Which Blood Culture Is Drawn First

Collection and Inoculation of Blood Specimens for Routine Culture (Bacterial, T.B. or Fungus)

Whenever feasible, it is preferable to get a peripheral sample rather than a sample from a line, unless there is a suspicion of a line infection. When collecting several blood samples from a single line, always draw the blood culture first and then the rest of the samples. Do not discard any of the blood that has been drawn. Make use of this early blood in the line since it may be the most reliable source if an organism is detected.

Equipment
  • Prescriptions for laboratory services
  • Name labels
  • Safety Lok Blood Collection Set/Saf-T E-Z Set
  • Angel Wing
  • Blood Culture Bottles*
  • Prescriptions for laboratory services Skin prep kit (ChloraPrep One-Step FreppTM)
  • Tourniquet
  • Gauze and paper tape
  • Unsterile examination gloves

*PLEASE NOTE: Mycobacterial cultures require different containers than other cultures.

Recommended Testing

  1. Adults with suspected bacteremia should have two sets of blood culture bottles drawn (one for aerobic bacteria and one for anaerobic bacteria) from two different venipuncture sites. There is a limit of four cultures. It is necessary to inoculate the aerobic bottle first since there is approximately 0.5 cc of air in the line of the collection set and it is sometimes difficult to extract 8-10 cc of blood per bottle (15-20 cc/set) when using the aerobic bottle. The aerobic bottle is the one that must be inoculated with brief samples since it contains the most bacteria. On the label, little lines signify roughly 5 cc, and there is a fill line that is marked by a line in the middle of the label. It is critical not to underfill or overfill the bottles, since this might have a negative impact on the outcome. One aerobic (yellowtop) bottle per pediatric/neonatal patient, as directed by the physician, is required. Amount of blood recommended per bottle: 1 to 2 cc of blood
  2. Blood Culture for Tuberculosis: two heparin-coated (green top) or two SPS-coated (yellow top) Vacutainers each. No more than once every 24 hours
  3. No more than once every 48 hours
  4. In order to test for fungus, one aerobic (bluetop) blood culture bottle must be used.
Method/Procedure
  1. Confirm the patient’s identify by checking the requisition and labels to ensure that they match the name bracelet
  2. Provide the patient with an explanation of the procedure. Choose a location for the venipuncture
  3. Remove the cap(s) off the bottle(s) and wipe the bottle top(s) with a prep pad with 70 percent alcohol
  4. Preparation of the skin and collection of specimens/inoculation:
  1. Identify the vein that will be utilized
  2. FreppTM should be removed from the bundle. When you hold the applicator in your hand, with the ChloraPrep One-Step FreppTM sponge facing downwards, gently press the wings to release fluid for a regulated flow. In order to soak the sponge, place it on the specified venipuncture site and depress once or twice. For at least 30 seconds, use a back and forth friction scrub technique. Allow approximately 30 seconds for the area to dry once it has been prepped. Continue with the collecting of blood
  1. It is not necessary to clean off since doing so will infect the location.
  1. Maintain a “hands-off” attitude during the preparation process. To palpate above and below the needle insertion site if it is required to contact the cleaned site, prep the glove finger in the same manner as before with a fresh prep pad and just palpate above and below
  2. A. Drawing on the Periphery 1. Perform the venipuncture using the butterfly Safety E-Z Collection Set and a “male” Angel Wing, as directed by the manufacturer. Blood should “flash” back into the tubing at the end of the tube. 2. Start with the aerobic bottle and then attach the blood culture bottles to the adapter. Collect 10 cc of blood into each vial and set it aside. Note: Collect blood in the aerobic bottle first since there is approximately 0.5 cc of air in the line of the butterfly, and in the event that less than 10 cc is collected, collect blood in the aerobic bottle second. A notation should be included on the request if less than 10 cc of blood is obtained from an adult patient since this might result in a false negative test result. c. Drawing a Line The following are the two approaches for drawing from a line: 1. Directly attach the “male” angel wing to the clave connection by inserting the wing directly into the connector. OR Secondly, insert the syringe into the clave and draw back the specimen. Then, remove the syringe and insert a “female” angel wing into the syringe. Place the blood in the appropriate containers. After the operation is completed, use an alcohol prep to remove any blood that may have accumulated on the gray stopper of the blood culture bottles. Label the bottle(s) with the patient’s name, patient number, the time and date, and the location of the specimen collection site, such as “right arm” or “left arm,” if appropriate. When drawing lines, always specify which line and/or port is being drawn. Position the label vertically on the bottle, and DO NOT place the label over the bar code on the blood culture vial (unless otherwise specified). Note: After the culture is taken from the identified patient, apply the patient label to the bottles at the bedside
  3. If further blood cultures are necessary, pull the extra tubes after the blood cultures are obtained.
TYPE OF CULTURE CONTAINER AMOUNT OF BLOOD ROUTE
Aerobic Blue top Bottle 8-10 cc. Blood Peripheral Or Line
Anaerobic Fuchsia top Bottle 8-10 cc. Blood Peripheral Or Line
Fungus Blue top Bottle 8-10 cc. Blood Peripheral Or Line
TB or AFB or Mycobacterium 2 green Vacutainer Tubes (Heparin) 7-10 cc. Blood Peripheral Or Line
Pediatric Blood Culture Yellow top Bottle 1-2 cc. Blood Peripheral Or Line

