Bacterial contamination workup/Transfusion Reaction

[new2BB]

Hello everyone.

Please let me know what you think about this.

Recently we sent a unit to micro for a gram stain and culture.  we do this for all the febrile transfusion reactions (>2 degrees F temperature rise).  Micro called back and reported no organisms seen, no WBCs.  After 24 hrs, they reported gram positive cocci in clusters.  The next day the organism identified was S. aureus.  My question is:  how would you report the gram stain?  Negative or positive?  Some of us believe it should be reported as positive, other techs say we should go by the initial call and report it as negative.  we informed the medical director and she contacted the patient's physician.  Our disagreement is on how to report the gram stain in the computer.

Hope everyone has a great weekend!!

 

 

 

 

[Yanxia]

I remember when I was as an intern in Micro department, there were a lot of specimens, some sent there to do direct organism tests using the dyeing technique under a microscop, which was quick but not so sensitive. So most of the specimens needed to be cultured for 24 hours to see what will happen. I will report positive in this case.

[new2BB]

Thank you Yanxia for replying.  I agree with you.  I believe we should report the gram stain as positive in these cases.

[exlimey]

It sounds as if the "real", actionable result is the 24-hour reading - this should be recorded in the medical files.

The "quick-and-dirty" initial test, while not very sensitive, may still be useful in some cases of extreme contamination. It may give the physicians a leg up on treatment.

Perhaps a two-field record could be designed? Test #1 = Immediate; Test #2: 24-hr. The interpretation algorithm would include both results.

[PalmerSil]

Being a generalist with Microbiology experience, here is my take on this: The unit should be reported as positive for bacterial contamination. I would not, though, report the gram stain as "positive" because that is changing the result that the microbiologist reported. They did not see any organisms on the gram stain, so it is negative. If the transfusion reaction workup only allows for a positive or negative result of a gram stain, with no place to report the culture result, then maybe report it as negative with a comment that the culture was positive. 

Ultimately, the culture shows that the unit was most likely contaminated, and that needs to be part of the transfusion reaction workup report. If the report doesn't allow for both the gram stain and culture report, maybe it should be changed to being positive or negative for "bacterial contamination" as opposed to "gram stain" (which, technically, isn't really reported as positive or negative).

 

[new2BB]

Thank you so much for your responses.  we will report the gram stain as negative and will add a comment if they call after 24 hrs to notify us of a positive culture.  

Thanks again.

 

 

[jalomahe]

We would report the gram stain as negative and the culture as positive with the identified organism. Actually blood bank wouldn't be reporting anything....microbiology would since they are the ones performing the testing. Our BB and Micro departments worked together to set up a procedure for handling transfusion reaction workups that required micro so that everything is consistent with best practices. Micro even takes care of notifying the patient physician in accordance with their critical call policy. After they notify the physician then they notify the blood bank so we can notify our blood supplier etc.

[jnadeau]

Years ago I worked in micro exclusively for 8 plus years.  In my experience, especially with normally sterile fluids (e.g. CSF, blood) it was not unheard of to have a negative smear (NOS) followed by growth (usually rare colonies).  We would review the slide to ensure we had not missed something on the smear.  I always thought it  was ALOT easier to call a "rare gram pos cocci" on a smear AFTER you got the growth on the plates - many times it looks like stain artifact / debris on initial read. You are initiating treatment on patients (many truly negative) calling a positive smear. This was a real problem with AFB smears and cultures with rare to few colonies growing weeks later.  Now on review of the slide, the supervisor "sees" 2 small bacilli amid a lot of sputum debris!  Really!  That's why micro is a specialty - but still not perfect.  Molecular testing has made a big improvement in this arena. 

 

[SMILLER]

Agree with those above, you cannot report any test as positive when it wasn't.  The unit did finally appear to be contaminated though.  

But I must add, a C&S on all febrile reaction units seems a bit  overboard.  We would generally only do a culture when our pathologist requests it.

Scott