Microbiological diagnosis of bacteraemia and fungaemia: Blood cultures and molecular methods | Enfermedades Infecciosas y Microbiología Clínica (English Edition)

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General Universitario de Alicante, Instituto Sanitario y Biomédico de Alicante (ISABIAL), Alicante, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diagnóstico microbiológico de la bacteriemia y la fungemia: hemocultivos y métodos moleculares" ] ] "textoCompleto" => "IntroductionThe detection of bacteraemia and fungaemia is one of the priorities of the Clinical Microbiology Department, given its diagnostic and prognostic relevance. These infections are associated with increased mortality that can range between 10 and 30% according to the series and the type of patient, the source and the initial management. The severity of this clinical entity requires the rapid administration of empirical antimicrobial treatment, based on clinical data and the local epidemiology of resistance. Despite this, the percentage of inadequate treatments may reach up to 25–30%, with this data being especially key in patients with underlying diseases, severe conditions or in centres with high rates of multidrug-resistant microorganisms.<a class="elsevierStyleCrossRef" href="#bib0105">1</a>Bacteraemia is defined as the presence of bacteria in the blood, which is revealed by isolating bacteria from blood cultures. The source of bacteraemia can be diverse depending on the patient's clinical characteristics. The term fungaemia is used to denote the presence of fungi in the blood, generally yeasts from the genus Candida spp. which, although may stem from similar foci to those that cause bacteraemia, frequently occur as a result of catheter infections.<a class="elsevierStyleCrossRef" href="#bib0110">2</a>Currently, sepsis is defined as life-threatening organ dysfunction in a patient caused by the individual's dysregulated response to infection. A new scale has been designed, known as the quick Sepsis-Related Organ Failure Assessment (qSOFA), which exclusively includes clinical criteria, meaning that it is easy to apply at any care level (not only in hospitals). Septic shock is defined as sepsis symptoms which develop with circulatory and cellular abnormalities, as well as metabolic abnormalities which are severe enough to substantially increase mortality to figures above 40%.The creation of a specific code for the management of sepsis, code sepsis, stems from the fact that this entity is the main infectious cause of death, affecting 100–150 in every 100,000 inhabitants/year, which accounts for more than 50,000 patients/year in Spain, of whom more than a third may die. Sepsis-related mortality may be combated with correct diagnosis and adequate management within the first few hours of onset. Implementing the package of measures recommended by the Surviving Sepsis Campaign successfully reduces morbidity and mortality to figures of around 25%.<a class="elsevierStyleCrossRef" href="#bib0115">3</a>Microbiological diagnosisIt should be taken into account that the limited number of microorganisms present in the blood during an episode of bacteraemia, which tends to range between 10 colony-forming units (CFU)/ml and 104CFU/ml, may be even lower than 0.1CFU/ml in 20% of cases. This characteristic means that only very sensitive techniques can be used in the rapid diagnosis of this infection. Currently, blood culture continues to be the main diagnostic method for bacteraemia, although its practical value is undermined by the delay in obtaining results and because results are not positive in all patients. Its performance is lower in patients on antibiotic treatment or if the infection is caused by fungi, slow-growing bacteria or bacteria with specific requirements. Another key factor is the high proportion of blood cultures contaminated by microorganisms belonging to the skin microbiota. This can result in diagnostic errors, inadequate treatments and lead to high economic costs for the health system. The sensitivity of blood cultures is largely related to the type of microorganism, as well as the volume of the sample, the timing of collection and the absence of previous antibiotic treatments.<a class="elsevierStyleCrossRef" href="#bib0120">4</a>BiomarkersNowadays, we cannot discuss the diagnosis of sepsis without taking into consideration the detection of biomarkers.<a class="elsevierStyleCrossRef" href="#bib0125">5</a> There are some better known biomarkers such as procalcitonin, C-reactive protein, interleukin-6 and mid-regional pro-adrenomedullin, and this is being investigated in a large number of other molecules of diverse origins, including those which reflect changes in the metabolome and some genetic markers of the host (RNA biosignatures) present in serum as a response to bacterial infections. Ideally, these molecules should allow the antimicrobial treatment to be de-escalated or even discontinued in some situations, help establish the severity of the patient's condition and allow their progress to be monitored.