Blood Culture Contamination Rates. Discussion
In this cluster randomized crossover trial, routine sterile gloving just before venipuncture reduced blood culture contamination rates by approximately 50%. To the best of our knowledge, our study is the first to evaluate the influence of sterile gloving on blood culture contamination rates. Although sterile gloving is a basic aspect of aseptic technique, most previous studies did not consider the gloving method when they evaluated blood culture contamination rates. To minimize confounding caused by a difference in phlebotomy skills and the consequential contamination risk for individual interns, we used a crossover design and included a random effect of interns for the statistical model.
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Previous studies found that trained phlebotomy teams decrease blood culture contamination rates compared with resident physicians or nurses. These findings suggest that personal phlebotomy skills influence blood culture contamination rates. Our data also showed that the contamination rates were diverse according to individual interns. Although blood culture was done by interns rather than dedicated phlebotomists in this study, the baseline contamination rate was relatively low, even when possible contaminants were included; although the baseline contamination rates reported by previous randomized, controlled trials were 3% to 9%, our contamination rate was roughly 1% during optional sterile gloving. The exclusion of the emergency department and pediatric ward may partly explain our low contamination rates because contamination rates tend to be higher in these areas than elsewhere. In addition, comprehensive education on the standard protocol for specimen collection might have contributed to the low contamination rates. Furthermore, an awareness of the research might increase intern adherence to the standard protocol. Our data imply that adherence to current guidelines can reduce blood culture contamination rates to approximately 1%, as shown in our control period.
The lower blood culture contamination rates associated with routine sterile gloving may indicate the possibility of contamination of the nonsterile gloves worn by the interns. An outbreak of contaminated blood cultures caused by nonsterile gloves contaminated by Bacillus species was reported. However, in our study, the contaminants during optional sterile gloving were diverse and were mainly skin flora, which suggests that an outbreak due to collective contamination of nonsterile gloves was less likely. The difference in blood culture contamination rates between the routine and optional sterile gloving groups was highest in the intensive care unit, in which relatively higher contamination rates during optional sterile gloving may be explained by phlebotomy difficulties due to the poor vascular condition of patients with chronic or severe illness, as well as by the less common use of sterile gloving as self-reported by the interns. A heavy workload in the busy intensive care unit might make optional sterile gloving by interns less common. Some previous studies also reported higher contamination rates in intensive care units than in general wards, although data comparing the contamination rates of intensive care units and other hospitalization units are limited.