sponge for approximately 30 seconds.
Allow solution to air dry for approximately 30 seconds. Do not blot or wipe away.



UW HEALTH CLINICAL POLICY 3
Policy Title: Blood Cultures for Adult Patients
Policy Number: 2.5.6

d. Discard the applicator after site prep.
vi. Venipuncture site cleansing for patient with known contraindications to cleansing solutions
a. If unable to use ChloraPrep® (for patients with contraindication), use iodine
1. The site must first be gently scrubbed with 70% alcohol followed by cleansing
with iodine in a concentric fashion beginning at the center of the site and moving
outward. Wait 1 minute for iodine to dry.
b. If unable to use ChloraPrep® or iodine, use alcohol
1. Use an alcohol pad to cleanse the patient’s skin, using a circular motion starting
at the site and moving outward.
2. Repeat with a second alcohol pad.
3. Allow to dry.
vii. Before inoculating, remove the bottle cap and wipe the septum with an alcohol swab using a
circular motion (iodine is NOT recommended) for 15 seconds. Allow the bottle to dry before
inoculating. Use a separate alcohol swab for each bottle. Leave alcohol swab on top of bottles.
B. Collecting blood for culture
i. Reapply tourniquet. After skin disinfection DO NOT palpate the venipuncture site again.
ii. Perform the venipuncture with a butterfly device attached to a 10 mL syringe. Draw the appropriate
volume of blood per Section II.F.
iii. Remove the syringe and immediately attach to a transfer device. Attach a second 10 mL syringe to
the needless connector and draw the appropriate volume of blood per Section II.F.
iv. Draw additional lab requests, if needed.
v. Release tourniquet.
vi. Withdraw needle, activate safety shield and dispose in sharps container.
vii. Transfer blood to the aerobic bottle using the first syringe. Transfer blood to the anaerobic bottle
using the second syringe.
viii. Repeat the above procedure for a second site (see Section IV. B. i-vii). The timing of collection may
be performed simultaneously (or over a short time frame, preferably less than one hour apart)
unless indicated by the provider.
ix. Dispose of used supplies in appropriate containers. See UW Health clinical policy #4.1.10, Sharps
Disposal.

V. PROCEDURE FOR BLOOD CULTURE COLLECTION VIA INTRAVASCULAR LINE

A. Site selection
i. If blood culture order indicates CVAD as the specimen source location:
a. Draw the peripheral culture first.
b. Cultures should preferably be drawn less than one hour apart unless indicated by the
provider.
c. Never draw blood cultures directly into blood culture bottles. Use a syringe and transfer
device to transfer blood specimen to blood culture bottles.
d. Select best CVAD lumen to use for culture collection
1. Use capped lumen if available.
2. If all lumens are in use, use lumen with hydrating fluids.
3. If possible, do not use lumens used to deliver TNA/TPN or antibiotics
B. Equipment and site preparation
i. Gather supplies
ii. Prior to use, check the expiration date of each blood culture bottle and examine each bottle for
evidence of damage, contamination or deterioration. Do not use expired bottles or bottles
displaying evidence of damage or contamination such as leakage, cloudiness, discoloration
(darkening), bulging or depressed septum.
iii. Perform hand hygiene per UW Health clinical policy #4.1.13 and don clean gloves.
iv. If applicable, pause IV solutions and disconnect IV tubing. Place an IV cap on distal end of the IV
tubing.
x. Remove the blood culture bottle caps and wipe the septum with an alcohol swab, using a circular
motion (iodine is NOT recommended) for 15 seconds. Allow the bottle to dry before inoculating.
Use a separate alcohol swab for each bottle. Leave alcohol swab on top of bottles.
v. Scrub top and sides of the needleless connectors with a new alcohol swab for 15 seconds and
allow to dry for 15 seconds.



UW HEALTH CLINICAL POLICY 4
Policy Title: Blood Cultures for Adult Patients
Policy Number: 2.5.6

vi. Attach syringe to needleless connector and withdraw 2 mL of blood for waste. Discard waste.
vii. Remove the needleless connector and place new needleless connector, keeping the CVAD lumen
sterile.
viii. Using two 10 mL syringes:
a. Attach first 10 mL syringe and draw back the appropriate volume of blood per section III.F.
b. Keeping the catheter lumen sterile, remove syringe and immediately attach to transfer
device (make note that this syringe was drawn first).
c. Attach second 10 mL syringe and draw back the appropriate volume per section III.F.
d. Remove syringe and immediately attach to a transfer device
e. Transfer blood to the aerobic bottle using the first syringe. Transfer blood to the anaerobic
bottle using the second syringe.
ix. A 20 mL syringe can be utilized if approved by the manufacturer of the central line. Using a 20 mL
syringe:
a. Attach 20 mL syringe and draw back the appropriate volume of blood per section III.F.
b. Remove syringe and immediately attach to a transfer device.
c. Transfer blood to the aerobic bottle first.
d. Using a new transfer device, transfer remaining blood to the anaerobic bottle.
x. Collect other blood samples if needed.
xi. Flush the catheter using the push-pause method to clear blood from catheter. Clamp the catheter
as the last mL is injected to create positive pressure, which prevents blood from flowing back into
the catheter tip. Refer to Flushing/Locking of Venous Access Devices – Pediatric/Adult –
Inpatient/Ambulatory.
xii. Replace needleless connector if blood is visible after flushing.
xiii. Dispose of used supplies in the appropriate containers. See UW Health clinical policy 4.1.10,
Sharps and Disposal.

