Drawing Blood Cultures Research Articles

Round pneumonia with Pseudomonas luteola and Escherichia vulneris bacteremia

A 40-year-old man with a past medical history of alcohol abuse presented with altered mental status. The patient’s wife reported that he had stopped drinking alcohol three days prior, and on the day of presentation had experienced two seizures and fever while at home. Physical examination at the time of admission revealed crackles over the left lower lung fields and a fluctuating mental status without focal neurological deficits or meningeal signs. Patient was febrile with a temperature of 101.4 F. Posteroanterior and lateral chest radiographs revealed a left sided pleural effusion with suspected pneumonia. After drawing blood cultures, he received ceftriaxone 1g IV Figure 1

Nurses' competency in drawing blood cultures and educational intervention to reduce the contamination rate.

Compared with truly negative cultures, false positive blood cultures (BCs) not only increase laboratory work but also prolong the lengths of patient stays, which are likely to increase patient morbidity and costs. The present study aimed to evaluate the effectiveness of a hospital-wide educational intervention on BC contamination rates. Nurses performed all phlebotomies; therefore, educational workshops were offered to all nurses twice a week over a 3-month period. The workshops consisted of a questionnaire, PowerPoint presentation, video show, demonstration of the different materials used to collect BCs, and question session. Data from the questionnaires and laboratory culture results were compared between the 6-month pre- and post-intervention periods. Of the 503 eligible nurses, 216 (42.9%) attended the workshops. The survey identified areas for improvement, which included time of disinfectant application, volume of blood to be cultured, and disinfection of BC bottle tops. Of the 9903 BC sets that were drawn from 3649 patients during the study period, 676 (6.8%) were contaminated. The monthly BC contamination rates for the 6-month pre- and post-intervention periods were 8.1% and 5.2%, respectively, representing a 36% reduction (P=0.008). Only three wards had an acceptable contamination rate of ≤3% before the intervention, compared with eight wards after the intervention. While contamination of BCs can never be completely eliminated, there is evidence that adherence to best practice BC collection techniques can minimize BC contamination, which might be best achieved with a dedicated phlebotomy team.

INCIDENCE OF PATHOGEN DETECTION IN BLOOD CULTURES OF SEVERE SEPSIS AND SEPTIC SHOCK PATIENTS IS HIGHER, IF BLOOD CULTURES WERE DRAWN BEFORE ANTI-INFECTIVE THERAPY

Actual guidelines for the management of severe sepsis and septic shock recommend to draw blood cultures before anti-infective therapy. The grade of recommendation for this approach is high, the evidence, however, is low (1C) [1]. Thus, data on the influence of anti-infective therapy on microbiology results in seriously ill patients are urgently warranted.

Discrepant results from sampling different lumens of multilumen catheters: the case for sampling all lumens

It is unclear whether blood culture samples should be obtained through one or multiple catheter lumens. We measured how frequently drawing blood cultures from all the lumens from a multilumen catheter resulted in discordant results and how often these caused medical interventions. We performed a retrospective review of the microbiology database of the National Institutes of Health (NIH) Clinical Center. Most patients were immunocompromised. All blood cultures obtained from May 1, 2007 to April 30, 2009 were reviewed. We analyzed all positive blood cultures (i.e., positivity of any of the blood cultures drawn through the catheter lumens) when simultaneous samples from different lumens were obtained, and reviewed the medical charts of those in which blood cultures from different lumens had discordant results (i.e., not all lumens revealed the same organism). We also analyzed how often the discordant results lead to a medical intervention, defined as a change of antimicrobials and/or removal of the catheter. There were 405 episodes of positive blood cultures, in which simultaneous samples of different lumens of a multilumen catheter were obtained. Eighty-five episodes (21 %) were considered to be contaminants and excluded. We analyzed 320 episodes of positive blood cultures in 153 patients; 173 episodes (54.1 %) had discordant results. In 77 % of the 173 episodes, the discordant isolate led to a medical intervention. In immunocompromised patients, sampling all the lumens of a multilumen catheter results in more positive blood cultures, and many of these result in medical interventions. When evaluating bloodstream infection in patients with multilumen catheters, sampling all lumens should be strongly considered.

