Obtaining Blood Cultures Research Articles

Physician practices in the diagnosis and treatment of infectious diseases in home care settings: A questionnaire study.

To elucidate the current practices of infectious disease management in home care settings in Japan, we sent a questionnaire to 36 physicians working at 13 clinics that specialize in providing care to patients in their homes or residential care facilities. The questionnaire described three hypothetical scenarios (aspiration pneumonia, pyelonephritis, and neoplastic fever) in older patients with terminal cancer, and 25 respondents answered questions on testing and treatment strategies. Most respondents chose to obtain cultures for aspiration pneumonia (sputum) and for pyelonephritis (urine), although fewer respondents chose to obtain blood cultures. For neoplastic fever, most of respondents elected to continue observation without antibiotic treatment. The most frequently selected antibiotics were cephalosporins and quinolones. The results indicated that most respondents would perform bacterial culture tests before prescribing antibiotics and observe patients when bacterial infections are not suspected. Standardized guidelines are needed to optimize infectious disease management in home care.

180 A Cellular Host Response Test May Enable Compliance With the Medicare Sepsis Quality Measure While Promoting Antimicrobial Stewardship Aims

Due to the need for rapid recognition and treatment of sepsis to positively impact outcomes in patients with the condition, guidelines to assist clinicians in management of the condition place emphasis on early recognition and intervention. The Sepsis CMS core measure (SEP-1) requires measuring of serum lactate, obtaining blood cultures prior to antibiotics, and administering antibiotics within 3-hours of presentation for those presenting with severe sepsis. In order to meet this measure, ED physicians often must intervene before adequate, objective diagnostic and prognostic data are available, resulting in a ‘one size fits all’ strategy for all those presenting that are suspected of sepsis.

249 Differences in Emergency Department Sepsis Care: Do Race, Sex, and Language Matter?

249 Differences in Emergency Department Sepsis Care: Do Race, Sex, and Language Matter?

Determining Time to Positivity of Blood Cultures in a Neonatal Unit.

Blood cultures are the gold standard for detecting bacteremia. We have studied the time to positivity of blood cultures in our neonatal unit to reduce antibiotic doses in patients with a negative blood culture. Empirical antibiotic treatment of neonatal sepsis could be withdrawn 24 hours after obtaining blood cultures.

Clinical decision support improves blood culture collection before intravenous antibiotic administration in the emergency department.

Surviving Sepsis guidelines recommend blood cultures before administration of intravenous (IV) antibiotics for patients with sepsis or moderate to high risk of bacteremia. Clinical decision support (CDS) that reminds emergency department (ED) providers to obtain blood cultures when ordering IV antibiotics may lead to improvements in this process measure. This was a multicenter causal impact analysis comparing timely blood culture collections prior to IV antibiotics for adult ED patients 1year before and after a CDS intervention implementation in the electronic health record. A Bayesian structured time-series model compared daily timely blood cultures collected compared to a forecasted synthetic control. Mixed effects models evaluated the impact of the intervention controlling for confounders. The analysis included 54 538 patients over 2years. In the baseline phase, 46.1% had blood cultures prior to IV antibiotics, compared to 58.8% after the intervention. Causal impact analysis determined an absolute increase of 13.1% (95% CI 10.4-15.7%) of timely blood culture collections overall, although the difference in patients with a sepsis diagnosis or who met CDC Adult Sepsis Event criteria was not significant, absolute difference 8.0% (95% CI -0.2 to 15.8). Blood culture positivity increased in the intervention phase, and contamination rates were similar in both study phases. CDS improved blood culture collection before IV antibiotics in the ED, without increasing overutilization. A simple CDS alert increased timely blood culture collections in ED patients for whom concern for infection was high enough to warrant IV antibiotics.