Updated on November 24, 2017

Blood Culture


Background: Properly obtained blood cultures are important to identify organisms and to ensure proper antimicrobial/antifungal coverage while minimizing false positive results.Principle Preparation of the skin for venipuncture is important to prevent contamination of blood cultures by bacteria that normally lie on the skin and to prevent introduction of these bacteria into the patient’s bloodstream.Patient Identification: Follow the HFHS Patient Identification Policy (HFHS Administrative Policies – Clinical Practice) to properly identify the patient.Follow the Department of Pathology specimen labeling policy to properly label each bottle with patient identification and collect time and date before the blood is drawn. Specimen Logistics Blood cultures should be drawn prior to initiation of antimicrobialtherapy.Preparation of skin prior to blood culture collection is important toprevent contamination of sample. At least two (2) sets of blood cultures should be obtained (each setincludes one (1) aerobic and one (1) anaerobic bottle).Each set of blood cultures are to be drawn from two separatevenipuncture sites at approximately 15 minutes apart.If two separate venipunctures are not able to be drawn, the providermust be notified, and collaboration should be done to determine if two sets arenecessary. Central lines (includes dialysis lines and Mediports) and PeripherallyInserted Central Catheters (PICCs)shouldnotbe used to obtain blood cultures due to the high probability ofcolonization and the likelihood of false positive results.Central lines from outside facilities may be cultured for up to two (2)calendar days (as opposed to 48 hours), after admission by provider order onlyfor a positive blood culture to be considered present on admission.Blood culture volume is essential. There is a 3% increase in sensitivityfor every extra mL collected. Blood culture bottles require 8- 10 mLs. to beaccurate. After positive blood cultures have been identified wait at least 48hours to draw any additional blood cultures. Surveillance blood cultures should not be routinely done.KEY POINT: Neutropenic (ANC1500 µL) orthrombocytopenic (Platelets30,000 µL) patients suspected of having ablood stream infection are to have peripheral blood culture attempted twicebefore considering drawing a blood culture from a central line or PICC. It isimperative that cultures in these patients are drawn within an hour ofsuspected infection has been identified.Do not send catheter tips for culture.Escalation orderof blood culture sites, General Practice Unit:
  1. Hospital Expert/IV team
  2. Arterial puncture by Rapid Response team (if available)
  3. Notify provider
  4. Peripheral venipuncture
  5. Hospital expert/IV team

Order for escalation of blood culture sites in the Intensive Care Unit:

  1. Venipuncture on the periphery
  2. Arterial puncture
  3. Unit expert
  4. Arterial line
  5. Hospital expert/IV team
  6. Notify provider

Preparation: Gather the necessary equipment:

  • A tourniquet, a 70% alcohol swab, 2 percent chlorhexidine with a 70% isopropyl alcoholapplicator, aerobic and anaerobic blood culture flasks, and a tourniquet are all required. Vacuette
  • Butterfly set, clean gloves, dressing, pen, and labels are all included.

Preparation of the blood culture bottles includes the following:

  1. Remove the cap from each blood culture vial and use a different alcohol swab to scrape the top of each bottle for 30 seconds
  2. Allow for natural drying.
  • To prepare each blood culture vial, remove the cap and clean the top for 30 seconds with a different alcohol swab. Dry by letting it air out.

Remove the cap from each blood culture vial and use a different alcohol swab to scrape the top of each bottle for 30 seconds. Allow for air drying.

  1. Provide the patient with an explanation of the procedure. Hand hygiene should be practiced. Set up a tourniquet.
  • The tourniquet should not be left on the patient for more than one minute.
  1. Prior to washing the skin, palpate and identify the appropriate place. Take off the tourniquet.

Obtaining the Culture: Collecting the culture with a butterfly set and a vacuette

  1. The Culture is obtained in the following methods: collection with a butterfly set and a vacuette
  • Allow for at least 30 seconds of drying time (the skin must be completely dry prior to venipuncture)
  • Once the skin has been washed, avoid using a fan or blowing it. Once the spot has been cleaned, do not palpate it.
  1. Venipuncture should be performed. Butterflyset and vacuette should be used for venipuncture procedures. Completely fill the aerobic bottle first, then the anaerobic bottle (see Appendix A for the proper amount of fluid to use). Fill each bottle with 10mLs at a time until it is full. Keep an eye on the volume because the bottle may overfill. Remove the tourniquet, maintain pressure, and apply the dressing. After removing the gloves, wash your hands thoroughly. While at the patient’s bedside, label cultures with a bedside labeling equipment or handwrite the site of draw on the label with a pen. (See Appendix B for more information.) Send to the lab in accordance with operational unit guidelines

When should blood be obtained from a vascular access device (VAD)? Blood should not be drawn from a VAD unless it is thought that the patient has line-related sepsis. Confirm that the doctor’s order for a blood culture specifies that a line draw be performed. It is more probable that blood cultures collected from lines may be contaminated; consequently, proper care should be taken to prevent contamination. In the case of drawing a blood culture from a VAD, it should always be followed by drawing a blood culture from a peripheral location.

Follow the directions for bottle preparation and blood culture volume volume as given in the preceding section.

Without the use of an adaptor, it is not possible to draw straight from the bottle.

If it is not possible to get a peripheral blood culture and a culture from an IV line must be performed, the following procedures must be followed for obtaining bloodcultures from peripheral IVs, central lines, and PICCs:

  1. Dispose of the needleless connection and replace it with a fresh, sanitary one.
  • Squeeze out the excess alcohol from the hub for at least 30 seconds and let it to dry
  1. Squeeze out the excess alcohol from the hub for at least 30 seconds and set aside to dry.

The number of blood cultures taken and when they are taken are important considerations.

