When questioned by the defense counsel about whether the expert was assuming that because blood cultures were ordered, the treating physician must have suspected bacteremia, the expert replied:

“I think doctors order things that have a low probability of being positive for a number of reasons, depending upon the disease. But in the case of blood cultures for bacteremia, it’s the only reason you do blood cultures. And if you suspect bacteremia in a patient who is immunocompetent, the treatment is antibiotics.”

When asked if the facilities at which he works discharge patients with pending blood cultures, the expert stated:

“Under certain circumstances, we do discharge patients with pending blood cultures—infants occasionally who are suspected of having occult bacteremia; patients with HIV known to have low CD4 counts; patients who have a febrile illness who are dialysis patients; and on certain occasions, certain types of immunocompetent cancer patients will have blood culture sent from the emergency department at discharge. Other than those patients, we do not do blood cultures on patients who are discharged because the only reason to do blood cultures is to suspect bacteremia, and bacteremia requires intravenous antibiotics.”

After reviewing the expert’s testimony and available literature on this topic, the Standard of Care Review Panel concluded that the expert witness presented opinions that did not represent the standard of care for several reasons.

1. Blood Cultures

1. The review panel was not able to find any studies providing definitive guidelines regarding when blood cultures should be ordered. In fact, one study specifically noted that “published guidelines do not clearly state when blood culture should be drawn.”¹ This study also noted that there is only a 2 percent pretest probability of bacteremia in febrile ambulatory outpatients and that isolated tachycardia was not helpful in improving the accuracy of diagnosing bacteremia.
2. The review panel also found literature noting that 3.8 percent of blood cultures obtained in patients discharged from the emergency department return positive and that 86 percent of those cultures were positive for pathogens that would typically necessitate inpatient antibiotic therapy. Only 50 percent of the patients in this study responded to a call for a return visit.²
3. With regard to the expert’s assertion that obtaining blood cultures mandates admission and antibiotic treatment, the review panel did not find any literature recommending such management, and they unanimously agreed that the statement did not reflect the standard of care in emergency medicine. As the expert noted, and as many sources confirm, most occult bacteremia resolves spontaneously without treatment. In addition, studies show that many blood cultures are falsely positive due to skin contaminants.
4. Using the above data, mandatory admission and antibiotic treatment after obtaining blood cultures in febrile ambulatory outpatients would result in a 50-fold increase in hospital admissions for this patient demographic.
5. Finally, the expert’s own testimony contradicted his statements about the standard of care. He noted that the facilities at which he works do discharge patients with pending blood cultures under some circumstances. The review panel noted that the types of patients the expert inferred could be discharged pending blood cultures were at higher risk for bacteremia and sepsis than the general population since they included patients more likely to be immunocompromised such as those with HIV, those with cancer, and those on hemodialysis.

2. Risk of Bacteremia