New predictive models of bacteremia in the emergency department: a step forward

La atención de pacientes con sospecha de un proceso infeccioso en los servicios de urgencias hospitalarios(SUH) se ha incrementado en la última década hasta suponer alrededor del 15-20% de todas las atenciones diarias. En la valoración inicial de estos enfermos se toman muestras para los distintos estudios microbiológicos en un 45% de los casos, donde predomina la obtención de hemocultivos (HC), en el 14,6% de todos ellos. La rentabilidad diagnóstica de estos HC es muy variable (2-20%). Los focos o procesos infecciosos más frecuentes sospechados o confirmados de las bacteriemias verdaderas(BV) en los SUH son la infección del tracto urinario (45%) y la infección respiratoria (25%). Por todo ello, la sospecha y confirmación de la BV tiene un relevante significado diagnóstico, pronóstico y obliga a cambiar algunas de las decisiones más importantes a tomar en el SUH. Entre otras, indicar el alta o ingreso, extraer HC y administrar el antimicrobiano adecuado y precoz. La intención de esta revisión es poner de manifiesto las evidencias científicas publicadas en los últimos cinco años, aclarar las controversias existentes actuales y comparar la capacidad para predecir bacteriemia de los últimos modelos predictivos publicados desde el año 2017 con los ya existentes en esa fecha, año en el que se publicó una revisión que dejaba abierta la propuesta de seguir buscando un modelo con un rendimiento adecuado para los SUH. Y así, a partir de ella, generar distintas recomendaciones que ayuden a definir el papel que pueden tener estos modelos o escalas en la mejora de la indicación de obtención de los HC, así como en la toma inmediata de otras decisiones diagnóstico-terapéuticas (administración precoz y adecuada del tratamiento antibiótico, solicitud de estudios complementarios y otras muestras microbiológicas, intensidad del soporte hemodinámico, necesidad de ingreso, etc.)

Hour-1 bundle adherence was associated with reduction of in-hospital mortality among patients with sepsis in Japan.

The updated Surviving Sepsis Campaign guidelines recommend a 1-hour window for completion of a sepsis care bundle; however, the effectiveness of the hour-1 bundle has not been fully evaluated. The present study aimed to evaluate the impact of hour-1 bundle completion on clinical outcomes in sepsis patients. This was a multicenter, prospective, observational study conducted in 17 intensive care units in tertiary hospitals in Japan. We included all adult patients who were diagnosed as having sepsis by Sepsis-3 and admitted to intensive care units from July 2019 to August 2020. Impacts of hour-1 bundle adherence and delay of adherence on risk-adjusted in-hospital mortality were estimated by multivariable logistic regression analyses. The final study cohort included 178 patients with sepsis. Among them, 89 received bundle-adherent care. Completion rates of each component (measure lactate level, obtain blood cultures, administer broad-spectrum antibiotics, administer crystalloid, apply vasopressors) within 1 hour were 98.9%, 86.2%, 51.1%, 94.9%, and 69.1%, respectively. Completion rate of all components within 1 hour was 50%. In-hospital mortality was 18.0% in the patients with and 30.3% in the patients without bundle-adherent care (p = 0.054). The adjusted odds ratio of non-bundle-adherent versus bundle-adherent care for in-hospital mortality was 2.32 (95% CI 1.09-4.95) using propensity scoring. Non-adherence to obtaining blood cultures and administering broad-spectrum antibiotics within 1 hour was related to in-hospital mortality (2.65 [95% CI 1.25-5.62] and 4.81 [95% CI 1.38-16.72], respectively). The adjusted odds ratio for 1-hour delay in achieving hour-1 bundle components for in-hospital mortality was 1.28 (95% CI 1.04-1.57) by logistic regression analysis. Completion of the hour-1 bundle was associated with lower in-hospital mortality. Obtaining blood cultures and administering antibiotics within 1 hour may have been the components most contributing to decreased in-hospital mortality.

Knowledge and perceptions of antimicrobial resistance and antimicrobial stewardship among staff at a national cancer referral center in Uganda.

As access to cancer care has improved throughout sub-Saharan Africa, treatment-associated infections have increased. Assessing healthcare worker knowledge of antimicrobial stewardship and identifying the barriers to infection management will inform the development of contextually appropriate antimicrobial stewardship programs, improving cancer outcomes in sub-Saharan Africa. Cross-sectional survey. The Uganda Cancer Institute (UCI), a national cancer referral center in Kampala, Uganda. We surveyed 61 UCI staff: 29 nurses, 7 pharmacists, and 25 physicians. The survey contained 25 questions and 1 ranking exercise. We examined differences in responses by staff role. All 60 respondents who answered the question had heard the term "antimicrobial resistance." Only 44 (73%) had heard the term "antimicrobial stewardship." Nurses were less likely than pharmacists or physicians to be familiar with either term. Also, 41 respondents (68%) felt that loss of antibiotic susceptibility is a major issue at UCI. Regarding barriers to diagnosing infections, 54 (93%) of 58 thought that it was difficult to obtain blood cultures and 48 (86%) of 56 thought that it was difficult to regularly measure temperatures. Although most recognized the term "antimicrobial resistance," fewer were familiar with the term "antimicrobial stewardship." Inappropriate antibiotic use was recognized as a contributor to antimicrobial resistance, but hand hygiene was underrecognized as a contributing factor. We identified numerous barriers to diagnosing infections, including the ability to obtain blood cultures and consistently monitor temperatures. Educating staff regarding antimicrobial selection, allocating resources for blood cultures, and implementing strategies to enhance fever detection will improve infection management.