83-jähriger Patient mit Salmonellenbakteriämie und Infekt-getriggertem Sweet-Syndrom

An 83 year-old man presented with watery diarrhea and a rash. He was hypotensive, febrile and dehydrated. The rash was maculopapular and most pronounced on the dorsal trunk. The lab tests showed an acute renal failure with hypokalemia and hyponatremia. Salmonella typhimurium was isolated from the aerobic blood culture, stool cultures were negative. The rash was consistent with an infection-associated Sweet's syndrome. THERAPY AND COURSE OF DISEASE: The patient was admitted and received iv fluids and potassium. An empiric antibiotic treatment with i. v. ciprofloxacin was started and changed to p. o. after 8 days. Antibiotic therapy was given 11 days total. After the administration of steroids the skin rash resolved. It is important to draw blood cultures in patients presenting with diarrhea if fever is present. Complications associated with non-typhoidal salmonella bacteremia occur most frequently in elderly patients and include pneumonia, infected aneurysms and bone/soft part infections. In rare cases patients can also present with a skin rash.

Blood Culture Contamination A Clinical and Financial Burden

Affiliation: 1. Clinical Microbiology-Immunology Laboratories and Phlebotomy Services, University of North Carolina Hospitals, Chapel Hill, North Carolina; and University of North Carolina School of Medicine, Chapel Hill, North Carolina. Received September 20, 2012; accepted September 20, 2012; electronically published November 26, 2012. 2012 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2013/3401-0003$15.00. DOI: 10.1086/668771 The study by Washer et al in this issue of the journal reminds us of the clinical and financial burden that contaminated blood cultures represent. Washer and colleagues ask a fairly simple question: of the 3 antiseptics most widely used to cleanse venipuncture sites prior to collection of blood for culture, which results in the lowest rate of contaminated blood cultures? The answer that none is superior is consistent with a recent Centers for Disease Control and Prevention (CDC) Laboratory Best Practices Guideline on practices that reduce blood culture contamination. Besides the finding that the type of antiseptic used does not influence blood culture contamination rates, 2 other practices are associated with reduced blood culture contamination rates: having blood cultures drawn by phlebotomists whose main duty is drawing blood and having blood drawn by venipuncture rather than from intravenous catheters are strongly associated with reduced rates of contamination. The finding that the type of disinfectant used does not influence the contamination rate may be at odds with the results of some previous studies, but the CDC’s systematic review of the data suggests otherwise. One of the key strengths of the study by Washer and colleagues is the use of a dedicated phlebotomy team. It is likely that training a small group of individuals to properly apply antiseptics with different dwell times contributes to the impressively low contamination rate of less than 1% regardless of antiseptic used. This rate is superior to that reported in many studies and is significantly below the American Society for Microbiology’s and College of American Pathologists’ benchmark for contaminated blood cultures, which is between 2.5% and 3%. Why are rates lower for phlebotomists than for other healthcare providers? Simply put, it is because of training, practice, resources, and professionalism. At our institution, phlebotomists routinely have a monthly blood culture contamination rate of less than 1%, as was seen in the study of Washer and colleagues. The training they receive includes one-on-one instruction by a senior phlebotomist during their initial series of blood culture collection and retraining if their individual contamination rates rise above 2%. This is not done with any other healthcare provider in a systematic manner in our institution. Phlebotomists draw the bulk of blood cultures obtained by venipuncture, so they are more practiced at this method. This is particularly key when drawing blood cultures from patients with poor venous access, who may require venipuncture of hand or foot veins, something that trained phlebotomists are comfortable doing, whereas many other healthcare providers are not. Phlebotomists also have all the supplies at hand on individual carts that travel with them, unlike other professionals, who may have to scrounge around for appropriate supplies. Finally, they take great pride in having contamination rates that are lower than those of any other professional who draws blood cultures at our institution. It is a benchmark of their worth to the institution, something of which they are well aware. Why is reducing blood culture contamination rates important? Simply put, contaminated blood cultures are expensive and put patients at risk for significant iatrogenic complications. The seminal work by Bates et al was the first to quantify the cost of a contaminated blood culture, at $4,500. This cost was due to increased length of stay, typically of 1 day; use of unnecessary antimicrobial therapy; and diagnostic testing. Subsequent studies have put this cost as high as $10,000. Let us use an illustration to understand the annual cost of contaminated blood cultures. Say that hospital A does 20,000 blood cultures annually and has a 2.5% contamination rate, while hospital B does 30,000 with a 1% contamination rate. The cost of a contaminated blood culture at each institution is $5,000. Hospital A, even though it does two-thirds the number of blood cultures, has an annual excess expense due to contaminated blood cultures of $2,500,000, while hospital B has a cost of $1,500,000. In addition, hospital A has 200 more hospital-days when a bed is not available compared with hospital B because of the increased length of stay of 1 day. In hospitals that have a chronic shortage of beds, those extra 200 hospital bed–days would be highly useful. The clinical impact of contaminated blood cultures is also

