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(Chest. 2003;123:854-861.)
© 2003 American College of Chest Physicians

Clinical Utility of Blood Cultures Drawn From Central Vein Catheters and Peripheral Venipuncture in Critically Ill Medical Patients*

Michelle Beutz, MD; Glenda Sherman, RN; Jennie Mayfield, RN; Victoria J. Fraser, MD and Marin H. Kollef, MD, FCCP

* From the Pulmonary and Critical Care Division (Drs. Beutz and Kollef) and Division of Infectious Diseases (Dr. Fraser), Washington University School of Medicine; and Departments of Nursing (Ms. Sherman) and Infection Control (Ms. Mayfield), Barnes-Jewish Hospital, St. Louis, MO.

Correspondence to: Marin H. Kollef, MD, FCCP, Pulmonary and Critical Care Division, Washington University School of Medicine, Box 8052, 660 South Euclid Ave, St. Louis, MO 63110; e-mail: kollefm{at}msnotes.wustl.edu


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objective: To determine the sensitivity, specificity, and positive and negative predictive values of blood cultures obtained through a central vein catheter compared with peripheral venipuncture.

Design: Prospective cohort study.

Setting: A medical ICU (19 beds) from a university-affiliated urban teaching hospital.

Patients: Between February 2001 and October 2001, 300 paired blood culture specimens were obtained from 119 patients (2.52 paired cultures per patient).

Intervention: Prospective patient surveillance and data collection.

Measurements and main results: Thirty-four paired culture results (11.3%; 95% confidence interval, 7.8 to 14.8%) were accepted as true-positives representing a true bacteremia. The sensitivity of catheter-drawn and peripheral venipuncture samples was 82.4% and 64.7%, respectively, and specificity was 92.5% and 95.9%. The positive predictive value was 58.3% for catheter-drawn samples and 66.7% for peripheral venipuncture samples, and the respective negative predictive values were 97.6% and 95.5%.

Conclusions: In critically ill medical patients, the negative predictive value of blood samples obtained by catheter draw or peripheral venipuncture for suspected bloodstream infection is good. However, the sensitivity of blood samples obtained by either catheter draw or peripheral venipuncture alone is not adequate to recommend the elimination of blood samples obtained from the other site. Clinicians should also be aware that additional blood samples may be necessary when interpreting positive blood culture results for common skin or central vein catheter contaminants.

Key Words: antibiotics • bacteremia • critical care • infection • intensive care


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Bloodstream infections are among the most serious infections acquired by hospitalized patients requiring intensive care. Early diagnosis of bloodstream infections and treatment with appropriate antibiotics are important clinical practices aimed at reducing the morbidity and mortality associated with this infection.1 2 Most patients in the ICU have central vein catheters that predispose to bloodstream infection with antibiotic-resistant bacteria.3 However, these catheters also provide ready access for the collection of blood samples. Several published reports discourage the use of central vein catheters for the collection of blood culture specimens due to concerns of contamination.4 5 6 However, studies performed in surgical patients and hospitalized patients with malignancy suggest that blood culture samples drawn from central vein catheters can be useful to exclude the presence of bloodstream infection.7 8 Similar data in critically ill medical patients have not been described. The evaluation of this population seems desirable given the large number of such patients and the heterogeneous nature of critically ill medical patients.3

We performed a study with two main goals. The first goal was to determine the overall yield of blood samples for true bacteremia obtained in medical patients admitted to an ICU. The second goal was to compare the performance of blood samples drawn from a central vein catheter and peripheral venipuncture. This investigation was undertaken to provide data that might improve the overall management of critically ill medical patients with suspected bloodstream infection.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Study Location and Study Population
Barnes-Jewish Hospital, a university-affiliated teaching hospital, is a 1,000-bed primary and tertiary care facility in St. Louis, MO. On average, 1,600 patients are admitted to the medical ICU annually. All patients admitted to the medical ICU between February 1, 2001 and October 30, 2001, were prospectively followed up by one of the investigators (M.B.) and surveyed for the acquisition of blood culture specimens. The medical ICU is a closed unit with medical house officers under the direct supervision of attending physicians board certified in critical care medicine. This study was approved by the Washington University School of Medicine Human Studies Committee as an observational study.

