Blood Culture Contamination Research Articles

Estimating the burden of antimicrobial resistance in Malawi: protocol for a prospective observational study of the morbidity, mortality and economic cost of third-generation cephalosporin resistant bloodstream infection.

Introduction: Antimicrobial resistance (AMR) is a global public health concern, but the problems are context specific, with each county or setting facing differing challenges. In sub-Saharan Africa, third-generation cephalosporin resistant Enterobacterales (3GCR-E) are of particular concern, given the widespread reliance on ceftriaxone for treatment of severe infection in this setting. In Malawi, despite rising prevalence of 3GCR-E, the health-impact of these infections has not been described. This study is designed to estimate attributable mortality, morbidity and economic cost of 3GCR-E bloodstream infection (BSI) in a large, urban hospital. Methods: This study will investigate the burden of AMR by recruiting a a prospective longitudinal cohort of patients who have bloodstream infection with 3GCR-E, at Queen Elizabeth Central Hospital, Blantyre, Malawi. Patients whose blood culture is positive for either third-generation cephalosporin susceptible (3GC-S) or third-generation resistant (3GC-R) Enterobacterales will be enrolled and provide clinical and healthcare economic data. Patients will be followed throughout their hospital stay and to 6-months post discharge. The primary outcomes for the study are mortality and morbidity from 3GCR-E. Healthcare economic outcomes will be assessed by comparing healthcare provider costs, indirect patient costs and health-related quality of life outcomes in patients with 3GC-S and 3GC-R BSI. Based on our observation that some patients with clinical suspicion of sepsis and 3GC-R BSI are surviving without an effective antibiotic, we review each patient prospectively and classify what role the isolated bacteria is playing in the patient's clinical presentation. Each BSI episode will be classified into the following categories: definite Gram-negative sepsis, probable Gram-negative sepsis, transient or occult bacteraemia, or contaminated blood culture. These classifications will be incorporated into our analysis. Ethics and dissemination: The study protocol has been approved by the Malawi College of Medicine Research Ethics Committee and by the Liverpool School of Tropical Medicine Research Ethics committee.

Culture-proven Bloodstream Infections at a Specialist Pediatric Hospital.

Bloodstream infection (BSI) is one of the leading causes of morbidity and mortality in children. This study was done to assess the local epidemiology and outcome of BSIs managed at a large specialist pediatric hospital with a focus on community-onset BSI. We retrospectively reviewed laboratory-confirmed BSI in children (0-18 years) at The Children's Hospital at Westmead over a 3-year period (2014-2016). Laboratory data and patient medical records were used to determine BSI rates, blood culture contamination rates, patient demographics, isolate profile, antimicrobial resistance and mortality rate in this cohort. In total, 47,368 blood cultures were collected; 1027 (2.2%) grew probable contaminants and 991 (2.1%) grew clinically significant isolates. Clinically significant bacteremia accounted for 4.8 per 1000 admissions, with 391 children managed for 465 culture-proven BSI episodes. One hundred thirty-one (28.2%) episodes were community-onset community-associated, and 334 (71.8%) were either community-onset healthcare-associated (HCA) (187; 40.2 %) or hospital-onset (147; 31.6%). Of the significant isolates, 243 (52.3%) were Gram-positive bacteria, 198 (42.6%) were Gram-negative bacteria, 6 (1.3%) were polymicrobial infections and 18 (3.9%) were yeast. Staphylococcus aureus (115; 24.7%) and Escherichia coli (54; 11.6%) were the most common organisms identified. Osteoarticular infection (44; 33.6%) and urosepsis (23; 17.6%) were the most frequent sites of infection associated with non-HCA BSI. Mortality at 30 days was reported in 15 (3.3%) children, all whom had preexisting comorbidities. The majority of BSI episodes managed in our hospital were either community-onset HCA or hospital-onset infections. This highlights the considerable importance of infection control and central venous catheter device care initiatives. Among community-associated BSI, S. aureus in association with osteoarticular infection was predominant.