<a class="elsevierStyleCrossRef" href="#bib0130">6</a>Processing of blood culturesThere is no universal recommendation as regards the indications for taking blood cultures, although it is generally recommended that they be collected in the presence of chills, fever (body temperature ≥38°C) or hypothermia in neonates and elderly patients. They are also recommended in case of leukocytopenia, leukocytosis or thrombocytopenia not related to haematological processes, in other signs of focal infection or sepsis, as well as in case of suspected endocarditis. Blood culture draws are likewise indicated in small children or elderly patients with a sudden decline in vitality, as these populations may not present with the typical signs and symptoms of bacteraemia. Furthermore, they should always be collected when a catheter tip is sent for seeding due to being suspected as the source of bacteraemia as, if this is not done, it is not possible to differentiate it from catheter colonisation.<a class="elsevierStyleCrossRef" href="#bib0135">7</a>When infection is suspected, blood cultures should be collected from patients who are susceptible to meningitis, osteomyelitis, pyelonephritis, intra-abdominal infection, arthritis, severe skin and soft-tissue infections, pneumonia, endocarditis and fever of unknown origin (occult abscess, typhoid fever, brucellosis, tularaemia, etc.). The blood culture should be accompanied by samples from other sites to try to determine the focus of the infection.Samples for blood cultures should be collected by venipuncture (peripheral collection) and draws performed with intravascular devices should be avoided, as recommended by the American College of Physicians, with the equipment and anatomical site being changed in each blood culture draw. Draws through a catheter should only be performed if they are intended to diagnose a catheter infection, and this should be accompanied by another draw by peripheral venipuncture. In exceptional circumstances, blood can be collected through a catheter in paediatric patients with haematological cancers. Furthermore, blood should be drawn before antibiotic treatment is initiated and, where this is not possible, when the antibiotic is at its trough concentration (just before the next dose).<a class="elsevierStyleCrossRef" href="#bib0140">8</a>The volume of blood is the most important factor for increasing the diagnostic performance of the blood culture. In general, the recommendations of the Infectious Diseases Society of America/American Society for Microbiology (ASM) are followed, according to which the volume of blood to be cultured is related to the patient's weight. Therefore, in small children, between 1 and 5ml (dilution 1:5) will be required, inoculated in a single aerobic bottle, while the accepted volume of blood to be cultured for older children and adults will be 10–20ml (dilution 1:10), divided between two bottles (anaerobic and aerobic).<a class="elsevierStyleCrossRef" href="#bib0145">9</a>The likelihood of recovering the causative agent increases in relation to the number of blood cultures collected from the patient. It is close to 60–80% in the first blood culture, 80–90% when two blood cultures are collected, and 95–99% in case of a third blood culture. There is no universal recommendation on the interval to be respected between each draw and, although in general it is advised that they be separated by 10–30min, this interval can be shortened in situations of extreme urgency and, in these cases, blood cultures can even be drawn simultaneously from different limbs so as not to delay the antibiotic treatment.Blood for blood cultures should be drawn under maximal aseptic conditions, scrupulously disinfecting the skin at the site where the venipuncture is going to be performed, as well as the rubber stoppers of the blood culture bottles, preferably with alcoholic 2% chlorhexidine in patients older than two months of age. In all hospitals, the percentage of contaminated blood cultures should be regularly monitored and training activities should be carried out periodically among the staff in charge of blood draws to raise awareness that they should be done in accordance with the protocol established at each centre. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the method to be followed for collecting blood cultures.