Chapter 11 : Processing Positive Cultures

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It can be said that the diagnosis of bloodstream infections is one of the most important roles of the clinical microbiology laboratory; the mortality rate associated with bloodstream infection ranges from 25 to 80% ( ). There are a number of factors that contribute to the mortality rate subsequent to bloodstream infection, with time to appropriate antimicrobial therapy frequently cited as one of the most important variables correlating with clinical outcome ( ). Herein, we describe procedures for optimization of positive blood culture specimens and describe current and future methodologies to augment blood culture to diagnose bloodstream infection.

Citation: Faron M, Ledeboer N. 2017. Processing Positive Cultures, p 207-244. In Dunne, Jr. W, Burnham C (ed), The Dark Art of Blood Cultures. ASM Press, Washington, DC. doi: 10.1128/9781555819811.ch11
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Image of Figure 1
Figure 1

Example of blood culture Gram stains with multiple morphologies to illustrate size differences of various organisms. Image was acquired by adding cells from each organism with the contents of a negative blood culture. Based on size, large to small pink/brown erythrocytes can be observed throughout the Gram stain (red arrow). cells are much larger than bacterial cells and stain GP (green arrow). Smaller bacteria are observed throughout the stain with GN rods (pink arrow) and GPC (purple arrows).

Citation: Faron M, Ledeboer N. 2017. Processing Positive Cultures, p 207-244. In Dunne, Jr. W, Burnham C (ed), The Dark Art of Blood Cultures. ASM Press, Washington, DC. doi: 10.1128/9781555819811.ch11
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Image of Figure 2
Figure 2

Representative image of several Gram stain morphologies that can be observed from blood culture. Most commonly observed are Gram-negative rods (GNR) and Gram-positive cocci (GPC) ( ; ). Larger budding yeasts are less common but may yield better growth when plated to Sabouraud agar ( ). Gram-positive rods (GPR) are also less frequent and many not require unique agar to grow ( spp.), but boxy poor staining GPR may indicate spp. which grow optimally at anaerobic conditions ( ). spp. are thin GN spirochetes often growing wavelike or “gull shaped” and may require growth at 42°C on specific agar depending upon the species ( ). Finally, morphologies that may require caution because of being highly infectious agents are small GN coccobacillus , beaded branching GP rods , or bipolar staining “safety pin” ; however, many other organisms can be observed with these morphologies, and restrictions can be lifted after colony morphologies and testing rule out biological safety agents (morphology represented by ; ; ).

Citation: Faron M, Ledeboer N. 2017. Processing Positive Cultures, p 207-244. In Dunne, Jr. W, Burnham C (ed), The Dark Art of Blood Cultures. ASM Press, Washington, DC. doi: 10.1128/9781555819811.ch11
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Various approaches to structuring laboratory policy of positive blood cultures. With the variety of assays available to identify organisms growing in blood cultures, laboratories can customize workflow to fit various criteria affecting turnaround time, cost, and complexity. Potential workflow approaches for laboratories are as follows. The traditional method should not be used alone, because results are too delayed and several viable rapid options are available; however, plating should be applied to all rapid testing where the * is placed to confirm results and check for polymicrobial cultures. For ease of workflow, a single molecular device can be used for all positive bottles. This is best done using a large panel that covers the most common blood pathogens. To reduce cost or improve patient care, a multifaceted approach can be implemented where the rapid assay used changes based on the Gram stain result. For instance, using cheaper methicillin-resistant (MRSA) assays for Gram-positive cocci in clusters (GPCCL) and a panel for all other testing. Although it is labor intensive to bring on matrix-assisted laser desorption ionization–time of flight mass spectroscopy (MALDI-TOF MS) or use antimicrobial susceptibility testing (AST), panels of product that insert these assays likely have the shortest TAT for reporting susceptibilities. Combinations of these approaches can be used to fit the laboratories’ needs and abilities.

Citation: Faron M, Ledeboer N. 2017. Processing Positive Cultures, p 207-244. In Dunne, Jr. W, Burnham C (ed), The Dark Art of Blood Cultures. ASM Press, Washington, DC. doi: 10.1128/9781555819811.ch11
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Table 1

Comparison of rapid identification assays for blood culture

Citation: Faron M, Ledeboer N. 2017. Processing Positive Cultures, p 207-244. In Dunne, Jr. W, Burnham C (ed), The Dark Art of Blood Cultures. ASM Press, Washington, DC. doi: 10.1128/9781555819811.ch11

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