/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/gen-care/,/policies/clinical/uw-health-clinical/gen-care/labsspecimens/,

/policies/clinical/uw-health-clinical/gen-care/labsspecimens/258.policy

20180103

page

100

UWHC,UWMF,

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

Blood Cultures for Pediatric Patients (2.5.8)

Blood Cultures for Pediatric Patients (2.5.8) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Labs/Specimens

2.5.8


UW HEALTH CLINICAL POLICY 1
Policy Title: Blood Cultures for Pediatric Patients
Policy Number: 2.5.8
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 28, 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 adult patients, please refer to the UW Health Clinical Policy #2.5.6, Blood Cultures for Adult Patients.

II. DEFINITIONS

A. “Intravascular lines” include central venous access devices (CVAD), arterial lines, 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: Blood culture for pediatric patients is performed based on provider discretion. See Appendix A
for common indications and for situations in which blood cultures may not be indicated.
B. Timing of initial blood cultures:
i. If the patient is not currently on antimicrobial therapy, it is critically important to draw blood cultures
before the patient receives initial antimicrobials when clinically feasible.
ii. If the patient develops a new fever (38 degrees C or greater) and/or other signs of sepsis while on
antimicrobial therapy, draw blood cultures prior to adding or changing therapeutic agents.
C. For optimum diagnosis of sepsis, draw blood cultures from two or more sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal diagnostic value.
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. If blood collections are being done from both a peripheral venipuncture and a central line it is
recommended that the peripheral venipuncture be drawn first.
iii. Collection of blood cultures from an intravascular line must be performed by an RN.
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. (Collection immediately after central line insertion is discouraged.)
F. The UW Health standards for type of blood culture (aerobic/anaerobic) and volume of blood to collect in
each bottle are based on patient weight. See table in Appendix B, UW Health Standard Blood Culture
Volume by Weight.
i. The sensitivity of a blood culture is relative to the volume of blood (greater volume of cultured blood
is associated with greater sensitivity). It is reasonable, at the discretion of the attending provider, to
exceed daily blood volume limits based on weight (for all lab draws) in order to optimize sensitivity
of the blood culture result. See document, Maximum Blood Draw Guideline for Pediatric Patients
(available on U-Connect).
G. Prior to collection of initial blood cultures, it is recommended that the ordering provider and RN discuss the
number and location of blood culture sites. General guidance:
i. If the patient does not have an intravascular line, is a previously healthy, non-toxic appearing child,
and central line associated blood stream infection (CLABSI) is NOT suspected:
a. Collect blood cultures from one site using peripheral venipuncture.
ii. If the patient has a central line and a CLABSI is suspected (i.e., no other obvious source of
infection):
a. Collect blood cultures from one site via peripheral venipuncture and from every lumen of
every intravascular line. (When referring to Appendix B, each lumen is considered a
separate site.)
1. Collection of one set of blood cultures via peripheral venipuncture is helpful to



UW HEALTH CLINICAL POLICY 2
Policy Title: Blood Cultures for Pediatric Patients
Policy Number: 2.5.8

determine differential time to positivity between peripheral and line cultures.
2. If there is a need to limit the amount of blood collected, consider collecting one
set of cultures via peripheral venipuncture, and a set from one lumen of each
intravascular line.
iii. In the case of suspected intravascular infection (i.e. endocarditis), at least three blood cultures
should be drawn from separate venipunctures during the first 24 hours.
H. 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.
ii. Only one site is necessary if doing repeat culture after initiation of antimicrobial therapy to ensure
adequate treatment.
a. If follow up cultures are performed to determine intravascular clearance, blood culture
collection can be from the infected site(s) only.
b. Daily repeated blood cultures are not needed if negative blood cultures have been drawn
within the previous 48 hours and there has been no clinical change other than fever.
I. Drawing blood cultures immediately following peripheral intravenous (PIV) line placement is very strongly
discouraged and should only occur in certain extenuating circumstances. The personnel collecting the blood
culture should notify the provider that there are limited options for access before proceeding. If blood is
drawn immediately following PIV placement, the specimen should be properly labeled with the PIV as the
site.

IV. PROCEDURE FOR BLOOD CULTURE COLLECTION VIA PERIPHERAL VENIPUNCTURE

A. Equipment and Site Preparation
i. Gather supplies
ii. Prior to use the expiration date should be checked on each blood culture bottle and each bottle
should be examined 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 thorough hand hygiene per UW Health Clinical Policy #4.1.13, Hand Hygiene.
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. An ultrasound probe should not be used during venipuncture (after cleansing has
occurred).
c. If ultrasound must be used during venipuncture, maintain sterility of the puncture site and
ultrasound probe using a sterile cover such as sterile Tegaderm or sterile ultrasound
probe cover and using sterile ultrasound gel.
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.
d. Discard the applicator after site prep.
e. For children less than 2 months corrected gestational age, it is recommended the site be
cleaned with sterile saline immediately after the procedure is completed to remove the
chlorhexidine from the skin.
vi. Venipuncture site cleansing for patient with 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.