VI. PROCEDURES FOLLOWING BLOOD CULTURE COLLECTION

A. Labeling and documentation
i. Each blood culture bottle must have a patient identification label affixed to it. Do not put the label
over the barcode on the blood culture bottles. Per Lab Procedure #1507. P014, Blood Culture
Collection, the label should also include:
a. Employee number (nurse, PCT, ED tech) or log-on code (phlebotomist)
b. Date and time of collection
c. Site
d. Amount inoculated
ii. Blood culture bottles will be labeled in accordance with UW Health clinical policy #2.5.1, Use of
Containers for Clinical Specimens, Lab Procedure #1502.5.06, Acceptance Policy for Specimen
Identification and #1502.5.07, Specimen Rejection.
iii. Patient information on the blood culture bottles must include at least 2 patient-specific identifiers as
defined in Lab Procedure #1502.5.06.
B. Specimen transport
i. Blood cultures specimens should be handled at room temperature and transported to the lab as
soon as possible. Send each set of cultures to the lab immediately, do not delay transport based on
collection difficulties of subsequent sets.
ii. Transport of blood culture specimens will be consistent with UW Health clinical policy #2.5.1, Use
of Containers for Clinical Specimens.
C. Follow-up and results communication
i. Positive blood cultures have been designated a critical result per the UWHC Clinical Laboratories
Critical Call Value List and must receive proper follow up in accordance with UW Health clinical
policy #3.3.6, Communication of Critical Results and Critical Tests/Procedures.

VII. COORDINATION

Author: Physician, Infectious Disease and Medical Director, Clinical Microbiology
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Director, Nursing Quality & Safety; CNS, Nursing Program Develop & Eval; Infection Control
Practitioner; Nurse Manager, SOS Activity Pool; CNS, Cardiothoracic Surgery-B4/5; Nursing-Overnight Care



UW HEALTH CLINICAL POLICY 5
Policy Title: Blood Cultures for Adult Patients
Policy Number: 2.5.6

– TAC; Manager, Lab Patient Svcs, Clin Labs-Phlebotomy; Pharmacy Coordinator (AMUS), Pharmacy-
Inpatient Services; Nurse Manager, Medical/Surgical & Short Stay; CNS, Nursing-Central Float; NES,
Education & Development; Nurse Manager, Emergency Services; Assoc Vice Chair/Quality, Med Dir of
EM/TAC; CNS, Oncology Services
Approval committees: UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: August 21, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VIII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

IX. REFERENCES

Lab Procedure #1502.5.06, Acceptance Policy for Specimen Identification
Lab Procedure #1502.5.07, Specimen Rejection
Lab Procedure #1507.P009, Venipuncture Technique
Lab Procedure #1507.P014, Blood Culture Collection
Nursing Patient Care departmental policy #1.11 A, Arterial Catheter/Insertion, Maintenance, Blood Drawing
and Discontinuation (Adult)
Nursing Patient Care departmental policy #1.23 AP, Continuous Peripheral Intravenous Therapy (Adult &
Pediatric)
Nursing Patient Care departmental policy #1.55A, Midline Intravenous Peripheral Catheters: Use,
Maintenance and Removal (Adult)
Nursing Patient Care departmental policy #1.56AP, Central Vascular Access Device Use, Maintenance and
Removal (Adult and Pediatric)
UW Health clinical policy #2.3.14, Insertion, Maintenance, and Discontinuation of Central Vascular Access
Devices for Prevention of Central Line-Associated Bloodstream Infection (CLABSI)
UW Health clinical policy #2.5.1, Use of Containers for Clinical Specimens
UW Health clinical policy #3.3.6, Communication of Critical Results and Critical Tests/Procedures
UW Health clinical policy #4.1.10, Sharps Disposal
UW Health clinical policy #4.1.13, Hand Hygiene
UWHC policy #8.19, Drawing Venous Blood Specimens on Inpatients

Guembe, M, Rodriguez-Creixems M, Sanchez-Carrillo C, Perez-Parra A, Martin-Rabadan P, Bouza E. How
Many Lumens Should Be Cultured in the Conservative Diagnosis of Catheter-Related Bloodstream
Infections? Clinical Infectious Disease. 2010; 50 (12):1575-1579.

Self WH, Speroff T, McNaughton CD, et al. Blood Culture Collection though Peripheral Intravenous
Catheters Increases the Risk of Specimen Contamination among Adult Emergency Department Patients.
Infection Control Hospital Epidemiology. 2012;33(5):524-526.

Shapiro NI, Wolfe RE, Wright SB, Moore R, Bates DW. Who Needs a Blood Culture? A Prospectively
Derived and Validated Prediction Rule. The Journal of Emergency Medicine. 2008;35(3):255-264.

Tabriz MS, Riederer K, Baran J Jr, Khatib R. Repeating Blood Cultures During Hospital Stay: Practice
Pattern at a Teaching Hospital and a Propsal for Guidelines. 2004;10(7):624-627.

Wiggers JB, Xiong W, Daneman N. Sending Repeat Cultures: Is there a Role in the Management of



UW HEALTH CLINICAL POLICY 6
Policy Title: Blood Cultures for Adult Patients
Policy Number: 2.5.6

Bacterermic Episodes? (SCRIBE study). BMC Infectious Disease. 2016;16:286.

X. REVIEW DETAILS

Version: Original
Last Full Review: October 20, 2017
Next Revision Due: October 2020