Methods: All BCX orders written by inpatient providers at a large VA teaching hospital from 10/1/14-4/15/15 were reviewed for indication and positivity on a daily basis. As part of the order, providers selected from among a list of indications. Classification of BCX into TP and FP was performed as part of independent ID review. A BCX order was defined as an electronic entry including all BCX sets drawn as a result of that order. Consistent with previous literature, a BCX episode was defined as all BCX within a 48 hour period. A chart review assessing for clinical predictors of TP was performed on all patients on the Medical service.
Results: 999 total orders were placed with 785 total episodes. The TP rate was 3.1% per order and 3.3% per episode. The FP rate was 1.8% per order and 2.3% per episode. Indication review was limited to 545 patients on the Medical service. The most common indications were fever (48.0%) and leukocytosis (22.4%), neither of which alone was predictive of TP BCX (LR+ 0.6, 95% CI 0.2-1.7 & LR+ 1.3, 95% CI .3-4.8, respectively). The only indication significantly associated with a TP BCX was “follow-up previous positive” (11.7%, LR+ 3.3, 95% CI 1.7-6.3) although fever plus leukocytosis as an indication approached significance (8.3%, LR+ 2.3, 95% CI 0.9-5.8). The only clinical predictor of TP BCX was absence of antibiotic exposure within 72 hours of culture (7.8%, LR+ 2.3, CI 1.8-2.9).
Conclusion: The rate of TP BCX among patients on a Medical service was notably lower than the expected rate of 10% from previous studies of primarily ER patients. This is the first real time capture of clinical thought processes triggering BCX orders and suggests that reflex ordering of BCX based on fever or leukocytosis alone may not yield accurate information regarding bacteremia. In patients on antibiotics, the likelihood of TP is so low that the utility is questionable. Improving the yield of TP BCX may not only contain cost but also reduce unnecessary antibiotic use.
J. Strymish, None
M. Dhanani, None
A. Breu, None