Estimating the burden of antimicrobial resistance in Malawi: protocol for a prospective observational study of the morbidity, mortality and economic cost of third-generation cephalosporin resistant bloodstream infection

Introduction: Antimicrobial resistance (AMR) is a global public health concern, but the problems are context specific, with each county or setting facing differing challenges. In sub-Saharan Africa, third-generation cephalosporin resistant Enterobacterales (3GCR-E) are of particular concern, given the widespread reliance on ceftriaxone for treatment of severe infection in this setting. In Malawi, despite rising prevalence of 3GCR-E, the health-impact of these infections has not been described. This study is designed to estimate attributable mortality, morbidity and economic cost of 3GCR-E bloodstream infection (BSI) in a large, urban hospital. Methods: This study will investigate the burden of AMR by recruiting a a prospective longitudinal cohort of patients who have bloodstream infection with 3GCR-E, at Queen Elizabeth Central Hospital, Blantyre, Malawi. Patients whose blood culture is positive for either third-generation cephalosporin susceptible (3GC-S) or third-generation resistant (3GC-R) Enterobacterales will be enrolled and provide clinical and healthcare economic data. Patients will be followed throughout their hospital stay and to 6-months post discharge. The primary outcomes for the study are mortality and morbidity from 3GCR-E. Healthcare economic outcomes will be assessed by comparing healthcare provider costs, indirect patient costs and health-related quality of life outcomes in patients with 3GC-S and 3GC-R BSI. Based on our observation that some patients with clinical suspicion of sepsis and 3GC-R BSI are surviving without an effective antibiotic, we review each patient prospectively and classify what role the isolated bacteria is playing in the patient’s clinical presentation. Each BSI episode will be classified into the following categories: definite Gram-negative sepsis, probable Gram-negative sepsis, transient or occult bacteraemia, or contaminated blood culture. These classifications will be incorporated into our analysis. Ethics and dissemination: The study protocol has been approved by the Malawi College of Medicine Research Ethics Committee and by the Liverpool School of Tropical Medicine Research Ethics committee.

Improving adherence to facility protocol and reducing blood culture contamination in an intensive care unit: A quality improvement project

BackgroundBlood culture contamination (BCC) is a safety and quality indicator for intensive care units (ICUs). BCC rates in our ICU ranged from 2.90% to 6.70% in 2017. ObjectiveThis quality improvement project aimed to reduce the contamination rate from a mean of 4.52% to <3.0% in 1 year by improving the adherence of nurses to the facility protocol during blood collection. MethodsThis project used a before–after design. It was conducted by a leadership team in a 32-bed ICU where approximately 4000 cultures are drawn annually. We observed the performance of ICU nurses during blood collection, interviewed them regarding the difficulties they encountered with protocol adherence, and conducted a cause-and-effect analysis to identify the main problems. Based on a literature review, we developed and implemented a countermeasure protocol, including a standardised medical order, an online learning program, a weekly departmental report and individual feedback routine, and phlebotomy training to address these problems in 2 months. ResultsThe interview results indicated that blood contamination resulted from the environment, difficult phlebotomy, and the inadequate knowledge and skill of the nurses. The countermeasure protocol reduced the average BCC rate from 4.52% to 2.59% during the intervention period and to 0.59% during the 10-month postintervention period. Nursing adherence to the standard protocol for blood culture collection also improved. ConclusionsBCC in ICUs is multifactorial. By optimising the work environment, offering skill training, and reinforcing education and individualised feedback, we successfully reduced BCC in our unit to a sustainable low rate.

Blood culture contamination in a tertiary care hospital of Saudi Arabia. A one-year study.