Outcome Measures
The main outcome measures were the sensitivity, specificity, and positive and negative predictive values of blood samples obtained with catheter draws and peripheral venipuncture for the presence of true bacteremia. The medical ICU has a standing protocol that directs the nursing staff to obtain blood culture specimens at least once daily when any patient’s temperature exceeds 38.3°C, and as ordered by the patient’s treating physician. Blood culture specimens can be drawn more than once daily if the patient has repeated temperatures exceeding 38.3°C. However, these additional blood culture specimens require approval from the patient’s treating physician.

Definitions
A paired culture was defined as at least one blood sample clearly labeled as drawn from a central vein catheter and at least one blood sample drawn by peripheral venipuncture. Blood samples had to be drawn within 4 h of each other as recorded by the patient’s ICU nurse in the bedside computer (EMTEK Health Care Systems; Tempe, AZ). Reasons for excluding blood samples from analysis included the following: only one blood sample was drawn (no paired cultures available), samples were drawn > 4 h apart, or when the source where the blood sample was drawn from was not clearly identified. Multiple blood sample pairs from the same patient were allowed if they were drawn at least 24 h apart from one another.

The diagnostic criteria used for establishing the presence of a true bacteremia were adapted from previous investigations.7 8 Two of the study physicians blinded to the site of blood collection classified paired cultures with at least one positive result as true bacteremia (or fungemia) if the following criteria were met: (1) certain pathogens, such as Staphylococcus aureus, Gram-negative bacilli, and Candida species isolated from any culture sample represented true bacteremia or fungemia; or (2) common skin contaminants (coagulase-negative staphylococci, diptheroids, Propionobacterium species, Bacillus species, or Micrococcus species) or viridans streptococci isolated from two or more culture samples from different sites and associated with fever (body temperature > 38.3°C), rigors, or hypotension (systolic BP < 90 mm Hg) were considered true bacteremias. Polymicrobial infection with the same organisms in more than one culture sample were also considered to represent true bacteremia if associated with fever (body temperature > 38.3°C), rigors, or hypotension (systolic BP < 90 mm Hg). When the above-mentioned criteria were not applicable, two study physicians reviewed available clinical data including all other culture results, antibiotic utilization, and the patient’s clinical course to make a determination as to the presence or absence of true bacteremia. All other paired specimens with a positive culture finding were classified as representing contamination. The definition used for sepsis was established by the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference.9

Fecal culture specimens for vancomycin-resistant enterococci (VRE) are routinely obtained in all patients admitted to the medical ICU at admission, every 7 days, and at the time of transfer out of the unit. Patients with a fecal culture result positive for VRE were classified as being "VRE positive." Acute renal failure was defined as a twofold increase in baseline creatinine or an absolute increase in creatinine by 176.8 mol/L (2.0 mg/dL). Acute respiratory failure was defined by the requirement for mechanical ventilation for a diagnosis of COPD or a PaO2 < 60 mm Hg while receiving a fraction of inspired oxygen >= 0.50, or the use of >= 10 cm H2O of positive end-expiratory pressure.

Blood Culture Technique
Blood samples were obtained by critical care nurses caring for the patient. Before collecting the blood sample, skin was disinfected with 70% isopropyl alcohol followed by 2% iodine tincture. The antecubital fossa was the preferred sampling site using a sterile needle and syringe. The blood samples from central vein catheters were obtained from needleless caps that were disinfected with 70% isopropyl alcohol, allowed to dry, and wiped with a Betadine pad (Cepti-seal; Blood Culture Prep Kit II; Medi-Flex Hospital Products; Overland Park, KS) for 30 s. The excess Betadine was wiped off with sterile gauze prior to obtaining the sample. Three milliliters of blood were aspirated and discarded from both the central vein catheter and peripheral venipuncture. A new syringe was used to aspirate an additional 20 mL of blood. A blood volume of 10 mL was injected into each of two blood culture bottles. Injection of <= 5 mL of blood into a blood culture bottle was not permitted to avoid false-negative results.10 11 All blood samples were inoculated into aerobic and anaerobic media and processed using the Bactec Blood Culture system (Bactec; Becton Dickinson; Sparks, MD).

