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

Matthew P. Cheng; Robert Stenstrom; Katryn Paquette; Sarah N. Stabler; Murtaza Akhter; Adam C. Davidson; Marko Gavric; Alexander Lawandi; Rehman Jinah; Zahid Saeed; Koray Demir; Kelly Huang; Amirali Mahpour; Chris Shamatutu; Chelsea Caya; Jean-Marc Troquet; Greg Clark; Cedric P. Yansouni; David Sweet

doi:10.7326/M19-1696

Original Research |15 October 2019

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

Matthew P. Cheng, MD; Robert Stenstrom, MD, PhD; Katryn Paquette, MD; Sarah N. Stabler, PharmD; Murtaza Akhter, MD; Adam C. Davidson, MD; Marko Gavric, BSc; Alexander Lawandi, MD; Rehman Jinah, BSc; Zahid Saeed, MD; Koray Demir, MD; Kelly Huang, BSc; Amirali Mahpour, MD; Chris Shamatutu, BSc; Chelsea Caya, MSc; Jean-Marc Troquet, MD; Greg Clark, MD; Cedric P. Yansouni, MD; David Sweet, MD; for the FABLED Investigators *

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

Article, Author, and Disclosure Information

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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