Condition Recommendations
Suspected acute primarybacteremia or fungemia, meningitis, osteomyelitis, arthritis, or pneumonia Obtain 2 sets at the sametime by separate venipuncture immediately following the clinical events thatprecipitate the blood culture.
Fever of unknown origin Obtain 2 to 3 blood culturesets initially at the same time by separate venipuncture.Then, 24 to 36hours later, obtain two more sets of cultures immediately before the expected(usually afternoon) temperature elevation.
Suspected bacteremia or fungemiawith persistently negative blood cultures Consider alternative bloodculture methods designed to recover rare or fastidious microorganisms (e.g.Isolator tube)
Infective endocarditis Obtain 4 blood culture setsduring the first 1-2 hours of evaluation.If all are negative 24 hourslater, obtain 4 more sets.From patients who have received antimicrobialagents within 2 weeks prior to admission, obtain two separate blood cultures oneach of three successive days.Request extended incubation if Brucellaor Bartonella is suspected.
Transport to the Lab Pneumatic tube: To send blood culture bottles by pneumatic tube,place each bottle in a biohazard bag.Seal the bags and place therequisition slips (if not preordered) in the outside pocket of one of the bags.Place the bottles in the carrier so that the bottoms of the bottles are end toend in the center of the carrier and the necks of the bottles face outward.Other specimen tubes may be placed in the carrier with the blood culturebottles as room permits.Regular courier: Use two specimen bags.Wrap one bottlesnuggly with a plastic specimen transport bag and insert the wrapped bottle inanother plastic transport bag. Place the second bottle of the set in thebag.Seal the bag and place requisition slips (if not pre-ordered) in theoutside pocket. Instructions for local laboratory sending blood cultures to CoreMicrobiology laboratory If there is no scheduled courier within 4 hours of blood culturereceipt in the laboratory, contact A1 cab for transport to core laboratory.This may require calling A1 cab more than once per day for blood culturesparticularly during large gaps between scheduled courier runs. Use of A1 cabfor specimen transport can be minimized by strategically scheduling A1 use(example: schedule A1 cab to arrive in the middle of an 8 hour gap betweenscheduled courier runs). If A1 is contacted to pickup blood culture specimens,any additional microbiology specimens pending transport should also be sentalong with batch list. Reference(s)/Source(s): ClinicalKey “Blood specimen collection: Blood cultures” accessed 7/12/18.WiggersJB, Xiong W, Daneman N. Sending repeat cultures: is there a role in themanagement of bacteremic episodes? (SCRIBE study). BMC infectious diseases.2016 Dec; 16(1):286. WilsonML, Mitchell M, Morris AJ, Murray PR, Reimer LG, Reller LB, Towns M, WeinsteinMP, Wellstood SA, Dunne JW, Jerris RC. Principles and procedures for bloodcultures; approved guideline. CLSI document M47-A. Clinical and LaboratoryStandards Institute, Wayne, PA. 2007.

Blood Sample Contamination Fast Facts

Who should be subjected to a blood culture examination? Patients with fever, chills, leukocytosis, septic shock, suspected endocarditis, or prior to initiating antimicrobial therapy in the elderly or immunocompromised patients are frequently subjected to blood cultures. Blood culture tests are performed immediately upon arrival in a hospital in the United States to rule out the possibility of a community-acquired bloodstream infection (BSI). A BSI that occurs during a patient’s hospitalization is considered a preventable adverse event, and reimbursement for the patient’s care may be threatened.

  1. A blood culture is used to evaluate whether or whether a patient has a bloodstream infection, commonly known as bacteremia or septicemia, by examining the patient’s blood.
  2. Blood is a sterile fluid by its own nature.
  3. As a best-case scenario, a blood culture test will offer an aetiological diagnosis as well as the chance to do antimicrobial susceptibility testing to advise appropriate antimicrobial therapy, which is an essential element of antibiotic stewardship.
  4. Unfortunately, contamination of blood cultures is a recurring concern when it comes to obtaining valid test findings.
  5. What is the purpose of requiring two specimens from two different locations?

True bloodstream infection (in which both specimens will be positive with the same organism) and contamination are distinguished by the presence of a positive result in one specimen and a negative result in the other (in which only one specimen will be positive.) Can skin antisepsis prevent the contamination of blood culture specimens?

  • Before collecting the blood culture, it is possible to disinfect the patient’s skin surface using an aseptic procedure that is followed exactly.
  • The butterfly needle cored out a skin plug from the specimen, and even if skin antisepsis is followed, bacteria inside the dermis layer, which are not reachable by surface disinfection procedures, may be transported into the specimen.
  • According to research, utilizing a device, also referred to as “a waste,” to prevent the initial flash of blood, which can be as little as 0.15ml, from entering the container can significantly minimize the number of contaminated culture samples.
  • How can I keep skin antisepsis intact when extracting a blood culture from a patient?
  • Maintain a “hands-off” approach following the prep process and refrain from palpating the region after antisepsis to avoid spreading infection.
  • In order to obtain the best possible blood culture collection, how will I know whether I am appropriately positioned in the vein?
  • Keep an eye out for the blood to “flash” back into the tube to check that you have reached the vein.

A blood culture set is comprised of two bottles, one of which is an aerobic bottle and the other of which is an anaerobic bottle.

Adults should have 8-10 mL of blood collected every bottle.

Pediatrics and newborn blood collection are handled in a different way at different facilities.

For example, a one-month-old infant will require 1ml of formula, but a two-month-old baby will require 2ml of formula, and so on.

Using the Aerobic Bottle, collect 1 mL minimum to 4 mL maximum for patients less than 9 kg, and the Anaerobic Bottle, collect 4 mL minimum to 10 mL maximum for patients more than 9.1 kg.

Do the culture bottles need to be disinfected before to use?

Even with the dust top in place, blood culture vials are not considered sterile for use in research.

In which blood culture bottle do I start with the most recent sample?

The aerobic bottle is the one that must be inoculated with brief samples since it contains the most bacteria.

It is critical not to underfill or overfill the bottles, since this might have a negative impact on the outcome.

Blood culture bottles must be kept upright in order to prevent backflow of the broth medium and to guarantee that the proper volume of blood is being supplied to the culture.

Some blood culture bottles contain a “fill line” that may be used to assist you determine the volume you need to collect.

What is the average number of blood culture tests required per patient?

There is a limit of four cultures.

What is the procedure for diagnosing a laboratory-confirmed bloodstream infection?

What is the most effective way of collecting blood cultures?