Statistical Analysis
All values are expressed as mean ± SD (continuous variables) or as a percentage of the group from which they were derived (categorical variables). Continuous variables were compared using the Student t test. The {chi}2 test was used to compare categorical variables. All p values were two tailed, and p <= 0.05 was considered to indicate statistical significance.

The influence of prevalence of true bacteremia on the operating characteristics of blood cultures obtained with peripheral venipuncture and through a central vein catheter was assessed using a range of prevalence values that could be expected to occur in clinical practice. This modeling method was used to estimate the changes in the predictive accuracy of the two blood culture techniques over this range of prevalence values.7 8

To identify variables independently associated with the presence of true bacteremia (dependent variable), a multiple logistic regression model was used to control for the effects of confounding variables.12 13 A stepwise approach was used to enter new terms into the logistic regression model, where 0.05 was set as the limit for the acceptance or removal of new terms. Variables entered into the logistic regression model were required a priori to have a plausible biological relationship to the dependent outcome variable in order to avoid spurious associations.14 Model overfitting was examined by evaluating the ratio of outcome events to the total number of independent variables in the final model, and specific testing for interactions between the independent variables was included in our analysis.14 Results of the logistic regression analyses are reported as adjusted odds ratios with 95% confidence intervals (CIs).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Culture Results and Clinical Characteristics
During the study period, 300 blood culture sets met our criteria for a paired blood draw from a central vein catheter and peripheral venipuncture. These 300 paired cultures were obtained from 119 patients (2.52 culture pairs per patient). For purposes of analysis, each paired blood culture constituted an independent observation. Catheter-negative/venipuncture-negative results accounted for 235 of the paired cultures (78.3%). Sixty-five paired cultures (21.7%) had at least one positive result; of these, 16 results (5.3%) were catheter-positive/venipuncture-positive, 17 results (5.7%) were catheter-negative/venipuncture-positive, and 32 results (10.7%) were catheter-positive/venipuncture-negative. Of the 300 paired blood samples, 223 were drawn from temporary multilumen central vein catheters (74.3%), 33 were from Hohn catheters (Bard; Salt Lake City, UT) [11.0%], 15 were from a multilumen dialysis catheter (5.0%), 13 were from a Cordis catheter (Arrow International; Reading, PA) placed in conjunction with a pulmonary artery catheter (4.3%), 10 were from other types of multilumen catheters (3.3%), 5 were from subcutaneous ports (1.7%), and 1 was from a catheter placed in a central vein from a peripheral vein site (0.3%).

Thirty-four paired culture results (11.3%; 95% CI, 7.8 to 14.8%) were accepted as true-positives representing a true bacteremia. This represented the occurrence of at least one episode of true bacteremia in 25 patients (1.36 episodes of true bacteremia per patient). Two of these (5.9%) were specimens that did not meet the preset criteria for true bacteremia and required confirmation from two study physicians. Each of these was a single positive blood culture result of a common skin contaminant in patients with evidence of sepsis and no other source of identifiable infection. In one of these cases, the central line was removed and the culture of the catheter tip grew the same organism identified in the single blood culture. Among the 34 paired culture results representing true bacteremia, 8 were classified as secondary bacteremias (23.5%). The infections associated with secondary bacteremia included pneumonia (n = 5), soft tissue/wound (n = 2), and urinary tract (n = 1).

The patient characteristics associated with blood specimens representing a true bacteremia and those negative for bacteremia are shown in Table 1 . The absence of IV antibiotics administered through the central vein catheter at the time blood samples were drawn was statistically more common among patients with a true bacteremia. Table 2 compares the characteristics of the central vein catheters through which the catheter drawn blood samples were obtained. Patients with a true bacteremia had their central vein catheters placed statistically later during their ICU stays, and the line day blood culture samples were drawn was statistically greater compared to patients negative for true bacteremia. In addition to patient and central vein catheter characteristics, patients with multiple pairs of blood samples were statistically more likely to have true bacteremia compared to patients having a single blood sample pair (20 true bacteremias among 70 patients [28.6%] vs 5 true bacteremias among 49 patients [10.2%]; p = 0.015).