Neonatal blood cultures: survey of neonatologists’ practices

There are currently no standard recommendations regarding the optimal method to obtain a blood culture in neonates. We performed an online survey of the membership of the Section on Perinatal Pediatrics of the American Academy of Pediatrics regarding their practices when drawing blood cultures. The survey included questions regarding the type of antisepsis used in preparing the site for sampling, the amount of blood drawn and preferred site for obtaining the culture. Overall 715 of 2955 (24%) members responded to the survey. There was wide variability in responses to all of the questions. However, virtually all providers washed their hands and wore gloves while performing the procedure, and virtually all providers obtained ≥0.5 mL of blood for the sample. Given the wide variability of practices among the members of the Section, evidence-based standards are needed to guide clinical practice for this procedure.

Improving the Quality of Care by Reducing Contamination When Drawing Blood Cultures in the Neonatal Intensive Care Unit

Improving the Quality of Care by Reducing Contamination When Drawing Blood Cultures in the Neonatal Intensive Care Unit

ATG Use Is Associated with Frequent Occurrence of Positive Blood Cultures in Patients in the Early Phase After Hematopoietic Stem Cell Transplantation

Abstract 4564 Background:Infectious complications remain an important cause of morbidity and mortality in the early phase after hematopoietic stem cell transplantation (HSCT). Aim:The aim of this study was to assess the frequency of positive blood cultures and its potential correlation with different studied parameters in large patient population studied in the first 30 days after HSCT. Material and methods:431 patients at median age of 47 years (range 18–85) transplanted between 2009–2011 for hematological and non-hematological malignancies were included in our analysis. There were 242 males and 189 females. Results:The indications for autologous and allogeneic HSCT were following: AML – 105 (24%), NHL – 86 (20%), MM – 75 (17,5%), HL – 48 (11%), ALL – 40 (9%), MDS – 17 (4%), AA – 15 (3,5%), CML – 12 (2,8%), PNH – 11 (2,6%), connective tissue diseases – 5 (1,2%), CLL – 3 (0,7%) and other – 14 (3,2%). The following transplant procedures were performed: ABCT – 213 (49%), ABMT – 3 (0,7%), alloBCT – 56 (13%), alloBMT – 21 (5%), URDBCT – 87 (20%), URDBMT – 51 (12%). Pre-transplant ATG and anti-CD52 antibody were used in 142 (33%) and 5 (1.2%) patients, respectively. Amongst 431 transplanted patients, 495 blood cultures were collected; range 0–8 (median 1). Eighty seven blood samples were positive (17,6%). The following pathogens were detected: gram-positive bacteria in 48% (n=42), gram-negative bacteria in 38% (n=33), fungi in 1% (n=1) and both G(+) and G(−) bacteria in 13%(n=11). The gram-positive bacteria included: Staphylococcus epidermidis: 21 (50%), Micrococcus spp: 4 (9%), Enterococcus faecium: 3 (7%), Enterococcus faecalis: 3 (7%), Streptococcus haemolyticus: 3 (7%). The following gram-negative bacteria were found: Enterobacter cloacae: 10 (30%), Escherichia coli: 7 (21%), Pseudomonas aeruginosa: 5 (15%), Klebsiella pneumonia: 5 (15%). Candida albicans was detected only in one case. The use of ATG was associated with higher number of total blood draw and positive blood cultures. No significant correlation was found between the specific pathogen and the use of ATG. Male gender was associated with significantly higher number of blood sampling and with tendency to higher number of positive blood cultures. The type of conditioning regimen, the source of stem cell and the donor origin (auto vs sibling vs unrelated) did not influence the number of positive blood culture. There was tendency to higher number of blood intake, but not positive blood culture in patients transplanted in NR if compared to PR or CR. Conclusions:Positive blood cultures were positive in about 20% of patients after HSCT. Only pre-transplant ATG use was associated with the higher number of positive blood culture. Disclosures:No relevant conflicts of interest to declare.