Blood specimens taken from existing intravascular lines should be avoided because they have a higher risk of contaminating the specimen.

Is there a preferred order for the collection of lab specimens for the patient if there are other lab specimens ordered for the patient?

In the event that extra blood is necessary for other laboratory testing, the additional tubes should be drawn after the blood cultures are collected.

Do I shake the vials with the specimens I’ve collected?

Don’t move them at all.

What should the labeling of a blood culture specimen look like?

When drawing lines, always specify which line and/or port is being drawn.

What role do contaminated blood cultures have in the reporting of false positive CLABSI results?

Contaminated blood cultures pose a major threat to the accuracy of laboratory results.

With over 1.2 million contaminated blood cultures happening in the United States each year, the frequency of needless CLABSI reporting, as well as the accompanying costs, are considerable.

These individuals who have been incorrectly diagnosed with a CLABSI are frequently treated with unneeded antibiotics, increasing their risk of secondary infection, including C.

When antibiotics are used inappropriately, they are the primary cause of antimicrobial resistance, which has become a significant and growing global problem.

In addition to the costs associated with CLABSI reporting, it is estimated that blood culture contamination results in over $1 million in avoidable costs to an average-sized hospital each year.

Evacuated Blood Collection Tube Guide

Which patients should have a blood culture performed? Patients with fever, chills, leukocytosis, septic shock, suspected endocarditis, or prior to starting antimicrobial treatment in the elderly or immunocompromised patients are the most common reasons for blood cultures to be collected. Blood culture tests are performed immediately upon arrival in a hospital in the United States to rule out the possibility of a community-acquired bloodstream infection (BSI). A BSI that occurs during a patient’s hospitalization is considered a preventable adverse event, and reimbursement for the patient’s care may be jeopardized.

  • A blood culture is used to determine whether or not a patient has a bloodstream infection, also known as bacteremia or septicemia, by analyzing the patient’s blood.
  • A sterile fluid by nature, blood is a clear, colorless substance.
  • As a best-case scenario, a blood culture test will offer an aetiological diagnosis as well as the option to do antimicrobial susceptibility testing to advise appropriate antimicrobial therapy, which is an essential part of antibiotic stewardship.
  • In the unfortunate event that blood culture contamination occurs, valid test results cannot be obtained.
  • The reason for requiring two specimens from two different locations is unclear.

As a result, it is easier to distinguish between actual bloodstream infection (in which both specimens would be positive with the same organism) and positive findings due to contamination or contamination-related contamination (in which only one specimen will be positive.) Can skin antisepsis prevent the contamination of blood cultures?

  1. Decontaminating the patient’s skin surface before taking a blood culture can be accomplished with the use of an aseptic approach.
  2. Microbes inside the dermis layer that cannot be reached by surface disinfection procedures, however, may be introduced into the specimen when the skin plug is cored out with the butterfly needle, even if skin antisepsis is performed as recommended.
  3. Using a mechanism known as “a waste” to avoid the initial flash of blood, which can be as little as 0.15ml, from entering the bottle will significantly minimize the number of contaminated culture rates, according to the research.
  4. While drawing a blood culture, how do I keep the skin antiseptic?
  5. Following the prep operation, maintain a “hands-off” approach and avoid palpating the region after antisepsis.
  6. In order to obtain the best possible blood culture collection, how will I know whether I am in the vein properly?
  7. Keep an eye out for the blood to “flash” back into the tube to indicate that you have reached the vein.

Two bottles, one of which is an aerobic bottle and the other of which is an anaerobic bottle, make up a blood culture collection set.

Collect 8-10 mL of blood each bottle for people over the age of 18.

Pediatrics and newborn blood collection are handled differently at various facilities.

For example, a one-month-old infant will require 1ml of formula, but a two-month-old baby will require 2ml of formula, and so on.

Using the Aerobic Bottle, collect 1 mL minimum to 4 mL maximum for patients less than 9 kg, and the Anaerobic Bottle, collect 4 mL minimum to 10 mL maximum for patients more than 9.1 kg.

Specifically, do the culture bottles require disinfection?

Yes.

Bottle tops should be disinfected as per hospital protocol, and the dust covers should be removed and let to dry.

As previously stated, the aerobic bottle should be infected first due to the presence of about 0.5 cc of air in the line of the collecting set and the difficulty in obtaining 8-10 cc of blood per bottle (16-20 cc/set) in some cases.

If I don’t collect enough blood or if I overfill a vial, what occurs is that I will be charged.

Which method should I use to ensure my withdrawals are in line with my expectations?

Use the tick marks on the edge of the label that indicate roughly 5 cc increments to fill the container.

Make careful to pre-mark the blood culture bottles with two tick marks above the broth to serve as your fill line target if your bottles do not have fill lines.

Blood culture bottles (aerobic and anaerobic) should be collected from two different venipuncture sites for persons who have a suspected bacteremia.

A blood culture series is defined as two or more sets of blood cultures that are performed in a row.

In the case of a venipuncture, there is one positive blood culture with a known pathogen, or more than two blood cultures collected on different dates return positive for the same organism, as well as clinical signs.

Vein puncture is preferable whenever possible for the collection of peripheral samples.

Even though the risk of contamination is raised, it is possible to collect a sample from a freshly implanted peripheral IV when necessary.

Yes.

Obtaining extra labs before collecting blood cultures might result in a contaminated blood culture sample being collected.

No.

After the specimens have been collected and placed in the blood culture bottles, invert the bottles slowly several times to properly mix the mixture.

Even while each hospital’s procedure may change significantly, in general, you will mark the bottle(s) with the patient’s name, patient ID, the time and date of the specimen collection, and the location of the specimen collection site, such as “right arm” or “left arm,” among other things.

Do not position the label above the barcode on the blood culture vial; instead, place the label vertically on the container.

CLABSIs must be reported to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network by all acute care hospitals (NHSN).