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  		Table 1.. Patient Characteristics Associated With Blood Culture Specimens Classified as True Bacteremia or Negative for True Bacteremia*

 

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  		Table 2.. Central Vein Catheter Characteristics Associated With Blood Culture Specimens Classified as True Bacteremia or Negative for True Bacteremia*

 
Logistic regression analysis demonstrated that the absence of IV antibiotic administration at the time blood samples were drawn was the only variable independently associated with true bacteremia (adjusted odds ratio, 2.62; 95% CI, 1.64 to 4.18; p = 0.039). Among the blood samples drawn while patients were receiving IV antibiotics, 16.0% of the blood samples representing true bacteremia were drawn from patients receiving vancomycin, compared to 26.6% of the samples not classified as true bacteremia (p = 0.273). Similarly, 20.0% of the blood samples representing true bacteremia were drawn from patients receiving at least one of our ICU formulary antibiotics directed against Gram-negative bacteria (ie, ciprofloxacin, imipenem, pipercillin-tazobactam, cefepime, tobramycin, gentamicin), compared to 55.3% of the samples not classified as true bacteremia (p = 0.002).

All 235 catheter-negative/venipuncture-negative paired culture results were accepted as true-negatives. All 16 catheter-positive/venipuncture-positive paired culture results were classified as true bacteremia or fungemia. True bacteremia was determined to be present in 6 of 17 catheter-negative/venipuncture-positive pairs (35.3%), and in 12 of 32 catheter-positive/venipuncture-negative pairs (37.5%). The pathogens isolated from the paired cultures for each category are shown in Table 3 .


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  		Table 3.. Organisms Isolated From the Paired Blood Cultures*

 
Performance of Catheter-Drawn and Peripheral Venipuncture Blood Samples
Using our definition of true bacteremia, sensitivity was 82.4% for a blood sample drawn from a central vein catheter and 64.7% for peripheral venipuncture samples (Table 4 ). Blood samples drawn from central vein catheters and peripheral venipuncture were similar in specificity, 92.5% and 95.9%, respectively. The positive predictive value was 58.3% for blood obtained from a catheter draw and 66.7% for peripheral venipuncture; the respective negative predictive values were 97.6% and 95.5%. The effect of prevalence of true bacteremia over a range from 2 to 30% on posterior probabilities is illustrated in Figure 1 . Negative predictive values decreased from 99.6 to 92.2% for catheter-drawn samples and from 99.3 to 86.2% for peripheral venipuncture blood samples. The positive predictive value increased from 19.2 to 77.9% for catheter-drawn blood samples and from 28.6 to 85.3% for peripheral venipuncture samples over the same range of true bacteremia prevalence.


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  		Table 4.. Comparison of Blood Cultures Obtained Through a Central Venous Catheter or Peripheral Venipuncture

 


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  		Figure 1.. Comparison of positive predictive values (PPVs) and negative predictive values (NPVs) of blood drawn for culture by peripheral venipuncture or through a central vein catheter using sensitivity and specificity for each test result over a prevalence range of bacteremia from 2 to 30%. The vertical line represents the prevalence of 11.3% observed in the study.

 
Hospital Mortality
The overall mortality of the 119 patients having paired blood cultures drawn was 41.2%. Univariate analysis demonstrated that hospital nonsurvivors were statistically older than hospital survivors (62.8 ± 16.2 years vs 51.8 ± 16.3 years; p < 0.001) and that hospital nonsurvivors had significantly greater APACHE (acute physiology and chronic health evaluation) II scores (27.3 ± 7.1 vs 24.0 ± 7.4; p = 0.018). There was no significant difference in the hospital mortality rate of patients with a true bacteremia compared to patients without a bloodstream infection (44.0% vs 40.4%; p = 0.747). There was also no significant difference in the mortality rate of patients with a true bacteremia compared to patients without true bacteremia, but with a positive blood culture result considered to represent contamination (44.0% vs 29.8%; p = 0.282).