136. Attitudes and Practices of Antimicrobial Resistance and Antimicrobial Stewardship at the Uganda Cancer Institute

BackgroundAs access to cancer treatment has increased in sub-Saharan Africa (sSA), infection-related complications are a growing concern. Little is known about infection management practices in this setting. Understanding the unique challenges to diagnosing and treating infections can inform the development of targeted strategies to improve infection management for cancer treatment programs throughout sSA. MethodsWe conducted a cross-sectional survey of doctors, nurses, and pharmacists at the Uganda Cancer Institute (UCI), a national cancer referral hospital in Kampala, Uganda. The 25-item survey was designed to assess staff knowledge of antimicrobial resistance and antimicrobial stewardship, investigate antibiotic decision-making practices, and identify barriers to diagnosing and treating infections. ResultsOf the 61 respondents, 25 (41%) were doctors, 7 (11%) were pharmacists, and 29 (48%) were nurses. In total, 98% (60/61) had heard of the term “antimicrobial resistance” and 84% (51/61) agreed that antimicrobial resistance is an important problem at UCI. Multiple factors were felt to contribute to antimicrobial resistance including the use of too many antibiotics, patient insistence on antibiotics, and poor patient adherence (Fig 1). While 72% (44/61) had heard of the term “antimicrobial stewardship”, only 25% (15/61) knew a lot about what it meant. Numerous factors were considered important to antibiotic decision-making including patient white blood cell count and severity of illness (Fig 2). Perceived barriers to infection diagnosis included the inability to obtain blood cultures and to regularly measure patient temperatures; perceived barriers to obtaining blood cultures included patient cost and availability of supplies (Fig 3). Figure 1. Factors that doctors, pharmacists, and nurses working at the Uganda Cancer Institute (UCI) perceive as contributing to antimicrobial resistance at the UCI. Percentages shown next to bars represent the combined total percentage of respondents reporting that the factor does not or usually does not contribute (left of bars, main chart), occasionally or frequently contributes (right of bars, main chart), or neither contributes nor does not contribute (right of neutral chart).Figure 2. Factors that doctors, pharmacists, and nurses working at the Uganda Cancer Institute consider to be important when choosing antibiotics to treat infections. Percentages shown next to bars represent the combined total percentage of respondents reporting that the factor is somewhat or very unimportant (left of bars, main chart), somewhat or very important (right of bars, main chart), or neither important nor unimportant (right of neutral chart).Figure 3. Factors that doctors, pharmacists, and nurses working at the Uganda Cancer Institute perceive as limiting the ability to diagnose infections and obtain blood cultures. ConclusionWhile most staff recognized the term “antimicrobial resistance” and identified this as a major local problem, fewer were familiar with the term “antimicrobial stewardship”. We identified numerous perceived barriers to infection diagnosis and treatment, including the ability to consistently measure temperatures and the cost of blood cultures. A multipronged approach is needed to improve staff knowledge of antimicrobial stewardship and to address the systematic barriers to infection management at UCI. Disclosures All Authors: No reported disclosures

Retrospective evaluation of the utility of blood cultures in dogs (2009-2018): 45 cases.

