Reducing Repeat Blood Cultures in Febrile Neutropenia: A Single-Center Experience

Abstract

Background Limited data exist to guide blood culture ordering in persistent febrile neutropenia, resulting in substantial variation in practice. Unnecessary repeat blood cultures have been associated with patient harm including increased antimicrobial exposure, hospital length of stay, catheter removal and overall cost. Methods We conducted a single-center study of adult hematology-oncology patients with ≥3 days of febrile neutropenia (FN). The yield of blood cultures was first evaluated in a two-year historical cohort. Additionally, a pilot PRE/POST-intervention study was performed in non-stem cell transplant (SCT) patients following a change in our population clinical practice guideline from a recommendation of daily blood cultures to a clinically-guided approach. The primary outcome was cultures collected per days of FN after day 3 of persistent FN. Results One-hundred forty-six episodes of ≥3 days of FN in 108 patients were identified during the historical period. Day 1 blood cultures were positive in 23/146 (16%) episodes. Blood cultures were drawn on 374/513 (73%) subsequent episode days (day 2-12) and were negative in 366/374 (98%). After the intervention, a 53% decrease was observed in the rate of total blood cultures collected (PRE 1.4 vs POST 0.7; p = 0.03). Blood cultures obtained after 48 hours rarely yielded clinically significant organisms. Conclusions Repeat blood cultures are low-yield in persistent FN without new clinical change. A pilot intervention in non-SCT patients successfully reduced the frequency of blood culture collection.

Yield of repeat blood cultures in acute myeloid leukemia patients with febrile neutropenia and bacteremia following allogeneic hematopoietic stem cell transplant

“…In this study, we found a low yield of repeat blood cultures after positive initial blood culture and an even lower yield of repeat positive blood cultures with a new pathogen, which is similar to findings in prior studies. [6][7][8][9] In addition, only one of 50 episodes of FN had an instance of positive repeat culture following a negative repeat culture.…”

Changing the culture of blood cultures: Opportunities for diagnostic stewardship in febrile neutropenia

“…However, this population has much to gain from diagnostic stewardship: reduced phlebotomy in patients who need frequent transfusions, less frequent detection of blood culture contaminants, improved antimicrobial use, and more accurate diagnosis of hospital-associated infections. [1][2][3][4][5] Ultimately, the balance between early detection of an infectious pathogen and avoidance of over-testing remains elusive in febrile neutropenia diagnostic investigations.…”

“…Though there are limited studies evaluating the impact of diagnostic stewardship in immunocompromised patients -including those with hematologic malignancies and recipients of solid organ transplants, hematopoietic cell transplants (HCT), or other cellular therapies -there is a growing body of literature suggesting that diagnostic stewardship can be feasible, safe, and effective even in this population who is at high risk for serious infections. [4][5][6] Several diagnostic stewardship opportunities that have been proposed for transplant recipients include appropriate stool testing for Clostridioides difficile infections, judicious use of urine cultures to reduce treatment of asymptomatic bacteriuria, targeted diagnostic testing of respiratory samples and limiting the use of surveillance blood cultures. 5,6 Febrile neutropenia, a common complication in patients with hematologic malignancies and HCT recipients, involves high utilization of diagnostic tests and presents unique diagnostic stewardship opportunities.…”

“…8 Furthermore, identification of an organism different than that in the initial positive blood culture or identification of a newly positive repeat blood culture after a preceding negative repeat blood culture was rare, 8 a finding that is also supported by previous studies investigating the yield of repeat blood cultures in febrile neutropenia. 4,9,10 Blood cultures are an essential diagnostic tool in the setting of severe sepsis and other clinical scenarios where there is a high probability of bacteremia or endovascular infection 2 and are recommended by the Infectious Diseases Society of America during the first 3 days of febrile neutropenia. 7 While it is common clinical practice to repeat blood cultures to document clearance of endovascular infections caused by certain organisms such as Staphylococcus aureus, time to repeat blood cultures is an important consideration, that is, has a patient received at least 24 h of effective therapy to allow for clearance?…”