It is possible that a contaminated blood culture will result in the reporting of a CLABSI in patients who have central lines in place.

Clabsis is a term used to describe the condition of a person who has been diagnosed with a disease that they have not contracted.

In many cases, patients who have been incorrectly diagnosed with a CLABSI are treated with unneeded antibiotics, increasing their risk of secondary infection, including C.

Antibiotic overuse is the primary cause of antimicrobial resistance, which is a substantial and rapidly expanding worldwide health issue.

An estimated $1.2 million in unnecessary expenses for an average-sized hospital per year, in addition to the expenditures associated with CLABSI reporting, is attributed to blood culture contamination, according to the CDC.

STOPPER COLOR SYMBOL CONTENTS VOL. USES/COMMENTS
Blood Culture Bottlesare ALWAYS drawn prior to other labs to reduce contamination.
Royal Blue No additive (serum); special glass and stopper material 7.0 mL Most drug levels, toxicology screens, and trace elements
Red No additive 7.0 mL Cryoglobulins and CH 50
Light Blue 3.2% Sodium Citrate 4.5 mL PT, PTT, TCT, CMV buffy coat, Factor ActivityTube MUST be filled 100% – No exceptions!
Gold Top (Serum Separator, “SST”) Contains separating gel and clot activator 6.0 mL Most chemistry, endocrine and serology tests, including Hepatitis and HIV
Light Blue -Yellow Label on Tube Thrombin 2.0 mL For FDP testONLY; Obtain tube from Core Lab Coag; Allow to Clot
Green Sodium heparin(100 USP Units) 5.0 mL Ammonia, Lactate, HLA Typing
Tan K 2EDTA 5.0 mL Lead levels
Yellow ACD Solution A consists of trisodium citrate, citric acid and dextrose 8.5 mL DNA Studies, HIV Cultures
Pink (K 2)EDTA Draws 6 mL – Minimum 4 mL Blood typeScreen, Compatibility Study, Direct Coombs HIV Viral Load
Pearl Top (Plasma Preparation, “PPT”) Separating gel and (K 2)EDTA 4.0 mL Adenovirus PCR Toxoplasma PCR HHV-6 PCR
Lavender (“Purple”) (K 2)EDTA 3.0 mL CBC/Diff/Retic/Sed Rate, FK506, Cyclosporin, Platelet Ab, Coombs, Flow Cytometry

PLEASE NOTE: All tubes are sterile. The following is the standard order of draw: BLOOD CULTURES, royal blue, red, light blue, SST (Gold), green, tan, yellow, pink, pearl, lavender, SST (Gold), green, tan, yellow, pink, pearl, lavender, SST (Gold). An additional 5 milliliters must be pulled from a coag tube (light blue) if it is the lone tube or first one drawn from the coag tubing. Different Types of Blood Cultures (Specify the culture type when placing your order.)

Culture Type Patient Population Test ID Test BottleType/Comments
Culture,Blood, Routine All Patients not Meeting Criteria BelowNOTE:This culture will recover HACEK organisms with no change in collection or incubationconditions. If Brucella or Francisella are in the differential, extended incubation may be required. Please contact the Microbiology Lab (966-4056). BROU 9500 BD BACTEC Plus Aerobic/F(Grey Cap/Blue Ring)(Optimal Volume 8-10 mL)Lawson052346(UOM box of 50 bottles)BD BACTEC Anaerobic Lytic/10(Purple Cap/Maroon Ring)(Optimal Volume 8-10mL)Lawson052347(UOM box of 50 bottles)
Culture,Blood, AFB HIV+patients with CD 4Count100;Suspected MAC infections AFBB 9684 BD BACTEC Myco/F Lytic(White Cap/Red Ring)Available from Phlebotomy Lab(Optimal Volume 1-5 mL)
Culture,Blood, Pediatric Patients Weighing40 kg BPED 9548 BD BACTEC Plus aerobic/F(Grey Cap/Blue Ring)(Optimal Bolume 8-10 mL)For Patients20 Kg, 1-4 mL is acceptable For Patients 20-40 Kg, 4-8 mL in one bottle. For Patients40 Kg (See Routine above)
Blood Culture Mould Suspected infections due todimorphic(endemic) fungi,Fusarium sp., Trichosporon sp.,Malassezia furfur (Specify at Collection). BPATH 9507 Isolator Yellow Top(10 mL Volume)Available from PlebotomyBD BACTEC Plus Aerobic/F(Grey Cap/Blue Ring)(Optimal Volume 8-10 mL)Lawson052346(UOM box of 50 bottles)BD BACTEC Myco/F Lytic(White Cap/Red Ring)Available from Phlebotomy Lab (Optimal Volume 1-5 mL)

Procedure: Drawing Blood Cultures

  • Make sure there is an order (communication order) or an indication backed by a Medical Directive
  • Otherwise, proceed to step 2. All new admissions should have their pan culture indications reviewed. If a patient has previously had a positive culture with questionable relevance (e.g., suspected contamination or following removal of a line with a positive culture when therapy was not commenced), cultures should be redone. Patients receiving a hypothermia program whose temperature is over goal for an extended period of time should be cultured. Consult with your doctor about the necessity for empiric antimicrobials. Patients who have blood cultures that are positive for staph aureus (either resistant or sensitive SA) or yeast should have blood cultures repeated every 2 days until the cultures are negative, at which point the patient should be discharged. Consult with your doctor about the need for more cultures. When dealing with some blood stream illnesses, it is important to rule out endocarditis (e.g., staph aureus). When yeast is isolated from blood, it is typically necessary to check with an ophthalmologist to rule out the possibility of intraocular involvement. Consult with your physician.
Notes:Many patients are admitted with sepsis as a differential diagnosis; prompt cultures are indicated. This should Ideally occur prior to antimicrobial therapy initiation but should not delay treatment.Staph aureus in the blood is associated with endocarditis. Staph aureus and yeast can be difficult to eradicate. Line removal is generally required (including tunneled catheters).Blood cultures are typically repeated until they become negative.The time when the cultures are first negative helps to determine the duration of antimicrobial therapy.
2. Identify Number of Samples to be CollectedSeeBlood Culture Ordering Decision Tree:1.If the patient has no intravascular lines,draw 2 sets of peripheral cultures from 2differentdraws (different lines or puncture sites).
  • Blood cultures taken at the time of line insertion are referred to as “venipunctures” in some circles. Once a line has been accessed for blood samples in the past, it cannot be used for venipuncture samples again. While waiting for a line to be placed, do not postpone blood culture collecting if a patient is hypotensive or suffering from shock. Obtain two peripheral cultures and begin antibiotic treatment as soon as possible
  • It is important not to postpone antibiotic therapy in a patient who is suffering from shock if blood cultures cannot be collected rapidly.

