BLOOD CULTURING�using automation

BLOOD CULTURING�using automation

1. BLOOD CULTURING using automation Dr.T.V.Rao MD Dr.T.V.Rao MD 1 2/9/2016

2. Need for Blood Culture? No microbiological test is more essential to the clinician than the blood culture. The finding of pathogenic microorganisms in a patient’s bloodstream is of great importance in terms of diagnosis, prognosis, and therapy.” - L. Barth Reller, Clin. Infect. Diseases, 1996 Dr.T.V.Rao MD 2 2/9/2016

3. Dr.T.V.Rao MD 3 2/9/2016

4. Sources of Bacteremia Spread Pericarditis and Peritonitis Pneumonias Pressure sores Prosthetic medical devices Total hip replacement Skeletal system Skin and soft tissue Dr.T.V.Rao MD 4 2/9/2016

5. Blood culturing most important and life saving Investigation Needs optimal Methods for Diagnosis of Blood Borne Pathogens Dr.T.V.Rao MD 5 2/9/2016

6. Blood Collection Aseptic collection procedure is critical Amount of blood 1:10 ratio of blood to broth Younger than 10 years – 1 ml of blood for every year of life Over 10 years – 20 ml Dr.T.V.Rao MD 6 2/9/2016

7. Blood Collection Frequency of Collection Depends if bacteremia is transient, intermediate or continuous Number of cultures collected are usually inversely related to the type of bacteremia Usually x3 from different body sites Dr.T.V.Rao MD 7 2/9/2016

8. Venipuncture Venipuncture is the process of obtaining intravenous access for the purpose of intravenous therapy or obtaining a sample of venous blood. This procedure is performed by medical laboratory scientists, medical practitioners, some EMTs, paramedics phlebotomists and other nursing staff. Venipuncture is one of the most routinely performed invasive procedures and is carried out for two reasons, to obtain blood for diagnostic purposes or to monitor levels of blood components (Lavery & Ingram 2005). Dr.T.V.Rao MD 8 2/9/2016

9. LABELING THE SAMPLE P roperly labelled sample is essential so that the results of the test match the patient. The key elements in labelling are: Patient's surname, first and middle. Patient's ID number. NOTE: Both of the above MUST match the same on the requisition form. Date, time and initials of the phlebotomist must be on the label of EACH tube. Dr.T.V.Rao MD 9 2/9/2016

10. Principles for Collection Gloves will be worn in accordance with standard precautions. •Appropriate verification of the patient's identity, by means of an armband or area specific procedure, will occur before the specimen collection. •Cultures should be drawn before administration of antibiotics, if possible . ??? • blood cultures should be drawn from lines, but should be drawn viavenipuncture. Dr.T.V.Rao MD 10 2/9/2016

11. The requisitions form should be completely filled out, and the requisition must indicate the tests ordered . Dr.T.V.Rao MD 11 2/9/2016

12. Self Protection A few ways to make sure your role in the collection process is carried out with efficiency, orderliness and safety Dr.T.V.Rao MD 12 2/9/2016

13. Steps 1 – 3, Check, Explain, Wash 1.Identify the patient 2.Explain the procedure to the patient. 3.Wash hands with soap and water with friction for 15 seconds or use alcohol based hand rub Dr.T.V.Rao MD 13 2/9/2016

14. Materials Chlorhexidine swabs (1-2 packages) Alcohol swabs Blood culture bottles (2 bottles per set) 2 syringes (adult: 20 cc, paediatric: 5 cc) 2 needles (adult: 22 gauge or preferably larger butterfly or standard needle; pediatric: 25 or 23 gauge butterfly or standard needle ) Gloves (sterile &nonsterile) Tourniquet Sterile gauze pad Adhesive strip or tape Self-sticking patient labels Plastic zip lock specimen bags Dr.T.V.Rao MD 14 2/9/2016

15. . Barrier protection for the phlebotomist consists of the latex gloves . Dr.T.V.Rao MD 15 2/9/2016