Reducing Contamination of Peripheral Blood Cultures in a Pediatric Emergency Department

Blood culture contamination rates (CRs) in emergency departments (EDs) vary from 1% to 9% in previous studies. High CRs cause unnecessary admissions, antibiotics, and costs. Different measures have been tried to improve CR. This study sought to determine the ED CR at Arkansas Children's Hospital (ACH) and evaluate an educational intervention. A slide presentation of the ACH's blood culture collection procedure was made. The ED nursing staff viewed this individually and demonstrated the procedure on a mock extremity. Data before (from June 1 to November 30, 2007; PRE) and after (from February 1 to July 31, 2008; POST) intervention regarding blood cultures positive for organism submitted to the ED and any descriptive data were collected retrospectively. Descriptive statistics described the CR, positivity rate (PSR), and pathogen rate (PR). Frequent collectors were identified as those submitting more than 72 blood cultures during PRE and during POST. Contamination rate in frequent collectors was independently assessed for improvement. This study was approved by the institutional review board of the University of Arkansas for Medical Sciences. Positivity rate during PRE was 6.8% (n = 15; 95% confidence interval [CI], 2.9-10.7); 114 were contaminants (CR, 5.0%; 95% CI, 1.04-8.98) and 40 were pathogens (PR, 1.8%; 95% CI, ± 4.28). Positivity rate during POST was 6.3% (n = 157; 95% CI, 2.6-10.0); 124 were contaminants (CR, 4.9%; 95% CI, 1.14-8.66) and 33 were pathogens (PR, 1.4%; 95% CI, ± 4.22). For both PRE and POST, contaminants represented 74% or greater of all the positives and more than 75% of contaminants occurred in patients 0 to 36 months old.Contamination rates of individual practitioners ranged from 0% to 17% (PRE) and from 0% to 21% (POST). The CR was lower in POST for samples submitted from frequent collectors (practitioners submitting >72 blood cultures per study period, n = 6), was evaluated separately, and found to improve in POST (from 4.1% to 2.7%). A t test for matched samples for these samplers revealed a significant decrease in the POST period, P = 0.03. The CR in the ACH ED for peripherally drawn blood cultures is approximately 5% monthly with less than 2% PR. For each culture positive for organism, the chance of contamination is 75% or higher. An intervention emphasizing the appropriate technique, monitored training, and improved CR of a group of frequent collectors is warranted.

Procalcitonin Levels Predict Bacteremia in Patients With Community-Acquired Pneumonia: A Prospective Cohort Trial

Guidelines recommend blood culture sampling from hospitalized patients with suspected community-acquired pneumonia (CAP). However, the yield of true-positive results is low. We investigated the benefit of procalcitonin (PCT) on hospital admission to predict blood culture positivity in CAP. This was a prospective cohort study with a derivation and validation set including 925 patients with CAP who underwent blood culture sampling on hospital admission. A total of 73 (7.9%) patients had true bacteremia (43 of 463 in the derivation cohort, 30 of 462 in the validation cohort). The area under the receiver operating characteristics curve of PCT in the derivation and validation cohorts was similar (derivation cohort, 0.83; 95% CI, 0.78-0.89; validation cohort, 0.79; 95% CI, 0.72-0.88). Overall, PCT was a significantly better predictor for blood culture positivity than WBC count, C-reactive protein, and other clinical parameters. In multivariate regression analysis, only antibiotic pretreatment (adjusted odds ratio, 0.25; P < .05) and PCT serum levels (adjusted odds ratio, 3.72; P < .001) were independent predictors. Overall, a PCT cutoff of 0.1 microg/L would enable reduction of the total number of blood cultures by 12.6% and still identify 99% of the positive blood cultures. Similarly, 0.25 microg/L and 0.5 microg/L cutoffs would enable reduction of blood cultures by 37% and 52%, respectively, and still identify 96% and 88%, respectively, of positive blood cultures. Initial PCT level accurately predicted blood culture positivity in patients with CAP. PCT measurement has the potential to reduce the number of drawn blood cultures in the emergency department and to implement a more targeted allocation of limited health-care resources.

