Beginning today, May 21, 2013, a new pediatric blood culture order will be implemented in Epic at the University of Iowa Hospitals and Clinics.  This order replaces the generic order currently in place for pediatric patients.  The new order reflects best practices in pediatric blood culture and is the result of a collaboration between the Departments of Pediatrics and Pathology faculty, Diagnostic Services Subcommittee, and Iatrogenic Blood Loss Committee.

The inpatient Phlebotomy service currently utilizes a protocol similar to the one attached below.  Other services may find that this order suggests changes to common practices regarding the type (aerobic and anaerobic) and number of blood culture bottles used and the volumes of blood drawn on pediatric patients.

The text of the new order follows.

Collection Information

A single set of blood cultures to detect BSIs is inadequate. See Blood Culture SmartSets to request multiple sets.

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:	50%  Aerobic (blue top, 924171)
	50% Anaerobic (purple top, 924172)
Up to 1 year:
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
Bottles to Inoculate:	50%  Aerobic (blue top, 924171)
	50% Anaerobic (purple top, 924172)

*To maximize volume, use the phlebotomy protocols at:
http://www.healthcare.uiowa.edu/path_handbook/Bulletin_pdfs/PHL-6.pdf
http://www.healthcare.uiowa.edu/path_handbook/Bulletin_pdfs/PHL-12.pdf

**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 culture of Candida bacteremia, a fungal culture is unnecessary and inefficient: instead, draw the volume above and inoculate into two aerobic bottles.

Draw Procedure:

Recommendations

• For suspected bloodstream infection (BSI), collect 2 sets (4 bottles) prior to antibiotic therapy (except for NICU infants < 1500 grams; see table above) from separate sites followed by a 3rd set after 4-6 hours.

Skin Preparation

• Pediatric: Cleanse skin with ChloraPrep 1.5 mL Frepp Applicator (907672)
• NICU: Follow the NICU standard of practice for skin prep.
• Hold the applicator sponge downward, pinch wings on applicator to break ampule and release antiseptic. Apply in concentric circles (start at center). Allow to dry > 1 min before venipuncture. If patient is also allergic to iodine, cleanse site with 70% alcohol for 1 min.
• Use side-to-side motion to scrub the site with the pad for > 30 sec; allow site to dry completely (> 30 sec) before venipuncture. Do not touch site after prep.

Inoculation

• Consult guidelines above for blood draw 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.
• Draw and inoculate bottles according to the chart above. Transport time <2 h.
• Label bottles with either Cerner or EPIC labels; do not cover the bar code label. Record the time, collection site, and your initials.

Questions concerning testing can be directed to Bradley Ford, MD, PhD,  Associate Medical Director of Microbiology, (ext. 6-2990, bradley-ford-1@uiowa.edu).