16. Obtaining Blood Locate the vein Prep kit Alcohol 5 sec. Dry 30-60 sec ( resource poor conditions ) Ideal to collect with alcohol swabs containing 2% Chlorhexidine and 70% isopropyl alcohol Remove caps, clean with alcohol Put on gloves Without palpating, draw 20 ml and put 10 in anaerobic and 10 in aerobic bottle Dispose of syringe in sharps container Label bottles and send to lab Dr.T.V.Rao MD 16 2/9/2016

17. Method of B lood Collection A minimum of 10 ml of blood is taken through venipuncture and injected into two or more "blood bottles" with specific media for aerobic and anaerobic organisms. The blood is collected using clean technique. This requires that both the tops of the culture bottles and the venipuncture site of the patient are cleaned prior to collection with alcohol swabs containing 2% Chlorhexidine and 70% isopropyl alcohol. Dr.T.V.Rao MD 17 2/9/2016

18. The area of skin is cleaned with a disinfectant, or an alcohol swab. Using sterile gloves, do not wipe away the surgical solution, touch the puncture site, or in any way compromise the sterile process. It is vital that the procedure is performed in as sterile a manner as possible as the persistent presence of skin commensals in blood cultures could indicate endocarditis but they are most often found as contaminants Dr.T.V.Rao MD 18 2/9/2016

19. The vein is anchored and the needle is inserted. Dr.T.V.Rao MD 19 2/9/2016

20. The vacutainer tube is depressed into the needle to begin drawing blood Dr.T.V.Rao MD 20 2/9/2016

21. Additional vacutainer tubes can be utilized. Determine what tests are ordered and what tubes will be necessary BEFORE you begin to draw blood, and determine the order of draw for the tubes. . Dr.T.V.Rao MD 21 2/9/2016

22. When the final tube is being drawn, release the tourniquet. Then remove the tube, and remove the needle. Dr.T.V.Rao MD 22 2/9/2016

23. After the needle is removed from the vein, apply firm pressure over the site to achieve haemostasis . Dr.T.V.Rao MD 23 2/9/2016

24. Apply a bandage to the area. Dr.T.V.Rao MD 24 2/9/2016

25. Preparation of Cap before Injecting Blood Prep the rubber cap of the blood culture bottles with an alcohol pad in a circular motion. Allow the alcohol to dry. Dr.T.V.Rao MD 25 2/9/2016

26. Inject the Blood ….. Inject the blood into the Selected Media Gently rotate the bottles to mix the blood & the broth (do not shake vigorously). Dr.T.V.Rao MD 26 2/9/2016

27. Follow the universal precautions when disposing Needle Dispose of needle in sharps container and dispose of other waste in proper container Dr.T.V.Rao MD 27 2/9/2016

28. Label the tubes, checking the requisition for the proper identification . Dr.T.V.Rao MD 28 2/9/2016

29. Give the all possible Medical Information Patient’s name • Hospital number (Patient ID) • Patient’s location (room and bed #) • Date and time of collection • Collector’s initials • Site of venipuncture • Or other information as per facility Include you Mobile Contact No – A vital information can be delivered any time Dr.T.V.Rao MD 29 2/9/2016

30. Document the Medical Records Document the following in the medical record: –Date & time specimen obtained –Site of specimen collectio n Dr.T.V.Rao MD 30 2/9/2016

31. Frequency of Collection Frequency of Collection Depends if bacteremia is transient, intermediate or continuous Number of cultures collected are usually inversely related to the type of bacteremia Usually x3 from different body sites Dr.T.V.Rao MD 31 2/9/2016

32. Second Set If 2 or more sets of blood cultures have been ordered, obtain the second set in the same manner as the first, making a new venipuncture at a different site . Dr.T.V.Rao MD 32 2/9/2016

33. Bacteria and Fungi Are Identified by Phenotypic Characters Dr.T.V.Rao MD 33 2/9/2016

34. Biochemical Tests gives Better Clues in Identification Dr.T.V.Rao MD 34 2/9/2016

35. Newer Blood Culture Methods Newer Blood Culture Systems Biphasic Broth-Slide System Agar “paddles” attached to top of bottle Closed system Continuous Monitoring Blood Culture Systems BacTec – measures 14CO2 BacTec 9000 Series – measures CO2 ESP – measures consumption of gases BacT-Alert – measures change in pH Dr.T.V.Rao MD 35 2/9/2016

