- Email: [email protected]
Increased culture sensitivity with direct inoculation of seroma fluid in blood culture bottles
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e428ee429
CORRESPONDENCE AND COMMUNICATION Increased culture sensitivity with direct inoculation of seroma fluid in blood culture bottles Dear Editor, We recently encountered a case in which seroma fluid sent to microbiology for microscopy, culture and sensitivities was negative for any pathogens on culture but fluid taken from the seroma at the same time and directly inoculated into blood culture bottles e i.e., direct inoculation of ‘‘enrichment cultures’’ yielded a Staphylococcus aureus. This has highlighted to us the greater sensitivity of the blood culture enrichment technique and we suggest it is incorporated routinely into plastic surgery practice, as the technique may especially be useful in cases where there is suspicion of infection but previous culture has been negative and in early infection with a low number of pathogens present or antecedent antibiotics. A patient presented to us three weeks after a latissimus dorsi and implant breast reconstruction with significant seroma at the donor site. There was erythema of the medial breast and the chest wall was palpably warm. Although the patient was systemically well with CRP of 21 mg/L and normal white cell count, an infection was suspected. Two hundred and 50 mL of clear yellow fluid was obtained with needle aspiration under aseptic technique. The fluid was sent in a sterile universal container for Gram staining and conventional culture and with a set of inoculated blood culture bottles for culture. On conventional culture the Gram stain was negative and there was no growth. However, S. aureus was grown from both the ‘‘enrichment’’ blood culture bottles. The patient was treated with a four-week course of oral antibiotics as recommended by microbiology (1 g Flucloxacillin qds po and 600 mg Clindamycin qds po) and the erythema and warmth resolved. Using the additional blood culture bottles as enrichment cultures, and inoculating them directly at the bedside gave a higher chance of growth of damaged or low numbers of bacteria. This also allows specific targeting rather than empiric treatment as a result contributed to the resolution of suspected infection. Whilst enrichment cultures must be interpreted with
caution, as only one bacterium inoculated can result in positive cultures, we feel the organism isolated was unlikely to be a contaminant as an aseptic technique was used to harvest the sample and the infection responded to antistaphylococcal therapy. Using blood culture bottles as enrichment cultures has already been useful in testing body fluids other than blood. Inoculating cultures at the bedside or in theatre lessens the possibility of delicate organisms dying in transit to the laboratory and intra-laboratory introduction of contaminants during addition of the fluids to the in house routine enrichment cultures (whether Robertson’s cooked meat medium or blood cultures). This method has been useful for testing joint fluid for bacterial septic arthritis,1,2 pancreatic pseudocyst fluid,3 vitreous fluid from the eye in cases of infectious endophthalmitis,4,5 ascitic fluid in detection of spontaneous peritonitis6 and continuous ambulatory peritoneal dialysis fluid effluent in cases of peritonitis.7 These are serious conditions where there may be difficulties in detecting the pathogen. Inoculation of blood culture bottles has also been shown to be a useful way to check corneal organ culture fluid8 and total paternal nutrition9 for sterility where it is important that these fluids are sterile. We therefore recommend that blood culture bottle method should be used for patients with seroma and suspected infection especially in cases where implants are used in the reconstruction like the case presented here.
Author statement All Authors have seen and approved the manuscript; the material is original and has not been published or submitted elsewhere. If accepted, the paper will not be published elsewhere in the same or similar form without written consent of the copyright holder.
Conflict of interest None.
Funding None.
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.11.041
Correspondence and communication
References 1. Hughes JG, Vetter EA, Patel R, et al. Culture with BACTEC Peds Plus/F bottle compared with conventional methods for detection of bacteria in synovial fluid. J Clin Microbiol. 2001 Dec;39: 4468e71. 2. von Essen R. Culture of joint specimens in bacterial arthritis. Impact of blood culture bottle utilization. Scand J Rheumatol 1997;26:293e300. 3. Ljubicic N, Bilic A. Inflamed pancreatic pseudocyst: optimization of pseudocyst fluid culture technique. Z Gastroenterol 1993;31:198e200. 4. Yospaiboon Y, Saree S, Pasadhika S. Blood culture and conventional media for vitreous culture in infectious endophthalmitis. J Med Assoc Thai 2005;88:639e42. 5. Joondeph BC, Flynn Jr HW, Miller D, et al. A new culture method for infectious endophthalmitis. Arch Ophthalmol 1989; 107:1334e7. 6. Runyon BA, Antillon MR, Akriviadis EA, et al. Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis. J. Clin. Microbiol. 1990;28:2811e2.
e429 7. Alfa MJ, Degagne P, Olson N, et al. Improved detection of bacterial growth in continuous ambulatory peritoneal dialysis effluent by use of BacT/Alert FAN bottles. J Clin Microbiol 1997; 35:862e6. 8. Carricajo A, Thuret G, Chiquet C, et al. Sensitivity and rapidity of blood culture bottles in the detection of cornea organ culture media contamination by bacteria and fungi. Br J Ophthalmol 2002;86:1422e7. 9. Murray PR, Sandrock MJ. Sterility testing of a total nutrient admixture with a biphasic blood-culture system. Am J Hosp Pharm 1991;48:2419e21.