Reducing Blood Culture Contamination: What Makes the Difference?

ISSUE: Blood cultures are widely appreciated by physicians to be among the most important diagnostic tool performed in the diagnosis of serious infections. It is equally recognized that falsely positive results due to contamination can result in inappropriate or delayed treatment, increase lenght of stay and increase cost of health care. Early in 2002, Microbiology Laboratory of the VANJHCS notified the Infection Control staff that the blood contamination rate was high. Retrospective review of blood culture contamination rates from the previous 10 years revealed a gradual increase in the rate. In 1990, there were 217 contaminated sets out of 6,241 blood culture sets(3.5%). In 2001 there were 224 contaminated sets of 3,209 blood culture sets (6.8%) tested. The College of American Pathologist and the American Society for Microbiology had set a goal of 3% blood contamination rate. If the institution has a dedicated Phlebotomy Team the rates are lower. VANJHCS is a teaching hospital with no dedicated Phlebotomy Team. Medical residents and ER nurses were drawing specimens. The medical residents rotation is every month. PROJECT: After review of current literature on the subject, the standard operating procedure (SOP) was revised. In the old SOP, 70% to 90% alcohol was used to cleanse the area followed by 2% iodine or iodophor. The skin de-germing agent at the venipuncture site was changed to 2% Chlorhexidine and 70% Alcohol (Chloraprep One-step applicator) in June 2002. The revised SOP and the blood contamination rate data were used to educate the ER nurses and medical residents. Since medical students rotate monthly, this information was made part of the monthly infection control orientation for residents given by the Infection Control Coordinator. Compliance with hand hygiene and keeping the skin flora out by using meticulous aseptic technique in drawing blood cultures are emphasized in those sessions. To facilitate compliance to the new SOP, each patient unit was provided dedicated containers for blood culture bottles, copies of the SOP, Chloraprep applicators and sterile blood transfer devices. RESULTS: Contamination rate of blood cultures decreased after all the measures mentioned were instituted. Table I . Blood Culture Contamination Rate Year Total # Sets # of sets contaminated BCC Rate (%) 2001 3,299 224 6.8% 2002 3,209 198 6.2% 2003 3,281 140 4.3% 2004 3,256 90 3% 2005 3,248 100 3.1% LESSONS LEARNED: Although progress has been made with those measures, continuous vigilance in staff education and dialogue proved to be the key in increasing awareness of providers to this problem. It is extremely important to continue to monitor and give feedback to the staff regarding results of action taken.

Impact of a Series of Interventions in Vancomycin Prescribing on Use and Prevalence of Vancomycin-Resistant Enterococci

In response to vancomycin-resistant bacteria, particularly vancomycin-resistant enterococci (VRE), measures have been recommended to improve on the appropriate use of vancomycin. Intervention 1 consisted of an automatic 72-hour vancomycin stop order; Intervention 2, a standardized procedure for sampling of blood cultures; and Intervention 3, an interdisciplinary critical care team. After Intervention 1, inappropriate use decreased, particularly in treatment of febrile neutropenia and undocumented gram-positive infections. After Intervention 2, the baseline rate of inappropriately drawn blood cultures (IDBCs) was unchanged, and use in patients with IDBCs was comparable during both periods. Before Intervention 3, 38/55 orders continuing > 72 hours were considered inappropriate versus 24/53 (p < .025) after. After the interventions, hospitalwide vancomycin use was reduced. Yet the overall rate of VRE infection initially decreased but then increased once again over time. Despite substantial reduction in hospitalwide vancomycin use, the impact on the overall rate of VRE was inconsistent and ward dependent.