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
We found that the overall rate of true bacteremia was 11.3% for blood samples drawn from our medical ICU population. The negative predictive value of catheter drawn blood was 97.6% compared to a value of 95.5% for blood obtained by peripheral venipuncture. However, the negative predictive value of these cultures is predicted to decrease to 92.2% and 86.8%, respectively, as the prevalence of true-positive bloodstream infections increases to 30% (Fig 1) . This suggests that a negative blood culture result, obtained with either peripheral venipuncture or through a central vein catheter, should be interpreted cautiously in ICU populations with high prevalence rates of bacteremia. We also found that six blood samples drawn from central vein catheters tested negative in patients with a true bloodstream infection as supported by positive venipuncture cultures (three S aureus bacteremias, one Candida bloodstream infection, and two enterococcal bacteremias). These findings also raise caution in the interpretation of blood cultures obtained from catheter draws, particularly in patient populations with a high prevalence for bloodstream infection or receiving antibiotics through their central vein catheters.

Our investigation is unique in evaluating medical patients in the ICU setting with suspected bloodstream infection. DesJardin et al7 found the negative predictive value for catheter-drawn and peripheral venipuncture cultures to be 99% and 98%, respectively, with little decrement over the prevalence range of positive blood culture results for hospitalized patients with cancer. The same investigators found similar results for critically ill surgical patients.8 Our study uniquely identified the presence of IV antibiotic administration as a potential confounding factor when interpreting blood culture results. Patients receiving IV antibiotics were statistically less likely to have a true bacteremia. Similar findings have been made with regards to BAL and protected specimen brush cultures for the evaluation of ventilator-associated pneumonia.15 16 However, unlike pneumonia, where histology can serve as a "gold standard" for the diagnosis of infection, true bacteremia has no other diagnostic "gold standard." Antibiotic administration has also been shown to interfere with the interpretation of cerebral spinal fluid culture specimens obtained to diagnose bacterial meningitis.17 18

Comparisons of blood cultures obtained by peripheral venipuncture and from central vein catheters for the detection of catheter colonization or catheter-related infection have also been performed. Juste et al19 found that the sensitivity and specificity of peripheral venipunture (41.5% and 77.7%, respectively) were similar to the sensitivity and specificity of culture results obtained from the catheter hubs (50.8% and 78.9%, respectively) for the identification of microorganisms colonizing the catheters. Similarly, Blot et al20 evaluated the accuracy of peripheral venipuncture and central vein catheter cultures for the diagnosis of catheter-associated bacteremia. They identified 28 instances where the same microorganisms were isolated from peripheral venipuncture cultures and catheter-drawn cultures. A definite diagnosis of catheter-related bacteremia was established in 16 of 17 patients whose catheter-drawn culture results were positive at least 2 h earlier than the peripheral venipuncture cultures. These data suggest that paired blood cultures obtained by peripheral venipuncture and from catheter draws can be helpful in the identification of catheter-related infections.

The relatively low positive predictive value of blood samples obtained from catheter draws is concerning for several reasons. First, treating contamination as infection can potentially prolong hospitalization and increase medical care costs.21 22 Second, antibiotic treatment may be needlessly started based on false-positive culture results.6 This increases the possibility that resistant bacteria can emerge resulting in more difficult to treat infections. Bloodstream infections are usually treated with at least 10 to 14 days of antibiotic therapy.23 This duration of treatment has been shown to be an important risk factor for the subsequent emergence of infections with antibiotic-resistant bacteria.24 Although the negative predictive value was relatively good for blood samples drawn through central vein catheters, there are important consequences associated with missing the diagnosis of bloodstream infection. Previous studies have identified a significant association between the administration of inadequate antimicrobial treatment of bloodstream infections and hospital mortality.2 25 26 27 28 29 A more recent study of medical and surgical patients requiring critical care found that individuals with a bloodstream infection who received initially inadequate antibiotic treatment had a significantly greater hospital mortality rate compared to patients receiving an adequate initial antibiotic regimen (61.9% vs 28.4%; p < 0.001).30 These data emphasize the importance of establishing an accurate diagnosis of bloodstream infection among hospitalized patients in order to begin treatment with an adequate antimicrobial regimen as soon as possible.