There is no consensus on obtaining blood cultures routinely in companion animals with suspected sepsis, and there is a paucity of evidence concerning their utility. The objectives of this retrospective study were to determine the yield of positive blood cultures from hospitalized dogs, the prevalence of resistant bacteria, and the frequency and nature of changes to antimicrobial therapy once the culture result became available. Forty-five dogs had a blood culture submitted over a 10-year period, of which 9(20%) yielded positive growth and 36 (80%) yielded no bacterial growth. The most frequent reasons for submission of blood culture were pyrexia of unknown origin (n=14), suspected soft tissue infection (7), and suspected discospondylitis (7). The most frequent final diagnoses were soft tissue infection (n=11), discospondylitis (7), and unknown (6). No significant difference was found between the culture-positive versus culture-negative groups with regard to the most frequent reasons for blood culture (P=0.55), final diagnoses (P=0.80), survival until the blood culture result (P=0.37), or whether the infection was hospital- or community-acquired (P=0.99). There were significantly more immunosuppressed dogs in the culture-positive group (P=0.02). Resistance to one or more antimicrobials was documented in all dogs with susceptibility reported. In the culture-positive dogs, 63% had antimicrobial de-escalation and none had escalation, whereas 19% of the culture-negative dogs had de-escalation and 7% had escalation. Blood cultures were submitted infrequently, but the proportion of resistance was higher than expected and supports the use of blood cultures in cases of suspected infection resulting in bacteremia.

Increase of blood culture contamination during COVID-19 pandemic. A retrospective descriptive study

BackgroundSecondary bacterial infection during the care of coronavirus disease 2019 (COVID-19) patients poses risks to the patients, but there are concerns of an increase in blood culture contamination.MethodsA retrospective comparative study was conducted from April 1 to December 31, 2020, when the patients with COVID-19 were taken care of (pandemic period, PP), and it was compared with the same period in 2019 (pre-pandemic period, pre-PP).ResultsA total of 346 patients with COVID-19 were hospitalized during the study period in 2020. A total of 1,040 and 918 blood cultures were taken during PPP and PP respectively. 38 and 56 contaminations occurred during pre-PP and PP respectively (3.7% [95% CI 2.6%-5.0%], vs 6.1% [95% CI 4.6%-7.8%], P = .015). For the ICU, 10 and 32 contaminations occurred during the same periods (5.0% [95% CI 2.4%-9.0%], vs 12.5% [95% CI 8.7%-17.1%], P = .0097). True bacteremia in the ICU per patient-day also increased during the PP.ConclusionsWe found a significant increase in blood culture contamination during the COVID-19 pandemic in the ICU setting, while true bacteremia also increased. A safe and effective way to obtain blood cultures from patients with COVID-19 should be sought.

Use of a Three-Dimensionally Printed Model to Assist for Open Surgical Repair of Extensive Mycotic Superior Mesenteric Artery Aneurysm

We have described the utility of a three-dimensionally (3D) printed model in the surgical repair of an extensive mycotic superior mesenteric artery (SMA) aneurysm. A 62-year-old woman with no pertinent medical history had presented with a 2-week history of fever, abdominal pain, and diarrhea. Laboratory analysis demonstrated leukocytosis. Computed tomography angiography (CTA) revealed an SMA mycotic aneurysm with degeneration along its entire length and endometrial/myometrial inflammation. After obtaining blood cultures, endometrial biopsy, and initiating broad-spectrum antibiotics, the patient was scheduled for urgent aneurysm repair because of the risk of rupture.

Results of a Multicenter Diagnostic Stewardship Collaborative to Optimize Blood Culture Use in Critically Ill Children

Group Name: Bright STAR Authorship GroupBackground: Blood cultures are fundamental in the diagnosis and treatment of sepsis. Culture practices vary widely, and overuse can lead to false-positive results and unnecessary antibiotics. Our objective was to describe the implementation of a multisite quality improvement collaborative to reduce unnecessary blood cultures in pediatric intensive care unit (PICU) patients, and its 18-month impact on blood culture rates and safety metrics. Methods: In 2018, 14 PICUs joined the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children (Bright STAR) Collaborative, designed to understand and improve blood culture practices in critically ill children. Guided by a centralized multidisciplinary study team, sites first reviewed existing evidence for safe reduction of unnecessary blood cultures and assessed local practices and barriers to change. Subsequently, local champions developed and implemented clinical decision-support tools informed by local patient needs to guide new blood-culture practices. The coordinating study team facilitated regular evaluations and discussions of project progress through monthly phone calls, site visits if requested by sites or the study team, and collaborative-wide teleconferences. The study team collected monthly blood culture rates and monitored for possible delays in obtaining blood cultures using a standardized review process as a safety balancing metric. We compared 24 months of baseline data to 18 months of postimplementation using a Poisson regression model accounting for the site-specific patient days and correlation of culture use within a site over time. Results: Across the 14 sites, before implementation, 41,768 blood cultures were collected over 259,701 PICU patient days. The mean preimplementation site-specific blood culture rate was 15.7 cultures per 100 patient days (rate range, 9.6–48.2 cultures per 100 patient days). After implementation, 22,397 blood cultures were collected over 208,171 PICU patient days. The mean postimplementation rate was 10.4 cultures per 100 patient days (rate range, 4.7–28.3 cultures per 100 patient days), which was 33.6% lower than the preimplementation (relative rate 0.66; 95% CI, 0.65–0.68 p <0.01). In 18 months post-implementation, sites reviewed 793 positive blood cultures, and identified only one suspected delay in culture collection possibly attributable to the site’s blood culture reduction program. Conclusions: Multidisciplinary quality improvement teams safely facilitated a 33.6% average reduction in blood culture use in critically ill children at 14 hospitals. Future collaborative work will determine the impact of blood culture diagnostic stewardship on antibiotic use and other important patient safety outcomes.Funding: NoDisclosures: None

