The collection of blood cultures in patients seen in the emergency room (ER) and ultimately hospitalized with community-acquired pneumonia (CAP) continue to increase despite recommendations to reserve the test for only severe illness, according to a research letter published online March 10 in JAMA Internal Medicine. The authors cite nonclinical factors, but not clinical indicators, as the significant predictors of blood culture use and call for further national attention to ensure the prudent use of blood cultures in pneumonia management. Practice guidelines were revised (2005 to 2007) in order to reflect changing sentiment regarding the limited clinical utility of routine blood cultures for all patients hospitalized with CAP. Recognizing that false-positive results from blood cultures can lead to inappropriate anti-microbial use and longer lengths of stay, modifications were made to recommendations shifting from routine culture collection to using the test only in those with severe pneumonia. Data from the National Hospital Ambulatory Medical Care Surveys (2002 through 2004 and 2007 through 2010) were analyzed to assess patterns in utilization of cultures in adults hospitalized with CAP. For comparison, trends in culture collection in patients hospitalized for a urinary tract infection (for which recommendations did not change over the course of […]
The collection of blood cultures in patients seen in the emergency room (ER) and ultimately hospitalized with community-acquired pneumonia (CAP) continue to increase despite recommendations to reserve the test for only severe illness, according to a research letter published online March 10 in JAMA Internal Medicine. The authors cite nonclinical factors, but not clinical indicators, as the significant predictors of blood culture use and call for further national attention to ensure the prudent use of blood cultures in pneumonia management.
Practice guidelines were revised (2005 to 2007) in order to reflect changing sentiment regarding the limited clinical utility of routine blood cultures for all patients hospitalized with CAP. Recognizing that false-positive results from blood cultures can lead to inappropriate anti-microbial use and longer lengths of stay, modifications were made to recommendations shifting from routine culture collection to using the test only in those with severe pneumonia.
Data from the National Hospital Ambulatory Medical Care Surveys (2002 through 2004 and 2007 through 2010) were analyzed to assess patterns in utilization of cultures in adults hospitalized with CAP. For comparison, trends in culture collection in patients hospitalized for a urinary tract infection (for which recommendations did not change over the course of the study period) were also assessed.
The researchers found that the percentage of patients hospitalized with CAP who had culture collections increased significantly from 29.4 percent in 2002 to 51.1 percent in 2010, while the rates of culture for urinary tract infection remained consistent over the same period. Culture collection was not predicted by disease severity. Admission to the intensive care unit was actually associated with lower odds of obtaining cultures. Hospital ownership and region were strong predictors of culture collection.
As a possible explanation for the pattern, the authors cite the 2002 mandate by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that culture collection in the ER should occur before antibiotic administration.
“[This] may encourage providers to reflexively order cultures in all patients admitted with CAP in whom antibiotic administration is anticipated, even though cultures are strongly indicated in only the sickest patients,” write the authors, led by Anil N. Makam, M.D., from University of Texas Southwestern Medical Center, Dallas. “Given rising trends in obtaining cultures in low-risk patients, we advocate for the JCAHO and CMS to reexamine this measure with consideration of eliminating it entirely to discourage overuse.”