Objectives:To monitor blood culture contamination (BCC) rates in a tertiary care hospital in Saudi Arabia.Methods:Blood cultures submitted to the Microbiology Laboratory of King Fahad Hospital, Madina, Saudi Arabia between January and December 2017 were analyzed prospectively. Positive blood cultures were either designated as true bacteremia with confirmed bloodstream infection or BCC.Results:Among 5,536 blood cultures from 2201 patients, 364 (6.6%) mirrored BCC. There was an upward trend in contamination rates in specific months. With respect to total blood cultures from respective units over a one-year period, medical ward contributed to the highest contamination rate (10.3%). Blood culture contamination rate in the wards ranged from 4.5-10.3%, with a higher contamination rate in elderly, aged 60-80 years. Staphylococcus epidermidis (S. epidermidis) was the most frequent contaminant (44.5%).Conclusion:The escalated contamination rates in September to October may be attributed to difficulty in sampling blood by the less competent nurses during annual pilgrimage season. High influx of patients and shortage of trained nurses may have resulted in increased incidence in December-January and March-April. The prevalence of skin-resident S. epidermidis may be due to improper aseptic conditions. Ours is the first report on evaluation of BCC rates in Madina and call for renewed efforts in this direction.

Reducing Blood Culture Contamination Rates: Experiences of Four Hospital Systems.

IntroductionBlood cultures (BCs) frequently become contaminated during the pre-analytic phase of collection leading to downstream ramifications. We present a summary of performance improvement (PI) interventions provided by four hospital systems and common factors that contributed to decreased blood culture contamination (BCC) rates.MethodsEach hospital independently formed a multidisciplinary team and action plan for implementation of their intervention, focusing on the use of educational and training tools. Their goal was to significantly decrease their BCC rates. Pre- and post-intervention data were compared during the sustainment period to determine their success.ResultsAll hospitals met their goals of post-intervention BCC rates and with most achieving and sustaining BCC rates ≤ 1.0–2.0%.ConclusionOur report highlights how four hospitals independently achieved their objective to decrease their BCC rate with the support of a multidisciplinary team. We propose a benchmark for BCC rates of 1.5 to < 2.0% as achievable and sustainable.

Blood culture contamination in the emergency department: An integrative review of strategies to prevent blood culture contamination

BackgroundBlood culture collection remains the gold standard to diagnose bacteraemia. Current evidence suggests that the emergency department (ED) often has blood culture contamination (BCC) rates above the recommended 3%, contributing to increased hospital length of stay, unnecessary or inappropriate antimicrobial treatment, and increased economic burden. The aim of this review is to identify effective strategies to improve blood culture collection in EDs to decrease contamination rates and improve patient safety. MethodsAn integrative literature review methodology was utilised to conduct a structured search of contemporary literature using CINAHL, Embase, Medline, Pubmed and Scopus databases. All eligible literature was screened with those included in the final review collated and appraised using a quality assessment tool. ResultsEleven reports were included in the final review, which identified bundled approaches, education and feedback, equipment and technique, and stakeholder engagement as strategies that improve BCC rates in the ED. ConclusionsAll studies reported a reduction in BCC rates regardless of the strategies implemented. A bundled approach yielded the most significant results and was identified to be practical, inexpensive, and adaptable. Further research focusing on specific aspects of a bundled approach may be beneficial to understand which strategies are most effective.

Effect of a bundle-approach intervention against contamination of blood culture in the emergency department

BackgroundTo prevent contamination when taking blood culture, there are various effective interventions. Whether there is greater efficacy by using a combination of these interventions has not been widely evaluated. MethodsOur six-element intervention bundle aimed to prevent contamination of blood culture in our emergency department (ED). Elements were: use of 1% chlorhexidine alcohol, alcohol wiping, hand hygiene, using sterile gloves, using holed sterile cover, and selection of upper extremities as the site of venipuncture. We compared the contamination rate of blood culture between the pre- and the post-intervention periods among all cases with two or more blood cultures taken in our ED. We also evaluated the rate of patients receiving vancomycin among all those transferred to the hospital from the ED. ResultsDuring the pre- and post-intervention periods, 460 and 450 cases were included in analysis, respectively. Contamination of blood culture occurred in 29 pre-intervention cases (6.3%) and five post-interventional cases (1.1%) (relative risk 0.18, 95% confidence interval 0.07 to 0.45; P < 0.001). After bundle implementation, there was significant increase in adherence to using 1% chlorhexidine alcohol, alcohol wiping, hand hygiene, and using holed sterile covers. Among patients admitted to hospital, fewer patients received vancomycin during the post-intervention period than in the pre-intervention period (5.4% vs. 3.2%, P = 0.03). ConclusionsOur intervention bundle dramatically reduced the contamination rate when drawing blood culture in our ED.