Use of a Clinical Audit System in Implementing Surviving Sepsis Campaign Guidelines in Patients With Peritonitis.

BackgroundSepsis is the predominant cause of morbidity and mortality in patients with peritonitis. "Surviving Sepsis Campaign" (SSC) is an international effort in reducing mortality based on evidence-based guidelines. This study aims to assess the impact of audit-based feedback in a Plan-Do-Study-Act (PDSA) format on improving the implementation of the SSC guidelines in patients with generalized peritonitis at our center.MethodsThis prospective observational study was conducted in four audit cycles in PDSA format. Multi-departmental inputs were taken to suggest modifications in practice. A questionnaire-based analysis of reasons for non-compliance was performed to find out the opinions and reasons for non-compliance. Morbidity, mortality, and the length of ICU and hospital stay among these patients were also analyzed.ResultsBaseline compliance with intravenous (IV) bolus administration, central venous pressure (CVP)-guided fluids, and inotropes support when indicated were 100%. Over the course of the three audit cycles, statistically significant improvement in compliance was noted for obtaining blood cultures before antibiotics, antibiotic administration within three hours of presentation, and serum lactate measurement. Overall bundle compliance improved from 9.2% to 64.7% by the end of audit cycle III.ConclusionsThis study demonstrates that audit-based feedback is a dependable means of improving compliance with SSC guidelines. It brings about improvement by educating users, modifying their behavior through feedback, and enhances process improvement by identifying and correcting systemic deficiencies in the organization.

COMPLIANCE TO SURVIVING SEPSIS CAMPAIGN HOUR–1 BUNDLE–A CROSS SECTIONAL STUDY AMONG PHYSICIANS INVOLVED IN CRITICAL CARE IN PAKISTAN

Objective: To determine physician’s compliance to surviving sepsis campaign updated Hour-one bundle incritically ill patients in Pakistan.
 Study Design: Cross-sectional study.
 Place and Duration of Study: Department of Anaesthesiology, Combined Military Hospital Lahore MedicalCollege, from Jun to Aug 2019.
 Methodology: This study was carried out among physicians managing critical patients in intensive care units.Participants were asked to fill out a 16-questions survey (work experience, qualification and individual components of surviving sepsis campaign hour-1 bundle. Data was collected using online access to survey and by sending hard copies.
 Results: Questionnaire was sent to 230 physicians while only 63 responses were received (response rate 27%).Only 45 (71%) respondents were aware of the updated Hour-1 bundle. There was no institutional protocolfor compliance to sepsis bundles in thirty three (55%) responses. 52% respondents used Systemic inflammatoryresponse syndrome (SIRS) criteria to diagnose sepsis while quick Sequential Organ Failure Assessment (qSOFA)was used by 36% respondents. Overall compliance to hour-1 bundle components was only 60%. Lactate levelswas not measured by 35 (55%) respondents while 24 (38%) did not obtain blood cultures before administeringantibiotics. Crystalloid and nor epinephrine was used by all respondents. Overall compliance with all the components of sepsis bundle had strong correlation with post-graduate qualification (p-value 0.001-0.049).
 Conclusion: Poor compliance to updated sepsis guidelines was one of the major reasons of high sepsis relatedmortality in Pakistan.

Compliance with the Surviving Sepsis Campaign guideline 1-hour bundle for septic shock in China in 2018.