36. Newer Technologies available at our Hospital Over the past few years, dramatic improvement has taken place in blood culture methods, media, and systems. Most of the technologically advanced blood culture systems are fully automated continuously monitored blood culture systems . These systems electronically monitor blood culture bottles every 8-10 minutes and detect algorithms based on assessments of changes associated with microbial growth. Dr.T.V.Rao MD 36 2/9/2016

37. SEPTIC SHOCK A PRIORITY Let us think of septic shock as a top priority, at least we receive 10% of the samples, we process are Blood cultures and the number of specimens increase with the expansion of ICU and MICU care, According to the literature, the risk of death from septic shock increases by over 7% with every hour that passes from the onset of shock until the start of targeted therapy. tools in clinical microbiology are primarily based on techniques that evolved 30 to 40 years ag o 2/9/2016 Dr.T.V.Rao MD 37

38. Reliable Microorganism Recovery BacT /ALERT® Culture Media provides a wide range of media bottles to rapidly and reliably recover an array of microorganisms, including bacteria, mycobacteria, fungi, and yeasts from various sample types. BacT /ALERT® Culture Media is FDA-cleared for blood, sterile body fluids, and platelets, and can detect 98% of isolates within 72 hours.* - 2/9/2016 Dr.T.V.Rao MD 38

39. Automation reduces the time requirement But this can be completed within 30 hours by using automated techniques. This is especially useful when large number of specimens needs to be cultured, as the instrument, which has been programmed for the same, automatically screens these. Dr.T.V.Rao MD 39 2/9/2016

40. BacT/AlerT 3D culture system BacT/AlerT 3D culture system. This is the first automated non-radiometric and non-invasive culture system that continuously monitors system for culture of bacteria (both aerobic and anaerobic), fungi and mycobacteria . All these bacteria can be cultured using different media as prescribed .. Dr.T.V.Rao MD 40 2/9/2016

41. bioMérieux BacT/ALERT® 3D The bioMérieux BacT/ALERT® 3D provides an optimal environment for the recovery of a wide range of pathological organisms, including bacteria, yeasts and mycobacteria; utilizing proprietary plastic culture bottles ensuring added safety to the user. Dr.T.V.Rao MD 41 2/9/2016

42. BacT/ALERT® 3D Microbial Detection System This newest generation of the time-tested BacT/ALERT system offers advantages in every dimension of testing. From its space-saving modular design to its easy touch-screen operation and flexible data management options, every laboratory will find something to love about the BacT/ALERT 3D! Dr.T.V.Rao MD 42 2/9/2016

43. Principles of functioning of BacT alert Monitors Microorganisms multiply in the media, generating CO2. As CO2 increases, the sensor in the bottle turns a lighter colour. Measuring reflected light, the BacT/ALERT 3D monitors and detects color changes in the sensor. Algorithms analyze the data to determine positivity, and the laboratory is notified immediately with visual and audible alarms. Dr.T.V.Rao MD 43 2/9/2016

44. Principles in BacT/AlerT 3D culture system This is a closed system and works on the colorimetric principle of detection of CO2 produced by the organisms. The CO2 causes a lowering of the pH of the medium, which in turn produces a colour change in a sensor attached to the CO2-sensitive base of each bottle. Dr.T.V.Rao MD 44 2/9/2016

45. What are other Specimens sent for culturing Cerebrospinal fluid Pleural Aspirates Joint Aspirates Peritoneal fluid CT guided Aspirates Dr.T.V.Rao MD 45 2/9/2016

46. Specimens Not suitable for BacT / AlerT 3D culture system Urine Stool Pus Aspirates from Surgical Site Infections Any specimen contaminated with contaminants and commensals including oral secretions Dr.T.V.Rao MD 46 2/9/2016

47. CT guided Aspirates CT guided aspirate is a valuable material we can try best out of the aspirates Dr.T.V.Rao MD 47 2/9/2016

48. WHO IS ACCOUNTABLE TO RUNNING THE SYSTEM 1The physicians should give many clinical details why they wish to culture blood, as automation is fraught with many errors if the coordination fails between treating doctor and laboratory personal the errors with automation are more expensive dangerous with loss of valuable time and the purpose of automation is lost 2 All the requests should be identified with caring Doctor or nurse responsible for treatment decision and better with active Mobile contact number for faster communication in case of any growth as the machine alerts every 10 minutes a valuable time is saved for faster decisions 2/9/2016 Dr.T.V.Rao MD 48

