The review panel found one study showing that the two-day mortality for patients with community-acquired bacteremia was 4.8 percent compared to 2.0 percent in culture-negative patients (0–2-day mortality rate ratio 1.9). After the first two days, mortality rates were 3.7 percent and 2.7 percent, respectively, with a mortality rate ratio of 1.1. At 30 days, the mortality in both culture-positive and culture-negative patients was approximately 10 percent, with no significant difference in mortality between the groups.3 However, this study included patients who had blood cultures performed within two days of hospital admission and who had no hospitalizations within the preceding 30 days, so the results may not necessarily apply to emergency department patients such as those presented in this review. This study also noted that as many as half of positive cultures were due to organisms inoculated from the skin into culture bottles at the time of sample collection and did not reflect true bacteremia. These false-positive blood culture results from skin contaminants may lead to unnecessary investigations and treatments.
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ACEP Now: Vol 36 – No 05 – May 20173. Retrospective Bias
The Standard of Care Review Panel believed that the expert’s opinions in this case were influenced by retrospective bias. The expert repeatedly stated that the treating physician should have known that the patient was bacteremic because the culture results returned positive. However, the preliminary culture results did not return until the following day. There is no way that the treating physician could have known the culture results at the time of treatment. It was the consensus of the Standard of Care Review Panel that strict prospective analysis is of utmost importance when reviewing the management of any patient care.
Conclusion
It was the consensus opinion of the review panel that obtaining Blood Cultures does not mandate antibiotic treatment or hospital admission.
Dr. Sullivan is clinical assistant professor emergency medicine at the University of Illinois at Chicago, attending physician at St. Margaret’s Hospital in Spring Valley, Illinois, and owner of Sullivan Law Office in Frankfort, Illinois.
Dr. Marco is professor of emergency medicine at Wright State University Boonshoft School of Medicine in Dayton, Ohio.
Dr. Solomon is an attending physician at UPMC St. Margaret in Pittsburgh.
References
- Coburn B, Morris AM, Tomlinson G, et al. Does this adult patient with suspected bacteremia require blood cultures? JAMA. 2012;308(5):502-511.
- Patel G, Kohlhoff S, Tejani N, et al. Evaluation of pediatric blood culture ordering practice in post-pneumococcal vaccination era in emergency department. Poster abstract presented at: IDWeek 2012; Oct. 18, 2012; San Diego. Accessed Feb. 17, 2017.
- Søgaard M, Nørgaard M, Pedersen L, et al. Blood culture status and mortality among patients with suspected community-acquired bacteremia: a population-based cohort study. BMC Infect Dis. 2011;11:139.
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5 Responses to “Should Emergency Department Patients with Pending Blood Cultures be Admitted?”
May 19, 2017
Christopher DarlingtonReally interesting read, thank you.
May 21, 2017
Robert J Halpern, MDThis article is especially important due to the advent of the surviving Sepsis campaigns. Early evaluation and treatment of sepsis has developed into protocols where blood cultures and lactate are obtained before the full clinical spectrum of the illness has been obtained.
Frequently we find that the patient has had blood cultures drawn, but subsequently the WBC does not support the diagnosis of Sepsis, or perhaps the patient has uncomplicated sepsis, and can be treated as an outpatient. The admission of all patients having had blood cultures drawn would be lead to untenable utilization of hospital beds, and untold illness of hospital acquired illnesses.
This admission of patients with blood cultures reflects the same unsupported dogma that a patient who receives parenteral antibiotics in the ED must be admitted.
May 21, 2017
Kathryn C. Peilen, MDMany blood cultured are ordered at triage as part of a triage protocol in order to meet (now antiquated) joint commission guidelines for pneumonia, etc. Often, full assessment of the patient indicates that bacteremia is unlikely, but the blood cultures have already been set up and the order is never removed (many EMR systems make deleting orders difficult.) On the other hand, no information was given about the liver function of this patient with history of Hepatitis C–patients with advanced liver disease are often immunocompromised.
May 21, 2017
Roderick FontenetteI guess the bigger question is why are we ordering blood cultures on patients we plan to discharge?
May 22, 2017
Tom BenzoniWell, yeah.
We know blood cultures are useless most of the time and order them only because we’re mandated to so do.
When we know the patient is ill, we order them and admit.
Most blood cultures ordered over my signature are too satisfy a process measure, not to improve patient care.