Our study has several limitations. First, it was conducted at a single hospital. Therefore, the results may not be applicable to ICUs with different patterns of central vein catheter utilization and different rates of bloodstream infection. Second, we allowed the inclusion of multiple blood culture specimens from individual patients. This may have prevented us from identifying additional factors predictive of true bacteremia as a result of the limited number of patients examined. We also could not evaluate the yield of blood cultures from patients having a single pair of culture samples drawn compared to patients having multiple sets of culture samples drawn. This may be an important area for future investigation, as our data suggest that multiple blood cultures are more often associated with patients having true bacteremia. Additionally, no "gold standard," other than a positive blood culture result, exists to define the presence of true bacteremia. As a result, we cannot be completely confident that some of our blood culture results were not misclassified. Finally, we did not routinely culture central vein catheters when they were removed. This prevented us from accurately determining the number of bacteremias due to catheter-associated infection.

In summary, blood culture specimens are commonly obtained in the ICU setting. Clinicians should be aware of the potential limitations of these samples to define the presence or absence of true bacteremia. We recommend that when a central vein catheter is present, one pair of blood samples should be obtained from the central vein catheter and the other via peripheral venipuncture. When the central vein catheter and peripheral venipuncture samples are concordant, then antimicrobial management should be straightforward. The main problem arises when the samples are discordant. Clinicians caring for patients will have to decide if the discordant positive culture represents true bloodstream infection or contamination. This may require obtaining additional cultures, monitoring the patient’s clinical status closely, and possibly beginning antibiotic treatment with or without the removal of the central vein catheter when catheter-associated bloodstream infection is suspected.31


   Acknowledgements
 
The authors thank the nursing staff of the Barnes-Jewish Hospital Medical ICU for their assistance in this investigation.


