In diagnosing a catheter-related bloodstream infection (CRBSI) 
multiple sets of bottles and a venipuncture are REQUIRED.  For a 
single draw from a catheter without a venipuncture please use Epic 
order LAB7646: BLOOD CULTURE - PEDIATRIC.

A blood culture "set" consists of an aerobic and anaerobic bottle.  To 
detect bacteremia with reasonable certainty, for each set, draw the 
following MINIMUM* volumes of blood and split this volume between two 
bottles as follows:

Prenatal/NICU < 1500g
Draw Volume:                  0.5 mL
Bottles to Inoculate:         Aerobic (blue top, 924171) 

Prenatal/NICU >1500g
Draw Volume:                  0.5-1.0 mL
Bottles to Inoculate:         Aerobic (blue top, 924171)
                              

Up to 1 year including newborn nursery
Draw Volume:                  1.0 mL
Bottles to Inoculate:         50%  Aerobic (blue top, 924171)
                              50% Anaerobic (purple top, 924172)

1+ years
Draw Volume:                  1 mL per year of age to maximum of 20 mL
Bottles to Inoculate:         50%  Aerobic (blue top, 924171)
                              50% Anaerobic (purple top, 924172)

 *To maximize volume, use the phlebotomy protocols listed below under
  Reference Links. 
**Do not exceed maximum of 2.5% of the estimated blood volume of the
  patient or 10 mL per bottle.  Filling bottles (10 mL each) may be
  appropriate for adult-size children regardless of age.

If molds, Blastomyces, Histoplasma, Nocardia, or Malassezia spp. are 
suspected, order: Microbiology: Fungus Blood Culture (LAB2217) as 
these organisms are not detected well by typical blood culture.  For 
detection of Candida bloodstream infection a fungal culture is 
unnecessary and inefficient, instead, draw the volume above and 
inoculate into two aerobic bottles.

Recommendations
1) For suspected CRBSI, 2 sets of bottles, with separate sets drawn
   from the catheter and a venipuncture, should be cultured before
   initiation of antimicrobial therapy, and the bottles should be
   appropriately marked to reflect the site from which the samples
   were obtained.  Fill bottles with equal volumes.

2) If a blood sample cannot be drawn from a venipuncture, it is
   recommended that at least 2 blood samples should be drawn through
   different catheter lumens.  In this case, check the boxes next to
   the "site #1, catheter" and "site #4, catheter" orders and fill in
   the source (e.g. "red lumen" or "PICC") for each in the individual
   orders that result.  Fill bottles with equal volumes. If a
   venipuncture cannot be obtained for what was intended to be a
   catheter draw, the documented source (catheter) will override the
   source on the initial order (venipuncture).

3) A definitive diagnosis of CRBSI is made when identical organisms
   are recovered from the catheter draw and venipuncture (or second
   lumen) cultures, and when the catheter culture is positive greater
   than or equal to 2 hours earlier than the peripheral culture.
   This "differential time to positivity" can be calculated from the
   time to positivity reported for each set in Epic.

Catheter Preparation
Refer to the Nursing standard of care for the appropriate pediatric 
service and hardware.

Skin Preparation
1) Clean the site with an alcohol pad, moving in a concentric circle.
   Allow the alcohol to dry.
2) Pediatric: Cleanse skin with ChloraPrep 1.5 mL Frepp Applicator
   (907672) 
NICU: Follow the NICU standard of practice for skin prep.
Open ChloraPrep applicator and squeeze the wings together to release 
the antiseptic.  Do not touch the sponge.  Wet the sponge by 
repeatedly pressing and releasing the sponge against the skin until 
the liquid is visible.  Scrub the site vigorously, with a side to side 
motion, for at least 30 seconds.  Allow the site to air dry for at 
least 30 seconds or until it is completely dry.
   2.1 (Alternate method) If the patient is allergic to chlorhexidine,
       prep site with a 30 second 70% alcohol scrub.  Let the site dry
       and then apply tincture of iodine in a concentric circle,
       starting at the center and let dry.
   2.2 (Alternate method) If the patient is allergic to chlorhexidine
        and iodine, scrub the site vigorously with 70% alcohol for 
        60 seconds and let dry.
3) Consult guidelines above for blood craw and bottle fill volumes.  As
   necessary, remove overcaps from bottles and cleanse each rubber
   septum with separate 70% alcohol swabs.  Allow septum to dry 1 min.
   before inoculating.
4) Draw and inoculate bottles according to the chart above.  Transport
   time <2 h.
5) Label bottles with either Cerner or Epic labels; do not cover the
   bar code label.  Record the time, collection site, and your
   initials.