Draw cultures and seek a “CAB” assessment if the patient has intravascular lines in place that will be removed in 24 to 48 hours.

  • Collection of blood cultures from a peripheral Stab and from each indwelling line (arterial, central line, PICC) should be done once. Each batch of blood cultures comprises of one anaerobic and one aerobic vial of blood cultures. Within 15 minutes, all cultures from all places should be pulled together. The cultures collected from dialysis lines should also be cultured
  • However, the cultures must be drawn by a nurse who has been approved to do CRRT or hemodialysis. As much as feasible, acquire blood cultures from the distal lumen of multilumen central venous catheters
  • Whenever a patient has a central venous catheter (for example, a Portacath for oncology), it must be accessed by a Vascular Access or Oncology nurse
  • Otherwise, the patient will not be able to get treatment.
3.If the patient has a previously established line that is being removedand obtain cultures from the line and at least one other site and send the tip for culture (done semiquantitatively).NOTE:ACatheter Associated Bacteremia (CAB)assessment will only be performed if a venipuncture sample is included (and labeled as a venipuncture sample). It required lab notification for appropriate setup of cultures.If any indwelling line becomes positive more than 2 hours before the venipuncture culture first became positive, the blood stream infection (bacteremia) is unidentified as a CATHETER ASSOCIATED BLOOD STREAM INFECTION.If all blood cultures become positive within a 2 hour window, the infection is not considered to be catheter associated.All samples must go to the lab at the same time so that they can be setup together.A newly established line can be considered a “peripheral stab” ONLY if it is newly established and has not been previously used for blood drawing. If the sample is drawn at the time of insertion, identify this as a “peripheral culture” in the lab orders.If a peripheral culture cannot be obtained, report this under “Comments” in Power Chart (see item 7) and document in the AI flow sheet. (A CAB assessment will not be performed without a sample that is labeled as “venipuncture”).Simultaneous results from multiple sites aids in the interpretation of the results (e.g., differentiates contamination, colonization and clinical infection).Multiple samples also increase the yield and potential for culture growth.Mortality increases 8% with every 1 hour delay in the administration of appropriate antimicrobial therapy (ie. covers the actual organism).The initial pre antibiotic blood culture is often the only one that shows the causative organism.TIP Cultures:A positive tip culture with15 CFUs of an organism is used to identify that the catheter is the likely source of the positive culture (indicates high burden of organism attached to the catheter tip).
3. Order Blood Cultures in Power Chart
  • Log in to Power Chart with your own user ID and password. Choose “Blood Culture” as shown below (please note that there is no “s” at the end of the culture name when entering it)
  • Figures 3, 4, and 5 illustrate how to enter the specimen information.
Notes:Power Chart will not allow 2 identical lab tests to be ordered with the same time.
Enter ordering physician.Choose “electronic order” for Communication Type if you received a “nurse to order blood culture” communication order.Choose “electronic order” if you are reordering a previously entered order to provide more detailsChoose Medical Directive if you are initiating an order based on the Medical Directive guidelines
4. Enter Specimen TypeUnder Specimen Type choose “Venipuncture”, “Arterial Line Blood ” or “Central Line Blood “from the drop down boxChoose “Central Line Blood for a blood culture from a PICC, introducer, dialysis catheter or tunneled CVCIn theLabel Comment, type in the information that you would like to appear on your label that will help you to ensure that the label matches the sampleNotes:Knowledge of the source of the culture is very important to the interpretation and treatment decision.
5. Enter Priority and Body Site:In the Priority box, leave the default entry of “Routine”.Blood cultures cannot be done STAT.From the BODY SITE drop down box, choose Left or Right (for speed of entry, type Left or Right)Notes:Interpretation of results and treatment decisions depends upon a clear understanding of the sample.Blood cultures require a minimum period of time for growth.Other specimens such as bronchoscopy sample or CSF specimen can be done STAT (this will provide a gram stain report).
6. Enter Collection Time and Specimen DescriptionAdjust the ordering time for each blood culture sample (e.g., peripheral, arterial, central) to ensure they are at least one minute apart.In the Specimen Description box, enter the following information:Site of insertion (e.g, IJ, femoral)Type of line (e.g., IJ, PICC, HD)Date insertedIf this is a newly inserted line and the first sample being drawn, identify this as”newly inserted”. Samples drawn at the time of line insertion may be labelled as “venipuncture” if needed for the purpose of obtaining a CAB assessment.
7. Request Catheter Associated Bacteremia (CAB) AssessmentIf the patient has indwelling lines and thelines are not being immediately removed:
  • Select “Order Comments Folder” from the drop-down menu. “CAB” should be typed in. Venipuncture samples must be obtained within 15 minutes of the line sample. It is possible to get the requisite “venipuncture” sample by starting a fresh line. ‘Venipuncture’ must be the name of the procedure. It will not be possible to do a CAB evaluation without first collecting a venipuncture sample in the lab. To ensure that each set of cultures is properly documented, every effort should be taken to get a venipuncture.
If the indwelling line is being removed, send cultures and a tip culture, but DO NOT request CAB assessment.CAB (Catheter Associated Bacteremia) assessment provides a “time to positivity result”. If an indwelling line becomes positive by2 hours earlier than the peripheral sample, it suggests increased colonization of the catheter. If both the peripheral and line cultures become positive within 2 hours, it suggests bacteremia.Click to viewCatheter Associated Bacteremia algorithm(only available from within LHSC).CAB assessment is not needed if the catheter is being removed. A tip culture provides a quantitative evaluation of organisms. A colony count15 plus a positive blood culture is indicative of Catheter Associated Bacteremia.
8. Collect SpecimensPerform hand hygiene and don non-sterile gloves.Change the needleless access port prior to obtaining blood culturesScrub the top of each specimen bottle with a separate swabScrub vigorously in a horizontal direction using the first swab.Scrub vigorously in a vertical direction with the second swab.Allow the prep to dry FOR ONE FULL MINUTE before sampling.DO NOT DRAW A DISCARD SAMPLE UNLESS THERE ISCITRATE BLOCKING SOLUTION IN THE LINE. Collect a 10 ml sample for EACH bottle (discard volume is included in 10 ml sample). Citrate has antimicrobial properties, therefore, it should be removed from the sample before introducing it into the broth.Ensure that air does not enter the anaerobic bottle during collection.Remove non-sterile gloves and perform hand hygiene.Send samples down to lab in a biohazardous bag.Notes:Citrate may have antiseptic properties; a discard sample is required (e.g., for hemodialysis catheters).The back and forth scrubbing loosens bacteria and provides more effective disinfection of the site.The prep must dry to activate the antimicrobial properties.The Centre for Disease Control (CDC) recommends cleaning injection sites with 70% alcohol or iodophors. Chlorhexidine is recommended for skin preps and has not been studied for injection sites. Use of a product that includes alcohol is recommended.
9. Label SpecimensPlace labels on specimens. Select one of the small square barcodes and place on each bottle.Verify that the label name and patient are correct.Verify that the label matches the correct sample (e.g., arterial samples and arterial labels).Sign sample requisition and record time sample was drawn.Notes:Samples will be discarded by lab if unsigned.
10. DocumentMedical orders are required for blood sampling. Many routine lab tests can be ordered by a Critical Care Nurse by authority of Medical Directive.The reason for ordering a test or intervention by medical directive must be documented.
11. View Ordering InformationSelect the desired blood culture order from thefrom the Power Chart Flowsheet, Orders List or Task List.Right click and select “Orders Information”All of the information entered when the test was ordered is revealed.The name of the nurse who ordered the test is also displayed.Notes:Ordering information is available to aid in the interpretation of results.
Always log off, by exiting the patient’s chart.