   Footnotes
 
Abbreviations: CI = confidence interval; VRE = vancomycin-resistant enterococci

Received for publication March 4, 2002. Accepted for publication July 10, 2002.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Ibrahim, EH, Sherman, G, Ward, S, et al (2000) The influence of inadequate antimicrobial treatment of blood stream infections on patient outcomes in the ICU setting. Chest 118,146-155[CrossRef][ISI][Medline]
  2. Weinstein, MP, Towns, ML, Quartey, SM, et al The clinical significance of positive blood cultures in the 1990s: a prospective comprehensive evaluation of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults. Clin Infect Dis 1997;24,584-602[ISI][Medline]
  3. Richards, MJ, Edwards, JR, Culver, DH, et al Nosocomial infections in medical intensive care units in the United States: National Nosocomial Infections Surveillance System. Crit Care Med 1999;27,887-892[CrossRef][ISI][Medline]
  4. Aronson, MD, Bor, DH Blood cultures. Ann Intern Med 1987;106,246-253[ISI][Medline]
  5. Weinstein, MD Current blood culture methods and systems: clinical concepts, technology, and interpretation of results. Clin Infect Dis 1996;23,40-46[ISI][Medline]
  6. Bates, DW, Goldman, L, Lee, TH Contaminated blood cultures and resource utilization: the true consequences of false-positive results. JAMA 1991;265,365-369[Abstract]
  7. DesJardin, JA, Falagas, ME, Ruthazen, R, et al Clinical utility of blood cultures drawn from indwelling central venous catheters in hospitalized patients with cancer. Ann Intern Med 1999;131,641-647[Abstract/Free Full Text]
  8. Martinez, JA, DesJardin, JA, Aronoff, M, et al Clinical utility of blood cultures drawn from central venous or arterial catheters in surgical patients. Crit Care Med 2002;30,7-13[CrossRef][ISI][Medline]
  9. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Definitions for sepsis and multiple organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992;101,1644-1655[Medline]
  10. Tenney, JH, Reller, LB, Mirrett, S, et al Controlled evaluation of the volume of blood cultured in detection of bacteremia and fungemia. J Clin Microbiol 1982;15,558-561[Abstract/Free Full Text]
  11. Weinstein, MP, Mirrett, S, Wilson, ML, et al Controlled evaluation of 5 vs 10 milliliters of blood cultured in aerobic BacT/Alert blood culture bottles. J Clin Microbiol 1994;32,2103-2106[Abstract/Free Full Text]
  12. Meinert, CL, Tonascia, S Clinical trials: design, conduct, and analysis. 1986,194-195 Oxford University Press New York, NY.
  13. SAS/STAT user’s guide (vol 2). 1990,1071-1126 SAS Institute Cary, NC.
  14. Concato, J, Feinstein, AR, Holford, TR The risk of determining risk with multivariate models. Ann Intern Med 1993;118,201-210[Abstract/Free Full Text]
  15. Dotson, RG, Pingleton, SK The effect of antibiotic therapy on recovery of intracellular bacteria from bronchoalveolar lavage in suspected ventilator-associated nosocomial pneumonia. Chest 1993;103,541-546[Medline]
  16. Wermert, D, Marquette, CH, Copin, MC, et al Influence of pulmonary bacteriology and histology on the yield of diagnostic procedures in ventilator-associated pneumonia. Am J Respir Crit Care Med 1998;158,139-147[Medline]
  17. Sigurdardottir, B, Björnsson, O, Jonsdottir, K, et al Acute bacterial meningitis in adults. Arch Intern Med 1997;157,425-430[Abstract]
  18. Kanegaye, JT, Soliemanzadeh, P, Bradley, JS Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics 2001;108,1169-1174[Abstract/Free Full Text]
  19. Juste, RN, Hannan, M, Glendenning, A, et al Central venous blood culture: a useful test for catheter colonization? Intensive Care Med 2000;26,1373-1375[CrossRef][ISI][Medline]
  20. Blot, F, Nitenberg, G, Chachaty, E, et al Diagnosis of catheter-related bacteraemia: a prospective comparison of the time to positivity of hub-blood vs peripheral-blood cultures. Lancet 1999;354,1071-1077[CrossRef][ISI][Medline]
  21. Vaisanen, IT, Michelsen, T, Valtonen, V, et al Comparison of arterial and venous blood samples for the diagnosis of bacteremia in critically ill patients. Crit Care Med 1985;13,664-667[ISI][Medline]
  22. Bryant, JK, Strand, CL Reliability of blood cultures collected from intravascular catheter vs venipuncture. Am J Clin Pathol 1987;88,113-116[ISI][Medline]
  23. Gross, PA, Barrett, TL, Dellinger, EP, et al Quality standard for the treatment of bacteremia: Infectious Diseases Society of America. Clin Infect Dis 1994;18,428-430[ISI][Medline]
  24. Dennesen, PJ, van der Ven, AJ, Kessels, AG, et al Resolution of infectious parameters after antimicrobial therapy in patients with ventilator-associated pneumonia. Am J Respir Crit Care Med 2001;163,1371-1375[Abstract/Free Full Text]
  25. Leibovici, L, Shraga, I, Drucker, M, et al The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection. J Intern Med 1998;244,379-386[CrossRef][ISI][Medline]
  26. Vidal, F, Mensa, J, Almela, M, et al Epidemiology and outcome of Pseudomonas aeruginosa bacteremia, with special emphasis on the influence of antibiotic treatment: analysis of 189 episodes. Arch Intern Med 1996;156,2121-2126[Abstract]
  27. Caballero-Granado, FJ, Cisneros, JM, Luque, R, et al Comparative study of bacteremias caused by Enterococcus spp. with and without high-level resistance to gentamicin. J Clin Microbiol 1998;36,520-525[Abstract/Free Full Text]
  28. Bryan, CS, Reynolds, KL, Brenner, ER Analysis of 1186 episodes of gram-negative bacteremia in non-university hospitals: the effects of antimicrobial therapy. Rev Infect Dis 1983;5,629-638[ISI][Medline]
  29. Chow, JW, Fine, MJ, Shlaes, DM, et al Enterobacter bacteremia: clinical features and emergence of antibiotic resistance during therapy. Ann Intern Med 1991;115,585-590[ISI][Medline]
  30. Ibrahim, EH, Sherman, G, Ward, S, et al The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest 2000;118,146-155[CrossRef][ISI][Medline]
  31. Pearson, ML Guideline for prevention of intravascular device-related infections: Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996;17,438-473[ISI][Medline]



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