BackgroundEffective implementation of the Surviving Sepsis Campaign (SSC) guidelines has effectively reduced sepsis mortality. The effects of hospital level and ownership on compliance with the SSC guideline 1-hour bundle (Cssc-1h) are unclear. We designed this study to identify the differences in Cssc-1h between secondary and tertiary hospitals, public hospitals, and private hospitals.MethodsIn this survey, 1,420 hospitals were enrolled, including 864 public tertiary hospitals, 482 public secondary hospitals, 34 private tertiary hospitals, 40 private secondary hospitals. The data were collected between January 1, 2018, and December 31, 2018. The outcomes were adherence to the SSC guidelines (2018 update). Monitoring indicators include 1-hour bundle and its sub-indicators (measure lactate level and remeasure lactate level if initial lactate is >2 mmol/L, obtain blood cultures before administering antibiotics, administer broad-spectrum antibiotics, begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L, apply vasopressor if hypotension is present during or after fluid resuscitation to maintain a mean arterial pressure ≥65 mmHg). Every monitoring indicator was stratified by the median, which is defined as 1 if greater than or equal to the median, and 0 if not.ResultsCssc-1h in tertiary hospitals was significantly higher than in secondary hospitals (P<0.05). However, there were no statistical differences in Cssc-1h in public hospitals and private hospitals.ConclusionsCssc-1h in tertiary hospitals was significantly better than that in secondary hospitals. There is an urgent need to improve Cssc-1h in secondary hospitals. The increase in private hospitals will not reduce Cssc-1h.

A Retrospective Study of the Optimal Number of Blood Cultures at a Hospital in Japan.

Blood culture tests have a major role in rapid and accurate diagnosis and selection of optimal antibiotic treatment for infectious diseases. The true-positive and contamination rates of blood cultures are performance indicators for the practice of blood culture. However, the optimal number of blood cultures has not been adequately elucidated. We aimed to assess the validity of the number of blood cultures obtained in the hospital. We conducted a retrospective study of blood cultures collected from hospitalized patients between 2010 and 2014 at a tertiary care hospital in Japan and assessed the validity of the number of blood cultures per 1,000 admissions as an indicator for the optimal practice of obtaining blood culture, considering the average length of stay. We also investigated the validity of true-positive and contamination rates of blood cultures in the hospital. The number of blood cultures in this study ranged from 28.6 to 56 per 1,000 patient-days and from 404.4 to 894.6 per 1,000 admissions. The median true-positive and contamination rates of blood cultures per year was 10.1% and 2.8%, respectively. The median contamination rate of blood cultures in a community-acquired group was significantly higher than that in a hospital-acquired group (4.1% vs. 1.9%, p = 0.029). We conclude that there is a possibility that the number of blood cultures per 1,000 admissions is a more appropriate factor to evaluate than per patient-days. Moreover, the true-positive and contamination rates of blood cultures in our hospital are valid.

265. Blood culture results pre- and post- antimicrobial administration in the Medicine Intensive Care Unit: a retrospective study in South Bronx

BackgroundIt is intuitive that obtaining blood cultures prior to administering antibiotics can increase the likelihood of a positive blood culture result. Surviving Sepsis Campaign Hour-1 bundle stipulates that obtaining a blood culture and administering antibiotics within 1 hour is a critical determinant of survival. However, the diagnostic sensitivity shortly after antibiotic administration remains unknown. In clinical practice, some health care providers delay antibiotic administration in order to first obtain a blood culture.MethodsAdult patients (> 18 years of age) admitted to the Medicine Intensive Care Unit in Lincoln Medical Center, located in South Bronx, New York City, from 09/2019 to 12/2019. Patients needed to have at least one blood culture obtained within 12 hours of admission and have received intravenous antibiotics during the admission to the Medicine Intensive Care Unit.ResultsOf 327 patients screened, 196 met enrolment criteria and 253 sets of blood cultures underwent analysis. Blood cultures grew bacteria in 21.8% of pre-antimicrobial group whereas 26.9% in post-antimicrobial group (p=0.37). 25.9% of patients received antibiotics within 1 hour before blood culture sampling, while 34.0% of patients received antibiotics >1 hour prior to obtaining blood culture. Blood culture results positive for coagulase-negative staphylococci were more prevalent in the pre-antimicrobial group.Table 1. Patient Characteristics Table 2. Number of blood cultures obtained and blood culture result Table 3. Initial antimicrobial agent and 30-day mortality ConclusionIn the sequence of blood culture and antibiotic administration, there is no 30-day survival difference in pre-antimicrobial group and post-antimicrobial group (p=0.15), as long as both received antibiotics within 12 hours of coming to the hospital. Coagulase-negative staphylococci were higher in the pre-antimicrobial group which may indicate that the health care provider hastily obtained the blood culture in a non-sterile manner. Antibiotic administration should not be delayed because of pending blood culture collection. In addition, given that more than 70% of patients were ultimately found to have negative blood cultures, it would be useful to develop practical tools to identify low-risk patients that can be treated without obtaining blood culture, as the blood culture would not be likely to provide diagnostic information.Figure 1: Hours Before and After IV Antibiotic Started Figure 2: Distribution of Blood Culture Before and After IV Antibiotics Disclosures All Authors: No reported disclosures