Blood Culture

Test Name Blood CultureAerobic/Anaerobic
Alternate Name(s) (Information Unavailable)
Laboratory Module Microbiology
Ordering Mnemonic CBL
Specimen Type BLOOD CULTURE SETS Two sets of blood culturesfrom separate venipuncture sites, drawn within a 24 hour period and prior to antibiotic therapy, are recommended. If endocarditis is suspected, collect a third set. Venipunctures at least 30 minutes apart is the preferred method.Adult sets -consists of 1 aerobic bottle with a green flip cap and 1 anaerobic bottle with a orange cap. Second set consists of one aerobic bottle.(3 bottles in total).Pediatric collection -consists of a single bottle that has a yellow cap. Two bottles should be collected. ** See note below**Check the expiry date, on the container prior to use. There is a growth sensor in the bottom of the bottle. The sensor should be olive green, this also should visually be inspected prior to use.Gradations on the side of the bottle may help to measure volume of blood being introduced.IMPORTANT Bottles for adults should be inoculated with 8 to 10 mL per bottle. *Caution* – there is a strong draw on these bottles. DO NOT EXCEED the maximum 10 mL per bottle.Pediatric bottles should be inoculated with 2 to 4 mL.**Although the optimal conditions indicated above comply with best practice and manufacturer guidelines, it is recognized that with premature babies and other newborns it may not always be possible to perform more than one collection. In this case, it is imperative that the one bottle collected has the required minimum volume of 2 ml as the incidence of false negative results is high with the low volume collection***In any venipunture the blood cultures are always the first collected.
Collection Container Blood Culture Bottles(also known as BacT/Alert bottles)
Container Information AerobicAnaerobic Paediatric
Collection Information Blood can be collected by venipuncture or intavascular cathetersSite selection – Select a different site for each culture drawn.Avoiddrawing blood through indwelling catheters unless blood cannot be obtained by venipuncture or if diagnosis of catheter sepsis is suspected. (Do not palpate the vein without gloves on)Wash hands and don gloves.Apply tourniquet.Site Preparation – select vein appropriate for venipuncture. After selection has been made, remove tourniquet and cleanse the venipuncture site with the 0.5% chlorhexidine-70% isopropyl combination swab in a circular motion from the center of the puncture site outward covering a circular area of 1 1/2 to 2 inches in diameter for a minimum of 30 seconds. Allow to air dry and do not touch after cleansing.Culture Bottle Preparation – Flip cap off. Clean rubber septum with 70% alcohol. Allow to dry.Indicate on the blood culture label 10ml mark from the level of the media in each bottle prior to attempting collection. Blood will then be collected to this line.Clean tops of any other tubes to be collected.Vacutainer Collection – This method is preferable for adults.Perform venipuncture and collect vacutainer specimens for other tests first using adapter cuff. Use of insert is optional. Collect blood culture bottles. Inoculate aerobic bottle first so as not to introduce air into the anaerobic bottle which is inoculated second.Butterfly Needle Set – Preparation of site and bottles is the same as for vacutainer collection. Collect blood culture bottles.Needle/Syringe System – This method is preferred for children. Preparation of site and bottles is the same as for vacutainer collection. Collect blood in syringe, change needles and inject up to the pre-marked lines on the bottles. Inoculate aerobic bottle first so as not to introduce air.Gently mix bottles to avoid clotting.Labeling – Both blood culture bottles in the set must have the same collection number. Affix one large collection label to each of the bottles in the space provided. Do not cover the bottle bar code. Send all remaining labels in the specimen bag with the blood culture set.Initial the barcode labels and affix to bottles. Indicate the time of collection on the lead label.Apply band aid to venipuncture site.Dispose of any collection system needles in accordance with standard precautions. Adapter cuffs and inserts are not disposable. Clean and sterilize these by disinfecting in bleach.Remove gloves and wash/disinfect hands between each patient.Transport to laboratory promptly.Second set to be collected 30 minutes later.
Test Schedule Daily
Routine Turnaround Time Preliminary: 48 hours Final: 5 days
Stat Turnaround Time Preliminary: 48 hours Final: 5 days
Reference Interval (Information Unavailable)
Critical Values Positives are reported to designated health care provider upon detection.Cultures are incubated for 5 days.
Lab Process Notes The blood culture instrument used for detection of bacterial growth monitors the samples once every 10 minutes. Gram stain will be performed when growth is indicated.Recovery of organisms depends mainly on volume of blood collected and frequency of collection. Blood cultures should be collected prior to antimicrobial therapy.A single set should be discouraged as it is difficult to interpret results.When drawing simultaneously from an indwelling cather/PICC and a peripheral site. A complete set is draw from the line (1 aerobic bottle with a green flip cap and 1 anaerobic bottle with a orange cap) and a single aerobic bottle is drawn from the peripheral site.
Storage and Transport The specimens should be transported as soon as possible to the lab.
Test Referred To On site, BGH laboratory