P.G. Ngan* J.K. O’Neill A. Goodwin-Walters Senior House Officer in Plastic Surgery, Department of Plastic and Reconstructive Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, United Kingdom *Corresponding author. Tel.: þ44 1392 402631; fax: þ44 1392 402894. E-mail address: [email protected]
CORRESPONDENCE AND COMMUNICATION Increased culture sensitivity with direct inoculation of seroma fluid in blood culture bottles Dear Editor, We recently encountered a case in which seroma fluid sent to microbiology for microscopy, culture and sensitivities was negative for any pathogens on culture but fluid taken from the seroma at the same time and directly inoculated into blood culture bottles e i.e., direct inoculation of ‘‘enrichment cultures’’ yielded a Staphylococcus aureus. This has highlighted to us the greater sensitivity of the blood culture enrichment technique and we suggest it is incorporated routinely into plastic surgery practice, as the technique may especially be useful in cases where there is suspicion of infection but previous culture has been negative and in early infection with a low number of pathogens present or antecedent antibiotics. A patient presented to us three weeks after a latissimus dorsi and implant breast reconstruction with significant seroma at the donor site. There was erythema of the medial breast and the chest wall was palpably warm. Although the patient was systemically well with CRP of 21 mg/L and normal white cell count, an infection was suspected. Two hundred and 50 mL of clear yellow fluid was obtained with needle aspiration under aseptic technique. The fluid was sent in a sterile universal container for Gram staining and conventional culture and with a set of inoculated blood culture bottles for culture. On conventional culture the Gram stain was negative and there was no growth. However, S. aureus was grown from both the ‘‘enrichment’’ blood culture bottles. The patient was treated with a four-week course of oral antibiotics as recommended by microbiology (1 g Flucloxacillin qds po and 600 mg Clindamycin qds po) and the erythema and warmth resolved. Using the additional blood culture bottles as enrichment cultures, and inoculating them directly at the bedside gave a higher chance of growth of damaged or low numbers of bacteria. This also allows specific targeting rather than empiric treatment as a result contributed to the resolution of suspected infection. Whilst enrichment cultures must be interpreted with
caution, as only one bacterium inoculated can result in positive cultures, we feel the organism isolated was unlikely to be a contaminant as an aseptic technique was used to harvest the sample and the infection responded to antistaphylococcal therapy. Using blood culture bottles as enrichment cultures has already been useful in testing body fluids other than blood. Inoculating cultures at the bedside or in theatre lessens the possibility of delicate organisms dying in transit to the laboratory and intra-laboratory introduction of contaminants during addition of the fluids to the in house routine enrichment cultures (whether Robertson’s cooked meat medium or blood cultures). This method has been useful for testing joint fluid for bacterial septic arthritis,1,2 pancreatic pseudocyst fluid,3 vitreous fluid from the eye in cases of infectious endophthalmitis,4,5 ascitic fluid in detection of spontaneous peritonitis6 and continuous ambulatory peritoneal dialysis fluid effluent in cases of peritonitis.7 These are serious conditions where there may be difficulties in detecting the pathogen. Inoculation of blood culture bottles has also been shown to be a useful way to check corneal organ culture fluid8 and total paternal nutrition9 for sterility where it is important that these fluids are sterile. We therefore recommend that blood culture bottle method should be used for patients with seroma and suspected infection especially in cases where implants are used in the reconstruction like the case presented here.
Author statement All Authors have seen and approved the manuscript; the material is original and has not been published or submitted elsewhere. If accepted, the paper will not be published elsewhere in the same or similar form without written consent of the copyright holder.
Conflict of interest None.
Funding None.
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.11.041
Correspondence and communication
References 1. Hughes JG, Vetter EA, Patel R, et al. Culture with BACTEC Peds Plus/F bottle compared with conventional methods for detection of bacteria in synovial fluid. J Clin Microbiol. 2001 Dec;39: 4468e71. 2. von Essen R. Culture of joint specimens in bacterial arthritis. Impact of blood culture bottle utilization. Scand J Rheumatol 1997;26:293e300. 3. Ljubicic N, Bilic A. Inflamed pancreatic pseudocyst: optimization of pseudocyst fluid culture technique. Z Gastroenterol 1993;31:198e200. 4. Yospaiboon Y, Saree S, Pasadhika S. Blood culture and conventional media for vitreous culture in infectious endophthalmitis. J Med Assoc Thai 2005;88:639e42. 5. Joondeph BC, Flynn Jr HW, Miller D, et al. A new culture method for infectious endophthalmitis. Arch Ophthalmol 1989; 107:1334e7. 6. Runyon BA, Antillon MR, Akriviadis EA, et al. Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis. J. Clin. Microbiol. 1990;28:2811e2.
e429 7. Alfa MJ, Degagne P, Olson N, et al. Improved detection of bacterial growth in continuous ambulatory peritoneal dialysis effluent by use of BacT/Alert FAN bottles. J Clin Microbiol 1997; 35:862e6. 8. Carricajo A, Thuret G, Chiquet C, et al. Sensitivity and rapidity of blood culture bottles in the detection of cornea organ culture media contamination by bacteria and fungi. Br J Ophthalmol 2002;86:1422e7. 9. Murray PR, Sandrock MJ. Sterility testing of a total nutrient admixture with a biphasic blood-culture system. Am J Hosp Pharm 1991;48:2419e21.
P.G. Ngan* J.K. O’Neill A. Goodwin-Walters Senior House Officer in Plastic Surgery, Department of Plastic and Reconstructive Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, United Kingdom *Corresponding author. Tel.: þ44 1392 402631; fax: þ44 1392 402894. E-mail address: [email protected]