Original Research
17 September 2019

Blood Culture Results Before and After Antimicrobial Administration in Patients With Severe Manifestations of Sepsis: A Diagnostic Study

Publication: Annals of Internal Medicine
Volume 171, Number 8
Visual Abstract. Blood Cultures Before and After Antimicrobial Therapy in Septic Patients Although prompt antibiotic treatment of patients with sepsis improves outcomes, treatment before blood cultures are obtained may reduce the accuracy and utility of microbiological data. This prospective investigation evaluated whether the sensitivity of blood cultures was altered when they were obtained after antibiotic administration. </TOC Summary>
Visual Abstract. Blood Cultures Before and After Antimicrobial Therapy in Septic Patients
Although prompt antibiotic treatment of patients with sepsis improves outcomes, treatment before blood cultures are obtained may reduce the accuracy and utility of microbiological data. This prospective investigation evaluated whether the sensitivity of blood cultures was altered when they were obtained after antibiotic administration. </TOC Summary>

Abstract

Background:

Administering antimicrobial agents before obtaining blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear how this strategy affects diagnostic sensitivity.

Objective:

To determine the sensitivity of blood cultures obtained shortly after initiation of antimicrobial therapy in patients with severe manifestations of sepsis.

Design:

Patient-level, single-group, diagnostic study. (ClinicalTrials.gov: NCT01867905)

Setting:

7 emergency departments in North America.

Participants:

Adults with severe manifestations of sepsis, including systolic blood pressure less than 90 mm Hg or a serum lactate level of 4 mmol/L or more.

Intervention:

Blood cultures were obtained before and within 120 minutes after initiation of antimicrobial treatment.

Measurements:

Sensitivity of blood cultures obtained after initiation of antimicrobial therapy.

Results:

Of 3164 participants screened, 325 were included in the study (mean age, 65.6 years; 62.8% men) and had repeated blood cultures drawn after initiation of antimicrobial therapy (median time, 70 minutes [interquartile range, 50 to 110 minutes]). Preantimicrobial blood cultures were positive for 1 or more microbial pathogens in 102 of 325 (31.4%) patients. Postantimicrobial blood cultures were positive for 1 or more microbial pathogens in 63 of 325 (19.4%) patients. The absolute difference in the proportion of positive blood cultures between pre- and postantimicrobial testing was 12.0% (95% CI, 5.4% to 18.6%; P < 0.001). Sensitivity of postantimicrobial culture was 52.9% (CI, 42.8% to 62.9%). When the results of other microbiological cultures were included, microbial pathogens were found in 69 of 102 (67.6% [CI, 57.7% to 76.6%]) patients.

Limitation:

Only a proportion of screened patients were recruited.

Conclusion:

Among patients with severe manifestations of sepsis, initiation of empirical antimicrobial therapy significantly reduces the sensitivity of blood cultures drawn shortly after treatment initiation.

Primary Funding Source:

Vancouver Coastal Health, St. Paul's Hospital Foundation Emergency Department Support Fund, the Fonds de recherche Santé–Québec, and the Maricopa Medical Foundation.

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Supplemental Material

Supplement. Supplementary Material.

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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 171Number 815 October 2019
Pages: 547 - 554

