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GUEST EDITORIAL
Optimising blood cultures: The interplay between
diagnostic and antimicrobial stewardship

Antimicrobial resistance (AMR), and espe­ In this issue of CME, Papavarnavas et al.[8]
cially bacterial resistance to antibiotics, provide a timely update to the guidelines
threaten our ability to provide a modern for optimal use of blood cultures published
health service, posing a high risk of morbidity in 2010.[9] Over the past decade, definitions
and mortality for common infections. of sepsis have altered[10] and advances in
Following publication by the Global Research understanding of the use of blood cultures
on Antimicrobial Resistance (GRAM) project, have been made. A common question that
we now have a far more accurate assessment remains is whether blood cultures influence
of mortality from AMR than the oft-quoted patient management. The answer is yes,
estimate of 10 million excess deaths by 2050.[1] including in our local context, where blood
In 2019, 4.95 million people worldwide died cultures taken from patients attending two
with an antimicrobial-resistant infection, and emergency departments in Cape Town
1.27 million of those – more than HIV and hospitals, as part of an observational
malaria combined – died as a direct result of cohort study, demonstrated that positive
resistance.[2] blood culture results influenced patient
The estimate was derived from statistical management in 95% of cases, when a
modelling of over 470 million pieces of data. pathogen was isolated. The pathogen was
However, it is widely recognised that data resistant to the empirical antibiotic choice in
from low- and middle-income countries are a quarter of cases.[11]
missing and that the true number of deaths Importantly, Boyles et al.[11] also demon­ Nectarios S Papavarnavas,
is much greater. Missing data talks to a strated that the amount of blood drawn Marc Mendelson
lack of laboratory infrastructure and access can significantly affect sensitivity. For Division of Infectious Diseases and HIV
to laboratories that are set up to perform adult blood culture bottles, culturing Medicine, Department of Medicine, Faculty
microbiological tests in low-resource <8 mL of blood was predictive of a of Health Sciences, University of Cape Town
settings. However, access is not the only negative result. Poor technique also ena­ and Groote Schuur Hospital, Cape Town,
issue. ‘Diagnostic stewardship’ – the optimal bles contamination of the blood culture South Africa
use of diagnostic tests to enhance infection bottles with skin commensals, so the [email protected]
management – requires intent. Even in high- addition to these updated guidelines of a
income countries such as the UK, where video describing the correct step-by-step
1. O’Neill J. Review on Antimicrobial Resistance. Tackling drug-
access to laboratories is not an issue, intent is procedure for taking an optimal blood resistant infections globally: Final report and recommendations.
May 2016. https://amr-review.org/sites/default/files/160525_
often lacking; fewer than one-fifth of patients culture is to be welcomed. Contamination Final%20paper_with%20cover.pdf (accessed 23 March 2022).
hospitalised for COVID-19 underwent a of blood cultures comes at a cost, not 2. Antimicrobial Resistance Collaborators. Global burden of
bacterial antimicrobial resistance in 2019: A systematic analysis.
diagnostic test for bacterial coinfection, yet only to infection management but to Lancet 2022;399(10325):629-655. https://doi.org/10.1016/
61 - 100% of admitted patients received an the health service as well. A study from S0140-6736(21)02724-0
3. Russell CD, Fairfield CJ, Drake TM, et al. Co-infections,
antibiotic.[3-5] Western Cape Province analysed direct secondary infections, and antimicrobial use in patients
Bloodstream infections are an important item and laboratory expenses in relation hospitalised with COVID-19 during the first pandemic wave
from the ISARIC WHO CCP-UK study: A multicentre,
contributor to global mortality, with an to contaminated cultures.[12] It found that prospective cohort study. Lancet Microbe 2021;2(8):e354-e365.
https://doi.org/10.1016/S2666-5247(21)00090-2
overall crude mortality rate of 15 - 30%. [6,7] associated with a 2.2 - 4.5% monthly 4. Rawson TM, Moore LSP, Zhu N, et al. Bacterial and fungal
Blood cultures play an important role in contamination rate reported at the National coinfection in individuals with coronavirus: A rapid review to
support COVID-19 antimicrobial prescribing. Clin Infect Dis
optimising the use of antimicrobials by Health Laboratory Service laboratory at 2020;71(9):2459-2468. https://doi.org/10.1093/cid/ciaa530
defining the pathogen responsible for Groote Schuur Hospital, Cape Town, was 5. ISARIC Clinical Characterisation Group, Baillie JK, Baruch J,
Beane A, et al. ISARIC COVID-19 Clinical Data Report issued:
infection, particularly when patients present a total cost of ZAR1 017 576 over 3 years. 27 March 2022. medRxiv 2022 (epub 13 April 2022). https://doi.
with undifferentiated febrile syndromes Tertiary-level hospitals were responsible org/10.1101/2020.07.17.20155218
6. Goto M, Al-Hasan MN. Overall burden of bloodstream
where a focus of infection is not apparent. for almost half of contaminated culture infection and nosocomial bloodstream infection in North
America and Europe. Clin Microbiol Infect 2013;19(6):501-509.
Furthermore, once cultured, antimicrobial bottles. https://doi.org/10.1111/1469-0691.12195
susceptibility testing can be performed, Optimising blood cultures is a critical 7. Dat VQ, Vu HN, Nguyen The H, et al. Bacterial bloodstream
infections in a tertiary infectious diseases hospital in Northern
enabling de-escalation of antimicrobial part of diagnostic stewardship, which in Vietnam: Aetiology, drug resistance, and treatment outcome.
choice, from a broad-spectrum empirical turn optimises antimicrobial stewardship BMC Infect Dis 2017;17(1):493. https://doi.org/10.1186/s12879-
017-2582-7
antimicrobial to a narrow-spectrum choice. and the management of infection. Knowing 8. Papavarnavas N, Brink AJ, Dlamini S, et al. Guideline to optimise
De-escalation reduces the risk of selection of when and how to use blood cultures in the performance and interpretation of blood cultures: 2022
update. S Afr Med J 2022;112(6):397-402. https://doi.org/10.7196/
antimicrobial-resistant pathogens and that daily practice and, critically, getting the SAMJ.2022.v112i6.16537
9. Ntusi N, Aubin L, Oliver S, Whitelaw A, Mendelson M.
of infection with Clostridiodes difficile, hence technique right, are imperative if this Guideline for the optimal use of blood cultures. S Afr Med J
limiting collateral damage. valuable tool is to prove its worth. 2010;100(12):839-843.

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10. Evans L, Rhodes A, Alhazzani W, et al. Executive summary: Surviving Sepsis Campaign: International 12. Opperman CJ, Baloyi B, Dlamini S, Samodien N. Blood culture contamination rates at different level
guidelines for the management of sepsis and septic shock 2021. Crit Care Med 2021;49(11):1974-1982. healthcare institutions in the Western Cape, South Africa. S Afr J Infect Dis 2020;35(1):a222. https://
https://doi.org/10.1097/CCM.0000000000005357. Erratum in: Crit Care Med 2022;50(4):e413-e414. doi.org/10.4102/sajid.v35i1.222
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11. Boyles TH, Davis K, Crede T, et al. Blood cultures taken from patients attending emergency
departments in South Africa are an important antibiotic stewardship tool, which directly influences
patient management. BMC Infect Dis 2015;15:410. https://doi.org/10.1186/s12879-015-1127-1 S Afr Med J 2022;112(6):395-396. https://doi.org/10.7196/SAMJ.2022.v112i6.16557

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