Mycobacterium tuberculosis bloodstream infection prevalence, diagnosis, and mortality risk in seriously ill adults with HIV: a systematic review and meta-analysis of individual patient data

SummaryBackgroundThe clinical and epidemiological significance of HIV-associated Mycobacterium tuberculosis bloodstream infection (BSI) is incompletely understood. We hypothesised that M tuberculosis BSI prevalence has been underestimated, that it independently predicts death, and that sputum Xpert MTB/RIF has suboptimal diagnostic yield for M tuberculosis BSI.MethodsWe did a systematic review and individual patient data (IPD) meta-analysis of studies performing routine mycobacterial blood culture in a prospectively defined patient population of people with HIV aged 13 years or older. Studies were identified through searching PubMed and Scopus up to Nov 10, 2018, without language or date restrictions and through manual review of reference lists. Risk of bias in the included studies was assessed with an adapted QUADAS-2 framework. IPD were requested for all identified studies and subject to harmonised inclusion criteria: age 13 years or older, HIV positivity, available CD4 cell count, a valid mycobacterial blood culture result (excluding patients with missing data from lost or contaminated blood cultures), and meeting WHO definitions for suspected tuberculosis (presence of screening symptom). Predicted probabilities of M tuberculosis BSI from mixed-effects modelling were used to estimate prevalence. Estimates of diagnostic yield of sputum testing with Xpert (or culture if Xpert was unavailable) and of urine lipoarabinomannan (LAM) testing for M tuberculosis BSI were obtained by two-level random-effect meta-analysis. Estimates of mortality associated with M tuberculosis BSI were obtained by mixed-effect Cox proportional-hazard modelling and of effect of treatment delay on mortality by propensity-score analysis. This study is registered with PROSPERO, number 42016050022.FindingsWe identified 23 datasets for inclusion (20 published and three unpublished at time of search) and obtained IPD from 20, representing 96·2% of eligible IPD. Risk of bias for the included studies was assessed to be generally low except for on the patient selection domain, which was moderate in most studies. 5751 patients met harmonised IPD-level inclusion criteria. Technical factors such as number of blood cultures done, timing of blood cultures relative to blood sampling, and patient factors such as inpatient setting and CD4 cell count, explained significant heterogeneity between primary studies. The predicted probability of M tuberculosis BSI in hospital inpatients with HIV-associated tuberculosis, WHO danger signs, and a CD4 count of 76 cells per μL (the median for the cohort) was 45% (95% CI 38–52). The diagnostic yield of sputum in patients with M tuberculosis BSI was 77% (95% CI 63–87), increasing to 89% (80–94) when combined with urine LAM testing. Presence of M tuberculosis BSI compared with its absence in patients with HIV-associated tuberculosis increased risk of death before 30 days (adjusted hazard ratio 2·48, 95% CI 2·05–3·08) but not after 30 days (1·25, 0·84–2·49). In a propensity-score matched cohort of participants with HIV-associated tuberculosis (n=630), mortality increased in patients with M tuberculosis BSI who had a delay in anti-tuberculosis treatment of longer than 4 days compared with those who had no delay (odds ratio 3·15, 95% CI 1·16–8·84).InterpretationIn critically ill adults with HIV-tuberculosis, M tuberculosis BSI is a frequent manifestation of tuberculosis and predicts mortality within 30 days. Improved diagnostic yield in patients with M tuberculosis BSI could be achieved through combined use of sputum Xpert and urine LAM. Anti-tuberculosis treatment delay might increase the risk of mortality in these patients.FundingThis study was supported by 10.13039/100010269Wellcome fellowships 109105Z/15/A and 105165/Z/14/A.

Compliance of clinical microbiology laboratories with recommendations for the diagnosis of bloodstream infections: Data from a nationwide survey in Italy.

