Diagnostic yield of routine daily blood culture in patients on veno-arterial extracorporeal membrane oxygenation

Abstract

Background Bloodstream infections (BSIs) are frequent on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Performing routine blood cultures (BCs) may identify early paucisymptomatic BSIs. We investigated the contribution of systematic daily BCs to detect BSIs on V-A ECMO. Methods This was a retrospective study including all adult patients requiring V-A ECMO and surviving more than 24 h. Our protocol included routine daily BCs, from V-A ECMO insertion up to 5 days after withdrawal; other BCs were performed on-demand. Results On the 150 V-A ECMO included, 2146 BCs were performed (1162 routine and 984 on-demand BCs); 190 (9%) were positive, including 68 contaminants. Fifty-one (4%) routine BCs revealed BSIs; meanwhile, 71 (7%) on-demand BCs revealed BSIs (p = 0.005). Performing routine BCs was negatively associated with BSIs diagnosis (OR 0.55, 95% CI [0.38; 0.81], p = 0.002). However, 16 (31%) BSIs diagnosed by routine BCs would have been missed by on-demand BCs. Independent variables for BSIs diagnosis after routine BCs were: V-A ECMO for cardiac graft failure (OR 2.43, 95% CI [1.20; 4.92], p = 0.013) and sampling with on-going antimicrobial therapy (OR 2.15, 95% CI [1.08; 4.27], p = 0.029) or renal replacement therapy (OR 2.05, 95% CI [1.10; 3.81], p = 0.008). Without these three conditions, only two BSIs diagnosed with routine BCs would have been missed by on-demand BCs sampling. Conclusions Although routine daily BCs are less effective than on-demand BCs and expose to contamination and inappropriate antimicrobial therapy, a policy restricted to on-demand BCs would omit a significant proportion of BSIs. This argues for a tailored approach to routine daily BCs on V-A ECMO, based on risk factors for positivity.

First nosocomial infections in children supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO)

“…In children, O’Neil et al showed that most infections occurred during the first week and Cashen et al described a similar timing nearly 20 years later [ 4 , 6 ]. Interestingly, in adults, two reports by de Roux et al and Schmidt et al found a similar timing of infection with high incidences during the first 7 days of VA-ECMO [ 13 , 14 ]. Our data supports such timing as well and recommend clinicians to be particularly aware of the risk of infections even during the first days of VA-ECMO support.…”

“…First, our institutional protocol did not recommend the use of routine blood cultures. Such practice is under debate in the literature, but some interesting data suggest it could be beneficial in certain high-risk situations and it may help to identify earlier bacteriemia [ 13 ]. Second, even if our institutional protocol did not recommend antibiotic prophylaxis, it is notable that the vast majority of patients had in fact an antibiotherapy in place at VA-ECMO initiation.…”

Biofilm Assessment and Metagenomic Analysis of Venoarterial Extracorporeal Membrane Oxygenation Cannulas and Membrane Oxygenators

“…Fourth, blood cultures were not systemically performed in four on 10 patients; thus we could have underestimated the rate of bacteremia. 33 Fifth, surgical cannulation of VA-ECMO as it is performed in our institution is associated with a higher rate of local infection compared to percutaneous cannulation. 34,35 It could lead to a higher rate of infection in our cohort compared to other studies.…”

Nosocomial infections during extracorporeal membrane oxygenation

“…Routine surveillance blood cultures are common practice according to an ELSO survey [33], despite past studies not showing any support for this practice [34] and concerns about the potential risk for inappropriate antibiotic treatment for contaminants and increased transfusion requirements after repeated blood extractions. However, a recent retrospective single centre study including 150 patients requiring V-A ECMO support showed that even though routine blood cultures identified significantly less BSI than on-demand clinically prescribed ones, a third of BSI would have been missed by on-demand cultures alone [35 ▪▪ ]. The sensitivity of on-demand cultures improved after identifying and removing patients with risk factors for positivity.…”