UW HEALTH CLINICAL POLICY 3
Policy Title: Blood Cultures for Pediatric Patients
Policy Number: 2.5.8

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 prep pad using a
circular motion (iodine should not be used) for 15 seconds. Allow the bottle to dry before
inoculating.
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 5 mL syringe if using a pediatric
bottle or a 10 mL syringe if using an adult bottle. Draw the appropriate volume of blood per
Appendix B, UW Health Standard Blood Culture Volume by Weight. If more blood is required
immediately attach another syringe to the butterfly device and draw the appropriate blood volume
required.
iii. Remove the syringe and immediately attach to a transfer device.
iv. Transfer the appropriate volume of blood to the aerobic bottle from the syringe
v. Transfer the appropriate volume of blood to the anaerobic bottle using the second syringe.
vi. Draw additional labs requests, if needed.
vii. Release tourniquet.
viii. Withdraw needle, activate safety shield, and dispose in sharps container.
ix. Repeat the above procedure for a second site, if applicable. The timing of collection may be
performed simultaneously (or over a short time frame, preferably less than one hour apart if
possible) unless indicated by the provider.
x. 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. Patients ≤ 8 kg or in an ICU setting
i. Open central line access kit.
ii. Drop stopcock and syringes onto open access kit field.
iii. Don sterile gloves.
iv. Connect syringes to ports of stopcock.
v. Scrub Microclave® with alcohol pad for 15 seconds and let dry.
vi. Pause infusions and clamp line before drawing.
vii. Attach stopcock to Microclave®
viii. Draw “waste” into one syringe and keep connected to the stopcock (refer to CVAD Flushing and
Locking guidelines).
ix. Draw specimen into other syringe.
x. Disconnect specimen syringe and place on sterile field.
xi. Connect flush to open port on stopcock.
xii. Return waste
xiii. Flush line with appropriate volume (refer to CVAD Flushing and Locking guidelines).
xiv. Unclamp and restart infusions.
xv. Transfer culture specimen to blood culture bottle(s).
B. Patients > 8 kg
i. Pause infusions and clamp line before drawing.
ii. Scrub Microclave® with alcohol pad for 15 seconds and let dry.
iii. Connect waste syringe to Microclave®.
iv. Draw waste (refer to CVAD Flushing and Locking guidelines).
v. Disconnect waste syringe.
vi. Connect specimen syringe.
vii. Draw specimen.
viii. Disconnect specimen syringe.
ix. Connect 10 mL saline syringe.
x. Flush line with appropriate volume (refer to CVAD Flushing and Locking guidelines).
xi. Unclamp and restart infusions.



UW HEALTH CLINICAL POLICY 4
Policy Title: Blood Cultures for Pediatric Patients
Policy Number: 2.5.8

xii. Transfer culture specimen to blood culture bottle(s).

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: Medical Director, Clinical Microbiology; and Medical Director, Pediatric Antimicrobial Stewardship
Program
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: CNS, PICU; CNS, Nursing Admin-Children’s Hosp; CNS, Nursing Program Develop & Eval;
Infection Control Practitioner; Pharmacy Coordinator, Antimicrobial Stewardship; Medical Director, NICU;
Pediatric Hospitalist; Medical Director, Pediatric Emergency Services; Medical Director, Children’s Hosp
Triage/Txport
Approval committees: UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: November 20, 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

Nursing Patient Care departmental policy #1.11P, Arterial Catheter/Insertion, Maintenance, Blood Drawing
and Discontinuation (Pediatric)



UW HEALTH CLINICAL POLICY 5
Policy Title: Blood Cultures for Pediatric Patients
Policy Number: 2.5.8

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 #2.5.6, Blood Cultures for Adult Patients
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.
UWH Clinical Policy #4.1.13, Hand Hygiene
UWHC Clinical Laboratories Departmental Policy #1502.5.06, Acceptance Policy for Specimen Identification
UWHC Clinical Laboratories Departmental Policy #1502.5.07, Specimen Rejection
UWHC Clinical Laboratories Departmental Policy #1507.P009, Venipuncture Technique
UWHC Clinical Laboratories Departmental Policy #1507.P014, Blood Culture Collection
UWHC policy # New Number once assigned, Drawing Venous Blood Specimens on Inpatients
Baltimore RS, Gewitz M, Baddour LM, et al. Infective Endocarditis in Childhood: 2015 Update. Circulation.
2015; 132:1487-1515.
Clinical and Laboratory Standards Institute (CLSI). Principles and Procedures for Blood Cultures; Approved
Guideline. CLSI document M47-A. Wayne, PA: Clinical and Laboratory Standards Institute 2007.
Woods-Hill CZ, Fackler J, Nelson McMillan K, et al. Association of Clinical Practice Guideline With Blood
Culture Use in Critically Ill Children. JAMA Pediatrics. 2017; 171(2):157-164.

X. REVIEW DETAILS

Version: Original
Last Full Review: December 28, 2017
Next Revision Due: December 2020
Formerly known as: N/A