In 2014, the Italian Working Group for Infections in Critically Ill Patient of the Italian Association of Clinical Microbiologists updated the recommendations for the diagnostic workflow for bloodstream infections (BSI). Two years after publication, a nationwide survey was conducted to assess the compliance with the updated recommendations by clinical microbiology laboratories. A total of 168 microbiologists from 168 laboratories, serving 204 acute care hospitals and postacute care facilities, were interviewed during the period January–October 2016 using a questionnaire consisting of nineteen questions which assessed the level of adherence to various recommendations. The most critical issues were as follows: (a) The number of sets of blood cultures (BC) per 1,000 hospitalization days was acceptable in only 11% of laboratories; (b) the minority of laboratories (42%) was able to monitor whether BCs were over or under‐inoculated; (c) among the laboratories monitoring BC contamination (80%), the rate of contaminated samples was acceptable in only 12% of cases;(d) the Gram‐staining results were reported within 1 hr since BC positivity in less than 50% of laboratories. By contrast, most laboratories received vials within 2–4 hr from withdrawal (65%) and incubated vials as soon as they were received in the laboratory (95%). The study revealed that compliance with the recommendations is still partial. Further surveys will be needed to monitor the situation in the future.

Outcomes of Staphylococcus aureus bacteraemia attributed to blood culture contamination

Staphylococcus aureus is a common skin commensal and leading cause of bloodstream infection. Given the formidable mortality and morbidity associated with S. aureus bacteraemia (SAB), it is uncertain whether S. aureus can be viewed safely as a blood culture contaminant. 19 episodes of SAB over two years were identified that were prospectively attributed as contaminants using Health Protection Scotland criteria and compared these with 168 cases of genuine SAB. All cases were assessed by an infection specialist and underwent multidisciplinary review to agree the source. Follow-up was a minimum of six months. Female sex, cognitive impairment and chronic skin conditions were more common in the contaminant group. No single clinical or laboratory feature reliably predicted contamination. No patients in the contaminant group subsequently developed a SAB or metastatic complications associated with SAB. Eighteen patients (95%) survived to hospital discharge. Compared to patients with genuine SAB surviving to discharge, the contaminant group had a shorter duration of hospital stay (median 14 days versus 19.5 days), a briefer exposure to intravenous antibiotics (median 1 day versus 14 days) and received less total antibiotic (median 7 days versus 19 days). Twelve patients received at least five days of antibiotics active against their SAB, though none would have been deemed appropriate SAB treatment under current guidelines. The careful attribution of SAB as a contaminant by an infection specialist, combined with appropriate follow-up, is associated with favourable clinical outcomes, shorter hospital stay and reduced antibiotic use. A more robust definition of genuine SAB is needed.

Efforts to improve diagnosis of bacteraemia by reducing blood culture contamination in an emergency department: strategies and outcome.

To assess the strategies and outcome for reducing blood culture contamination in order to improve the diagnosis of bacteraemia. The interventional study was conducted at a tertiary care hospital in Karachi from January 1, 2013, to December 31, 2016. The blood culture contamination data related to the first year of the study was taken as the baseline pre-intervention data. Strategies were planned as intervention for improvement by consolidating training and education in the form of dedicated lectures, practising on mannequins and developing in-house video, replacing povidone with 2% chlorhexidine preparation spray plus 70% isopropyl alcohol swabs and inducting dedicated phlebotomy team whose only responsibility was blood sample collection and minimising the probability of error. In 2013, there were 8868 samples; 7402 in 2014; 6897 in 2015; and 9756 samples in 2016. The contamination rate in 2013 was 8% which went down to 7.75% in 2014, 4.25% in 2015 and 3.9% in 2016. The decline became statistically significant (p<0.001) after implementing a dedicated phlebotomy team in the emergency department. Apart from teaching and training, the concept of blood culture collection kit with checklist and dedicated blood collection team was found to be vital in reducing blood culture contamination.