49. WHO IS ACCOUNTABLE TO RUNNING THE SYSTEM 3 The Medical Microbiologists should be well know ledged to identify the contamination and source to make the system running with scientific efficacy 4 With experience I wish to say automation needs more knowledge of Medical Microbiologists or the matters will be counterproductive in false identification of contaminants 2/9/2016 Dr.T.V.Rao MD 49

50. WHO IS ACCOUNTABLE TO RUNNING THE SYSTEM 5 A regular audit of the functioning and reporting both by internal and external experts. 6 I wish who wish to run the Automation must read from more at Bailey and Scot diagnostic microbiology available in our libraries 7 Ill qualified and careless Microbiologists, and technicians are more dangerous as the errors at many stages multiplies faster than traditional methods of culturing leasing greater misuse of Antibiotics 2/9/2016 Dr.T.V.Rao MD 50

51. Automation improves quality of services Overall, laboratories transitioning from conventional to automated processes find that technologists and microbiologists are more open to innovation and improved quality. Dr.T.V.Rao MD 51 2/9/2016

52. Automation Signals Bacteremia cases After inoculating the culture vials, they are sent to the clinical pathology microbiology department. Here the bottles are entered into a blood culture machine, which incubate the specimens at body temperature. The blood culture instrument reports positive blood cultures (cultures with bacteria present, thus indicating the patient is "bacteremia"). Most cultures are monitored for 5 days after which negative vials are removed. Dr.T.V.Rao MD 52 2/9/2016

53. The positives cases to be proceeded without delay A vial is positive, a microbiologist will perform a Gram Stain on the blood for a rapid, general ID of the bacteria, which they will report to the attending physician of the bacteremic patient. The blood is also subcultured onto agar plates to isolate the pathogenic organism for culture and susceptibility testing, which takes up to 3 days. This culture & sensitivity (C&S) process identifies the species of bacteria. Antibiotic sensitivities are then assessed on the bacterial isolate to inform clinicians on appropriate antibiotics for treatment. Dr.T.V.Rao MD 53 2/9/2016

54. Rapid Susceptibility Testing Rapid susceptibility will be carried out for gram negative and staphylococcal isolates and other isolates on request. These will be reported within 12 hours using API systems. Automation has made it easier to arrive at a precise laboratory diagnosis of infection  2/9/2016 Dr.T.V.Rao MD 54

55. VITEK® MS VITEK® MS Mass spectrometry microbial identification system An automated mass spectrometry microbial identification system that uses Matrix Assisted Laser Desorption Ionization Time-of-Flight (MALDI-TOF) technology and a comprehensive database of clinically relevant species for results in minutes Robust & accurate ID with Advanced Spectra Classifier Seamless integration of ID/AST results for optimized workflow Complete traceability & flexibility - 2/9/2016 Dr.T.V.Rao MD 55

56. Rapid & clear identification VITEK® MS is an innovative, automated microbial identification system that uses MALDI-TOF (Matrix Assisted Laser Desorption Ionization Time-of-Flight) technology. In just minutes, this mass spectrometry technology can provide clear identification at the species, genus and family level. You can provide clinicians with quick information to start appropriate treatment, contributing to overall patient care and outcomes. 2/9/2016 Dr.T.V.Rao MD 56

57. The Contaminated Blood Culture If the skin is not adequately cleansed before drawing blood for culture, bacteria on the skin will be injected into the bottle, producing a false positive blood culture It is difficult for the physician to determine whether the bacteria growing in the blood culture is a real pathogen causing bloodstream infection or whether bacteria on the skin have contaminated the culture. This can lead to excess use of antibiotics and prolongation of hospital stay. Dr.T.V.Rao MD 57 2/9/2016

58. Program Created by Dr.T.V.Rao MD for Medical and Microbiology Professionals Globally for improving the Skills in Diagnostic Microbiology Email d [email protected] Dr.T.V.Rao MD 58 2/9/2016