History

Published online: 17 September 2019
Published in issue: 15 October 2019

Keywords

Authors

Affiliations

Matthew P. Cheng, MD
Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (M.P.C.)
Robert Stenstrom, MD, PhD
University of British Columbia, St. Paul's Hospital, and the Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada (R.S.)
Katryn Paquette, MD
Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada (K.P.)
Sarah N. Stabler, PharmD
Surrey Memorial Hospital, University of British Columbia, Surrey, British Columbia, Canada (S.N.S.)
Murtaza Akhter, MD
University of Arizona College of Medicine, Phoenix, Arizona (M.A.)
Adam C. Davidson, MD
University of British Columbia and Lion's Gate Hospital, Vancouver, British Columbia, Canada (A.C.D.)
Marko Gavric, BSc
University of British Columbia, Vancouver, British Columbia, Canada (M.G., R.J., K.H., C.S.)
Alexander Lawandi, MD
McGill University Health Centre, McGill University, Montreal, Quebec, Canada (A.L., K.D., C.C., J.T., G.C., C.P.Y.)
Rehman Jinah, BSc
University of British Columbia, Vancouver, British Columbia, Canada (M.G., R.J., K.H., C.S.)
Zahid Saeed, MD
Banner University Medical Center, Phoenix, Arizona (Z.S.)
Koray Demir, MD
McGill University Health Centre, McGill University, Montreal, Quebec, Canada (A.L., K.D., C.C., J.T., G.C., C.P.Y.)
Kelly Huang, BSc
University of British Columbia, Vancouver, British Columbia, Canada (M.G., R.J., K.H., C.S.)
Amirali Mahpour, MD
London Health Sciences Centre, London, Ontario, Canada (A.M.)
Chris Shamatutu, BSc
University of British Columbia, Vancouver, British Columbia, Canada (M.G., R.J., K.H., C.S.)
Chelsea Caya, MSc
McGill University Health Centre, McGill University, Montreal, Quebec, Canada (A.L., K.D., C.C., J.T., G.C., C.P.Y.)
Jean-Marc Troquet, MD
McGill University Health Centre, McGill University, Montreal, Quebec, Canada (A.L., K.D., C.C., J.T., G.C., C.P.Y.)
Greg Clark, MD
McGill University Health Centre, McGill University, Montreal, Quebec, Canada (A.L., K.D., C.C., J.T., G.C., C.P.Y.)
Cedric P. Yansouni, MD
McGill University Health Centre, McGill University, Montreal, Quebec, Canada (A.L., K.D., C.C., J.T., G.C., C.P.Y.)
David Sweet, MD
University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada (D.S.)
for the FABLED Investigators
Financial Support: By Vancouver Coastal Health, St. Paul's Hospital Foundation Emergency Department Support Fund, the Fonds de Recherche Santé–Québec, and the Maricopa Medical Foundation.
Disclosures: Dr. Akhter reports grants from Maricopa Medical Foundation during the conduct of the study. Dr. Yansouni reports grants from bioMérieux outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-1696.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Data Sharing Statement: The following data and supporting documents will be made available with publication: deidentified participant data, data dictionary, and statistical/analytic code (contact Matthew P. Cheng; e-mail, [email protected]). These data will be made available to researchers whose proposed use of the data has been approved, for a specified purpose, with investigator support and with a signed data access agreement (restrictions: none).
Corresponding Author: Matthew P. Cheng, MD, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, PBB-A4, Boston, MA 02115; e-mail, [email protected].
Current Author Addresses: Dr. Cheng: Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, PBB-A4, Boston, MA 02115.
Dr. Stenstrom: St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V1S1Y1, Canada.
Dr. Paquette: Montreal Children's Hospital, 1001 boul Décarie, B05.2043, Montreal, Quebec H4A 3J1, Canada.
Dr. Stabler: Surrey Memorial Hospital, 13750 96th Avenue, Surrey, British Columbia V3V 1Z2, Canada.
Dr. Akhter: Maricopa Integrated Health System, 2601 East Roosevelt Street, Phoenix, AZ 85008.
Dr. Davidson: Lions Gate Hospital, 231 East 15th Street, North Vancouver, British Columbia V7L-2L7, Canada.
Mr. Gavric: 1908 Scotia Street, Vancouver, British Columbia V5T0E8, Canada.
Drs. Lawandi, Demir, and Yansouni and Ms. Caya: McGill University Health Centre, 1001 boul Décarie, Glen Site Block E, Montreal, Quebec H4A 3J1, Canada.
Drs. Jinah and Sweet: Vancouver General Hospital, 899 West 12th Avenue, Intensive Care Unit JPN2, Room 2438, Vancouver, British Columbia V5Z 1M9, Canada.
Dr. Saeed: Banner University Medical Center, 1111 East McDowell Road, Phoenix, AZ 85006.
Dr. Huang: Vancouver General Hospital, 899 West 12th Avenue, Vancouver, British Columbia V5Z 1M9, Canada.
Dr. Mahpour: London Health Sciences Centre, 1151 Richmond Street, London, Ontario N6A4V2, Canada.
Mr. Shamatutu: University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, British Columbia V6T 1Z3, Canada.
Dr. Troquet: McGill University Health Centre, 1001 boul Décarie, CS1.6143, Montreal, Quebec H4A 3J1, Canada.
Dr. Clark: McGill University Health Centre, 1001 boul Décarie, CS1.6224, Montreal, Quebec H4A 3J1, Canada.
Author Contributions: Conception and design: M.P. Cheng, R. Stenstrom, K. Paquette, A. Mahpour, J.-M. Troquet, C. Yansouni, D. Sweet.
Analysis and interpretation of the data: M.P. Cheng, R. Stenstrom, K. Paquette, Z. Saeed, C. Caya, C. Yansouni, D. Sweet.
Drafting of the article: M.P. Cheng, R. Stenstrom, K. Paquette, R. Jinah, Z. Saeed, C. Yansouni, D. Sweet.
Critical revision of the article for important intellectual content: M.P. Cheng, R. Stenstrom, K. Paquette, S.N. Stabler, M. Akhter, A. Lawandi, C. Caya, J.-M. Troquet, C. Yansouni, D. Sweet.
Final approval of the article: M.P. Cheng, R. Stenstrom, K. Paquette, S.N. Stabler, M. Akhter, A.C. Davidson, M. Gavric, A. Lawandi, R. Jinah, Z. Saeed, K. Demir, K. Huang, A. Mahpour, C. Shamatutu, C. Caya, J.-M. Troquet, G. Clark, C. Yansouni, D. Sweet.
Provision of study materials or patients: R. Stenstrom, S.N. Stabler, M. Akhter, A.C. Davidson, R. Jinah, K. Huang, A. Mahpour, C. Shamatutu, C. Caya, J.-M. Troquet, G. Clark, C. Yansouni, D. Sweet.
Statistical expertise: R. Stenstrom, K. Paquette, C. Caya, D. Sweet.
Obtaining of funding: R. Stenstrom, M. Akhter, Z. Saeed, C. Yansouni, D. Sweet.
Administrative, technical, or logistic support: R. Stenstrom, A.C. Davidson, R. Jinah, Z. Saeed, K. Huang, C. Shamatutu, C. Caya, J.-M. Troquet, G. Clark, D. Sweet.
Collection and assembly of data: M.P. Cheng, R. Stenstrom, S.N. Stabler, M. Akhter, A.C. Davidson, M. Gavric, A. Lawandi, R. Jinah, Z. Saeed, K. Demir, K. Huang, A. Mahpour, C. Shamatutu, G. Clark, C. Yansouni, D. Sweet.
This article was published at Annals.org on 17 September 2019.
* For members of the FABLED Investigators, see the Appendix.

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Matthew P. Cheng, Robert Stenstrom, Katryn Paquette, et al; for the FABLED Investigators . Blood Culture Results Before and After Antimicrobial Administration in Patients With Severe Manifestations of Sepsis: A Diagnostic Study. Ann Intern Med.2019;171:547-554. [Epub 17 September 2019]. doi:10.7326/M19-1696

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