A prospective study on the comparison of contamination rate and risk factors of blood culture done in the emergency department and medical high-dependency unit/medicine intensive care units

Background: Blood culture (BC) is an important tool and also considered the “gold standard” for the diagnosis of bacteremia. Emergency departments (EDs) and medical high-dependency units/medicine intensive care units (MHDUs/MICUs) are particularly susceptible to contaminated BCs due to high staff turnover. However, the need to collect cultures in critically ill patients is essential before the first dose of antibiotics. Aim: This study aimed to calculate the rate and risk factors of contamination of BC in ED and MHDU/MICU. Materials and Methods: This is a 2-month prospective observational study with a total of 998 patients – 570 in ED and 428 in MHDU/MICUs. The primary investigator collected the data, and culture reports were followed up to 7 days. Categorical variables were presented as percentages, and quantitative variables were summarized using mean and standard deviation. Results: The mean age of the population in the ED culture arm was 51 years and in the MHDU/MICU was 46 years. There was a male predominance of 61%. From ED, the most common admission diagnosis was acute undifferentiated febrile illness accounting to 23% of total patients. Lung pathologies were the most common MHDU/MICU admission diagnosis encountered in the study comprising 193 (19.3%) cases. The most common site for culture in ED was the brachial vein (81%) followed by the dorsum of the hand (14%). The most common contaminant was coagulase-negative Staphylococcus (CoNS) with 26 cases, of which 16 were from MHDU/MICU. A total of 48 cases (4.8%) were contaminated in the study, of which 25 (4.4%) cases were from ED and 23 (5.4%) from MHDU/MICU. Conclusions: BC contamination is a common clinical problem and often leads to adverse impacts on both health care and costs. It is challenging to prevent contamination because of inadequate inpatient capacity, high severity of illness, the rapid turnover of staff, and the high workload and overcrowding.

Reducing The Rate Of Contaminated Blood Cultures Collected In The Pediatrics Emergency Department: A Quality Improvement Project

Reducing The Rate Of Contaminated Blood Cultures Collected In The Pediatrics Emergency Department: A Quality Improvement Project

Successful Reduction of Blood Culture Contamination in an Emergency Department by Monitoring and Feedback

Background:Blood Culture (BC) contamination is a common problem in the Emergency Department (ED) and is associated with prolonged length of patient stay and excess costs.Objective:The study aimed to investigate the impact of monthly monitoring and feedback of BC results on contamination rates.Methods:Data from a previous study showed that the contamination rate in the ED consistently exceeded the recommended level. This triggered an ad hoc Quality Improvement team to develop and implement a corrective action plan. In 2017, BC contamination rates were reported to the ED on a monthly basis. In response to this, ED staff conducted intensified educational workshops, followed by private counselling and competency assessment of nurses who collected contaminated BCs.Results:A total of 12 educational workshops were conducted in February and March, 2017. The intervention resulted in &gt;60% reduction in the contamination rate, from 8.6% baseline level to less than 3%. Of the 2660 BC sets drawn in 2017 from 1318 patients, 128 (4.8%) were contaminated, accounting for 39.5% of the total number of positive cultures. Sixty percent of the contaminated BCs grew Coagulase-negativeStaphylococcusspecies; other contaminants includedCorynebacteriumspp.,Micrococcusspp.,Propionibacteriumspp.,viridansStreptococcus, andNeisseriaspp.Conclusion:Continuous monitoring and feedback of contamination rates reduced BC contamination.

A Study in Reducing Blood Culture Contamination Rates

A Study in Reducing Blood Culture Contamination Rates

Reducing Blood Culture Contamination in the Emergency Department.

Blood culture contamination results in delayed or unnecessary treatments, increased morbidity risk, extended lengths of hospital stay, and increased health care costs. Collecting 2 sets of blood cultures from separate sites helps differentiate bloodstream infections (BSIs) from contamination. Blood culture contamination rates trailed the national threshold of less than 3% in one southeastern US emergency department (ED). Same-site and single-set collection issues were also identified. This pre-/postintervention quality improvement study included 1137 patients (preintervention: n = 560; postintervention: n = 577) of all ages with blood culture orders in a 13-bed tertiary care ED. A staff educational program, blood culture collection checklist with protocol, and monthly collective and individual feedback were implemented. Blood culture contamination rates decreased from 3.39% to 2.6%. Same-site collection rates decreased from 15.13% to 4.14%. The interventions effectively reduced blood culture contamination rates and same-site blood culture collections in the ED, enhancing the quality of care for patients with BSIs.