Drawing blood culture specimens for reliable results

Drawing blood culture specimens for reliable results

Utility of blood cultures in pneumonia patients admitted through the emergency department

Study objectives: The American Thoracic Society and the American Society for Infectious Diseases recommend 2 sets of blood cultures as part of the evaluation of hospitalized pneumonia patients. Several studies have questioned the utility of blood cultures in community-acquired pneumonia, suggesting positive cultures seldom lead to important therapeutic changes. Our institution uses a pneumonia pathway requiring 2 sets of blood cultures with antibiotic guidelines for different clinical situations. Our objective is to identify risk factors that would enable emergency department (ED) clinicians to reduce or eliminate blood cultures in pneumonia patients. Methods: York Hospital institutional review board approval was obtained. A retrospective chart review using a standardized data collection form was conducted by the 3 investigators. The study was conducted in a community teaching hospital with an ED residency program and an annual census of 60,000 patients. Patients admitted through the ED during calendar years 2001 and 2002 with an admission diagnosis of pneumonia (diagnosis-related group 96, 97) were reviewed. Patients younger than 18 years or with a hospital discharge diagnosis other than pneumonia were excluded. Antibiotics were started in the ED according to a pneumonia pathway order set. The following risk factors were evaluated for positive blood culture results: pneumonia severity index (PSI), recent hospitalization, immunocompromised state, nursing home residency, and chronic obstructive pulmonary disease. Sensitivity to standard pneumonia pathway antibiotics was reviewed. Data were analyzed by descriptive statistics. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Results: Six hundred eighty-six charts were reviewed. Eighty-two (12%) were excluded because of nonpneumonia discharge diagnoses, which resulted in 604 eligible charts. Of 44 (7.3%) positive blood cultures identified, 25 (4.1%) were found to be contaminants, and 19 (3.1%) were true positives ( Streptococcus pneumoniae , group B streptococcus, Staphylococcus aureus, Escherichia coli, Haemophilus influenzae ). All organisms were sensitive to standard pneumonia pathway antibiotics. The antibiotic was changed from Levofloxacin to penicillin in 1 positive culture for S pneumoniae. PSI level V (OR 3.2, 95% CI 1.306 to 7.850) was the only statistically significant risk factor for a positive blood culture result. All other PSI scores, individually or combined, had ORs less than 1. Other risk factors examined did not reach statistical significance: recent hospitalization (OR 0.805, 95% CI 0.232 to 2.797), nursing home resident (OR 0.560, 95% CI 0.162 to 1.938), chronic obstructive pulmonary disease (OR 0.480, 95% CI 0.158 to 1.455), and immunocompromised state (OR 1.112, 95% CI 0.319 to 3.880). Conclusion: Only PSI level V patients had a statistically significant OR for positive blood culture results. All positive blood culture results were sensitive to pneumonia pathway antibiotics. The only culture-driven antibiotic change was to an antibiotic with a narrower spectrum. In our community hospital population, the addition of blood cultures did not affect clinical management, suggesting that cultures could be eliminated in many patients. We recommend drawing blood cultures and ordering their completion for PSI level V patients.

Infective endocarditis in the elderly: diagnosis and management.

Infective endocarditis is seen with increasing frequency in older patients. This increase is due to the general aging of the population, improved survival of patients with congenital and valvular heart disease, and the increasing use of catheters and other prosthetic devices with resulting higher incidence of nosocomial endocarditis. In older patients, infective endocarditis frequently develops in the absence of underlying structural heart disease; atheromatous deposits and mitral annular calcification are two important risk factors in this population. Infective organisms in older patients are frequently enterococci and other gastrointestinal tract bacteria. A marked febrile response is uncommon whereas central nervous system symptoms are more common in older patients. Transesophageal echocardiography can be performed safely and is a major diagnostic tool with sensitivity of more than 90% in detecting vegetations as small as 2-5 mm. Appropriately drawn blood cultures provide bacteriologic diagnosis in 80%-99% of patients. Prolonged antibiotic therapy may be required in many instances depending on the infective organism. Early surgical therapy is advisable for patients who develop heart failure as a result of severe acute aortic valvular regurgitation. Valve replacement surgery can be performed with acceptable mortality and morbidity even in very elderly patients.

