The review panel found one study showing that the two-day mortality for patients with community-acquired bacteremia was 4.8 percent compared to 2.0 percent in culture-negative patients (0–2-day mortality rate ratio 1.9). After the first two days, mortality rates were 3.7 percent and 2.7 percent, respectively, with a mortality rate ratio of 1.1. At 30 days, the mortality in both culture-positive and culture-negative patients was approximately 10 percent, with no significant difference in mortality between the groups.3 However, this study included patients who had blood cultures performed within two days of hospital admission and who had no hospitalizations within the preceding 30 days, so the results may not necessarily apply to emergency department patients such as those presented in this review. This study also noted that as many as half of positive cultures were due to organisms inoculated from the skin into culture bottles at the time of sample collection and did not reflect true bacteremia. These false-positive blood culture results from skin contaminants may lead to unnecessary investigations and treatments.
Explore This IssueACEP Now: Vol 36 – No 05 – May 2017
3. Retrospective Bias
The Standard of Care Review Panel believed that the expert’s opinions in this case were influenced by retrospective bias. The expert repeatedly stated that the treating physician should have known that the patient was bacteremic because the culture results returned positive. However, the preliminary culture results did not return until the following day. There is no way that the treating physician could have known the culture results at the time of treatment. It was the consensus of the Standard of Care Review Panel that strict prospective analysis is of utmost importance when reviewing the management of any patient care.
It was the consensus opinion of the review panel that obtaining Blood Cultures does not mandate antibiotic treatment or hospital admission.
Dr. Sullivan is clinical assistant professor emergency medicine at the University of Illinois at Chicago, attending physician at St. Margaret’s Hospital in Spring Valley, Illinois, and owner of Sullivan Law Office in Frankfort, Illinois.
Dr. Marco is professor of emergency medicine at Wright State University Boonshoft School of Medicine in Dayton, Ohio.
Dr. Solomon is an attending physician at UPMC St. Margaret in Pittsburgh.
Did you know?
ACEP members can request a review of questionable expert witness testimony regarding emergency medicine’s standards of care. Procedures for this review are found here.
- Coburn B, Morris AM, Tomlinson G, et al. Does this adult patient with suspected bacteremia require blood cultures? JAMA. 2012;308(5):502-511.
- Patel G, Kohlhoff S, Tejani N, et al. Evaluation of pediatric blood culture ordering practice in post-pneumococcal vaccination era in emergency department. Poster abstract presented at: IDWeek 2012; Oct. 18, 2012; San Diego. Accessed Feb. 17, 2017.
- Søgaard M, Nørgaard M, Pedersen L, et al. Blood culture status and mortality among patients with suspected community-acquired bacteremia: a population-based cohort study. BMC Infect Dis. 2011;11:139.