Impact of Peptide Nucleic Acid Fluorescence in Situ Hybridization Testing for Coagulase-Negative Staphylococci in a Pediatric Setting

Background Coagulase-negative staphylococci (CoNS) are common blood culture contaminants, whereas Staphylococcus aureus is a pathogen with isolation from blood requiring therapy. Peptide nucleic acid fluorescence in situ hybridization (PNA-FISH) permits distinction of CoNS and S. aureus and has been demonstrated to decrease hospital costs, vancomycin use, and length of stay when paired with antimicrobial stewardship intervention. The impact of this testing in a children's hospital in the absence of stewardship intervention is unknown. The objective of this study was to determine the impact of PNA-FISH in a setting without an antimicrobial stewardship protocol for response to rapid testing. Methods This retrospective cohort study included pediatric patients with at least 1 CoNS-positive blood culture between January 1, 2012, and August 1, 2016. Patients were categorized based on the use of Staphylococcus QuickFISH, a rapid PNA-FISH method of identification. The primary outcome was hours of vancomycin exposure. Secondary outcomes included time-to-therapy change, time to culture result, and hospital length of stay. Results Of the 211 identified patients who had at least 1 blood culture bottle positive for CONS, 179 (85%) received vancomycin. Median hours of vancomycin exposure decreased between groups (63 rapid diagnostic testing group vs 81 conventional testing group; P = 0.019). Conclusions Despite an observed decrease in vancomycin exposure with use of rapid PNA-FISH testing, the full benefits of rapid diagnostic testing are unrealized in the absence of an appropriate stewardship protocol. Further studies may allow determination of the full impact of rapid diagnostic testing in pediatric settings.

The Monitoring and Evaluation of a Multicountry Surveillance Study, the Severe Typhoid Fever in Africa Program.

BackgroundThere is limited information on the best practices for monitoring multicountry epidemiological studies. Here, we describe the monitoring and evaluation procedures created for the multicountry Severe Typhoid Fever in Africa (SETA) study.MethodsElements from the US Food and Drug Administration (FDA) and European Centre for Disease Prevention and Control (ECDC) recommendations on monitoring clinical trials and data quality, respectively were applied in the development of the SETA monitoring plan. The SETA core activities as well as the key data and activities required for the delivery of SETA outcomes were identified. With this information, a list of key monitorable indicators was developed using on-site and centralized monitoring methods, and a dedicated monitoring team was formed. The core activities were monitored on-site in each country at least twice per year and the SETA databases were monitored centrally as a collaborative effort between the International Vaccine Institute and study sites. Monthly reports were generated for key indicators and used to guide risk-based monitoring specific for each country.ResultsPreliminary results show that monitoring activities have increased compliance with protocol and standard operating procedures. A reduction in blood culture contamination following monitoring field visits in two of the SETA countries are preliminary results of the impact of monitoring activities.ConclusionsCurrent monitoring recommendations applicable to clinical trials and routine surveillance systems can be adapted for monitoring epidemiological studies. Continued monitoring efforts ensure that the procedures are harmonized across sites. Flexibility, ongoing feedback, and team participation yield sustainable solutions.

Practical Guidance for Clinical Microbiology Laboratories: A Comprehensive Update on the Problem of Blood Culture Contamination and a Discussion of Methods for Addressing the Problem

In this review, we present a comprehensive discussion of matters related to the problem of blood culture contamination. Issues addressed include the scope and magnitude of the problem, the bacteria most often recognized as contaminants, the impact of blood culture contamination on clinical microbiology laboratory function, the economic and clinical ramifications of contamination, and, perhaps most importantly, a systematic discussion of solutions to the problem. We conclude by providing a series of unanswered questions that pertain to this important issue.