Improved operational efficiency through elimination of waste and redundancy

Improved operational efficiency through elimination of waste and redundancy

Sensitivity of a blood culture drawn through a single lumen of a multilumen, long-term, indwelling, central venous catheter in pediatric oncology patients.

The study assessed the sensitivity of a blood culture drawn from only one lumen of a multilumen, long-term, indwelling, central venous catheter in pediatric oncology patients. Episodes of positive blood cultures were included if cultures were sent simultaneously from multiple lumens of a long-term, indwelling, central line and if the culture was thought to represent a true bacteremia. Discordant results from cultures drawn simultaneously from different lumens occurred in 13 (32%) of 41 episodes. The estimated sensitivity of a culture drawn from a single lumen was 84%. Drawing blood cultures from all lumens of these lines should be considered in this patient population.

Prevention of intravascular catheter-related infections.

To review the literature on prevention of intravascular catheter-related infections. The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles. Primary authors were contacted directly if data were incomplete. Studies met the following criteria unless otherwise stated: Trials were prospective and randomized; catheters were inserted into new sites, not into old sites over guidewires; catheter cultures were done by using semi-quantitative or quantitative methods; and, for prospective studies, catheter-related bloodstream infection was confirmed by microbial growth from percutaneously drawn blood cultures that matched catheter cultures. Data on population, methods, preventive strategy, and outcome (measured as catheter-related bloodstream infections) were gathered. The quality of the data was graded by using preestablished criteria. The recommended preventive strategies with the strongest supportive evidence are full barrier precautions during central venous catheter insertion; subcutaneous tunneling short-term catheters inserted in the internal jugular or femoral veins when catheters are not used for drawing blood; contamination shields for pulmonary artery catheters; povidone-iodine ointment applied to insertion sites of hemodialysis catheters; specialized nursing teams caring for patients with short-term peripheral venous catheters, especially at institutions with a high incidence of catheter-related infection; no routine replacement of central venous catheters; antiseptic chamberfilled hub or hub-protective antiseptic sponge for central venous catheters; and use of chlorhexidine-silver sulfadiazine-impregnated or minocycline-rifampin-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies that do not incorporate antimicrobial agents (for example, maximal barrier precautions). Simple interventions can reduce the risk for serious catheter-related infection. Adequately powered randomized trials are needed.

Critical care nurses' perceptions of appropriate care of the patient with orders not to resuscitate

To determine critical care nurses' perceptions of appropriate care of patients with and without do-not-resuscitate (DNR) orders. Descriptive, cross-sectional. Large, northeastern, metropolitan teaching hospital. Eighty-seven staff nurses divided into DNR and non-DNR groups whose demographic characteristics were coincidentally similar. Responses to an original questionnaire. Questionnaires describing one of two hypothetical patients (DNR or non-DNR) were distributed to all available staff nurses working in adult intensive care units. After construct validity and internal consistency reliability were established (Cronbach's coefficient alpha = 0.84 for the physical subscale, 0.79 for the psychosocial), analysis of variance was used in the data analysis. Mean total scores were 60.7 for the DNR group and 69.6 for the non-DNR group (p = 0.0031). Mean scores on the physical subscale were 33.6 and 41.9 for the DNR and the non-DNR groups, respectively (p = 0.0032). Results on the psychosocial subscale showed no significant differences between the groups. Item analysis showed significant differences on weighing the patient (p = 0.0002), monitoring neurologic status (p = 0.0082), drawing blood cultures (p = 0.0094), checking vital signs (p = 0.0071), performing complete nursing assessments (p = 0.0179), and treating the patient in an intensive care unit (p = 0.0001). Compared with the patient without a DNR order, significantly lower levels of agreement were expressed with interventions involving monitoring for the patient with the DNR order. Agreement with placement of the patient with the DNR order in an intensive care unit may be seen to follow the same pattern. Education of caregivers and communication among them might help to clarify what may be ambiguous policies and orders.