Elevated bands as a predictor of bloodstream infection and in-hospital mortality.

Although >10% bands on a CBC has been a part of the definition for sepsis, scant data exists regarding the clinical significance of lower percentages of bands. Our aim was to determine whether any associations exist between percentage of bands on an initial CBC and likelihood of a bloodstream infection and in-hospital mortality. We performed a retrospective study of emergency department adults from January 1, 2016 to September 1, 2019 who had a CBC with manual differential and blood cultures obtained during their initial evaluation. Band percentages were grouped into zero (0% bands), minimal (1-2% bands), mild (3-4% bands), moderate (5-10% bands) and high (>10% bands). The primary outcomes were bloodstream infections and in-hospital mortality. Increasing rates of bloodstream infections were observed as bands went from zero (95% CI: 9.3%-10.5%) to minimal (17.5%-19.1%, p<0.0001), minimal to mild (19.2%-22.0%, p=0.0039), mild to moderate (23.5%-26.7%, p<0.0001), and moderate to high (33.0%-37.4%, p<0.0001). Similar observations were seen when comparing mortality. The most common bloodstream infections were due to Gram-negative bacilli. Elevated bands on an initial CBC were correlated with the likelihood of a concurrent bloodstream infection and in-hospital mortality, even at levels below 10%. Our results suggest that clinical suspicion for a bloodstream infection due to Gram-negative bacilli should rise if bands are elevated on an initial CBC. Therefore, clinicians should consider obtaining blood cultures if bands are elevated on an initial CBC.

Healthcare Utilization Patterns for Acute Febrile Illness in Bangladesh, Nepal, and Pakistan: Results from the Surveillance for Enteric Fever in Asia Project.

BackgroundCharacterizing healthcare-seeking patterns for acute febrile illness is critical for generating population-based enteric fever incidence estimates from facility-based surveillance data.MethodsWe used a hybrid model in the Surveillance for Enteric Fever in Asia Project (SEAP) to assess incidence of enteric fever at 6 study hospitals in 3 countries. We recruited individuals presenting to the hospitals and obtained blood cultures to evaluate for enteric fever. For this analysis, we undertook cluster random household surveys in Dhaka, Bangladesh (2 sites); Karachi, Pakistan; Kathmandu, Nepal; and Kavrepalanchok, Nepal between January 2017 and February 2019, to ascertain care-seeking behavior for individuals with 1) fever for ≥3 consecutive days within the past 8 weeks; or 2) fever resulting in hospitalization within the past year. We also collected data about disease severity and household demographics and assets. We used mixed-effect multivariable logistic regression models to identify determinants of healthcare seeking at study hospitals and determinants of culture-confirmed enteric fever.ResultsWe enrolled 31 841 households (53 926 children) in Bangladesh, 25 510 households (84 196 children and adults) in Nepal, and 21 310 households (108 031 children and adults) in Pakistan. Children <5 years were most likely to be taken to the study hospitals for febrile illness at all sites. Household wealth was positively correlated with healthcare seeking in 4 of 5 study sites, and at least one marker of disease severity was positively associated with healthcare seeking in 3 of 5 catchment areas. Wealth and disease severity were variably predictive of blood culture-confirmed enteric fever.ConclusionsAge, household wealth, and disease severity are important determinants of healthcare seeking for acute febrile illness and enteric fever risk in these communities, and should be incorporated into estimation models for enteric fever incidence.