Center for Phlebotomy Education: The Order of Draw:

Yes. Yes, you do. Despite the fact that evidence supporting the necessity for a certain order in which blood collection tubes should be filled was first published more than 30 years ago, the notion of sample collection order remains elusive to many healthcare professionals who are responsible for sample collection. It is explained in this article how additive carryover during the collecting procedure might influence the test result reported by the laboratory. It also outlines what might happen if the order of the draws is not followed in the game.

Both syringe and vacuum draws have the potential to cause this problem.

(According to the Occupational Safety and Health Administration, blood taken by syringe should be transferred to the tubes using a safety transfer device, rather than the same needle used to execute the venipuncture, as previously stated.) When tubes are replaced in a tube holder draw, carryover from the needle within the tube holder happens as the tubes are exchanged.

Patient posture is such that the tubes are inclined upright with relation to a horizontal plane, allowing them to fill from bottom to top as a result of this tilting.

When utilizing a tube holder, people who take blood samples may find that they are unable to maintain complete control over the position of the tubes as they are filled.

However, due to the fact that patients come with a broad variety of arm postures and that contamination of the needle that punctures the stopper cannot always be avoided, a court order is required.

When additives are carried over into a different tube type, the results of the test may be significantly influenced. As an illustration:

  • If the EDTA from a lavender-stopper tube, which has a high concentration of potassium, contaminates a potassium-testing tube (a green-, red-, gold-, or speckle-top tube), the potassium level may be mistakenly raised, resulting in potentially life-threatening medical errors
  • The prothrombin time (PT) or activated partial thromboplastin time (aPTT) may be fraudulently reduced if a clot activator is carried over into a tube to be examined for coagulation tests (blue stopper)
  • In the event that blood cultures are obtained at the same time as other lab work and are not filled first, germs from the non-sterile stoppers of the tubes might contaminate the bottles used to collect blood cultures.

Due to our knowledge of which additives are detrimental to certain tests, we are able to arrange the tubes and blood culture bottles in such a way that any carryover is rendered irrelevant. That is the sequence in which the draws will take place. When tubes are filled in the approved order of draw, any additive carryover that may occur will have no major influence on the test findings when tubes are filled in the appropriate order of draw. The sequence is universally applicable to both glass and plastic tubes, and it is not dependent on whether samples are pulled using a tube holder or a syringe or both.

  1. The following are examples of tubes: blood culture tubes
  2. Sodium citrate tubes (e.g., blue-stopper)
  3. Serum tubes with or without clot activator, with or without gel separator (e.g., red-, gold-, speckled-stopper)
  4. Heparin tubes with or without gel (e.g., green-stopper)
  5. EDTA tubes (e.g., lavender-stopper)
  6. Glycolytic inhibitor tubes (e.g., gray-stopper)
  7. And

The sequence of the draws has varied several times throughout the years, with the most recent alteration being in 2003. The move was necessitated by the industry-wide transition away from glass blood collecting tubes in favor of plastic. Plastic, on the other hand, is not a natural clot activator, although glass is. Enable this reason, in order for blood to coagulate in safer plastic tubes, manufacturers coat the interior of the tube with a chemical that facilitates clotting, such as silica particles, to make the tubes more clotting friendly.

When the venipuncture standard was amended in 2003, CLSI made a single adjustment to the sequence of draw based on the unanimous agreement of all major U.S.

This transformation was only achievable as a result of the debunking of a popular myth concerning tissue thromboplastin.

However, because several studies have demonstrated that tissue thromboplastin values are unaffected when the citrate tube is the first tube drawn, it was considered safe for NCCLS (now CLSI) to relocate the serum tube immediately after the citrate tube in the sequence of draw.

If this fundamental idea is overlooked, it can lead to medical errors that can be potentially fatal to the patient.

Is it mandatory to follow the order of the draw?

Note: To find any of the several articles we’ve published about the order of draw in our newsletter archives, simply type “Order of Draw” into the search box at the top of this page.

Additionally, please see our Free Stuff page if you would like to download an interactive PDF of this article to display at your facility.

More materials to help you promote the proper order of draw in your facility or training program:

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