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In cases where the bacteraemia source is suspected to be the catheter and it is not easy to replace or do without it, using the differential time to positivity technique is recommended to confirm the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0150">10</a>Once the sample has been obtained and the blood culture bottles have been inoculated, they should be suitably identified in terms of the patient's data and the pairs of bottles corresponding to each of the blood draws. They should be quickly sent to the laboratory and kept at room temperature at all times. The bottles should not be stored in an oven, as it may be that, when they are placed in the smart incubator, they have already reached the stationary growth phase and are thus not detected as positive. It has been reported that there is a significant reduction in pathogen recovery if, instead of placing the bottles immediately in the incubator, they are kept at room temperature over a long period of time. Therefore, the CLSI guidelines recommend that blood culture bottles be placed in the incubator within 2h of when they are drawn. The need to have satellite incubators in places which cannot comply with this requirement should also be assessed.The development of new automated methods (BacT/Alert® VIRTUO™ [bioMérieux] and BD BACTEC™ FX [Becton Dickinson]) for processing blood cultures has resulted in a substantial breakthrough, as the bottles are placed in automated incubation systems which keep them at a temperature of around 36±1°C. These systems consist in a series of individual cells with continuous agitation to facilitate the multiplication of bacteria, and perform regular monitoring to detect positive bottles.In addition, each of these companies develops different bottles with particular specifications. Generally speaking, there are bottles designed for the isolation of aerobic bacteria and facultative anaerobes, and bottles for the isolation of facultative and obligate anaerobes. There are also bottles optimised for small volumes of blood, useful in paediatrics, and those selective for mycobacteria (Middlebrook 7H9 broth) or fungi, which can be used in specific cases.Although the usefulness of the bottles for anaerobes has been questioned due to the low number of obligate anaerobic bacteria responsible for bacteraemia, currently they continue to be recommended in adults as their use helps to locate the focus of the infection and, in addition, 10% of facultative anaerobic bacteria are more quickly recovered in this type of bottle. This is not applicable to the paediatric population, in which the risk of developing bacteraemia due to these microorganisms is much lower.A total of 85–90% of the blood cultures are positive in less than 48h, except in the event of fungaemia or bacteraemia caused by a slow-growing bacterium. In general, the bottles are incubated for five days before being reported as negative. This time tends to be sufficient for the recovery of most microorganisms, including the fastidious bacteria belonging to the HACEK (Haemophilus spp., Aggregatibacter spp., Cardiobacterium spp., Eikenella spp. and Kingella spp.) group. Incubation should be prolonged in diseases such as endocarditis, which can be caused by slow-growing bacteria, or when the presence of fungi, mycobacteria, Legionella spp., Brucella spp., Bartonella spp. or Nocardia spp. is suspected. It must be taken into account that prolonging the incubation time favours the recovery of contaminants, which is why late findings should be assessed with great caution, always considering the isolated microorganism.<a class="elsevierStyleCrossRef" href="#bib0155">11</a>If the clinical professional and microbiologist must always work together, this is even more the case in light of a suspected infection where the aetiological agent is difficult to isolate and grow. The majority of these bacteria need special culture media due to their nutritional requirements and, in some cases, their incubation should be prolonged because of their slow growth. In some of these infectious processes, serological testing and molecular microbiology techniques are essential procedures for diagnosis.Yeasts grow well in routine blood culture bottles. However, this test is only positive in approximately half of patients in whom fungaemia is suspected due to the fact that monocytes and other cells of the immune system lyse the fungal cells, there may be a very low inoculum or fungaemia may be transitory or intermittent. In order to improve the technique's sensitivity, the volume of blood cultured is a crucial factor. The usefulness of performing an additional draw for a fungi-specific bottle is disputed, although some authors have reported that they improve recovery rates, particularly for infections associated with Candida glabrata.In relation to the incubation time of the blood culture bottles with suspected fungal infections due to yeasts, the vast majority of these microorganisms are isolated within the first three days of incubation, with C. glabrata and Cryptococcus neoformans being the pathogens which exhibit the slowest growth. Despite this, due to the low profitability of this diagnostic method in this process, it is advised to extend the incubation time of these bottles if after five days they remain negative and there is a high clinical suspicion of fungaemia.<a class="elsevierStyleCrossRef" href="#bib0160">12</a>A key issue when establishing the clinical significance of microbiological findings is to successfully differentiate between contamination and infection. The United States National Healthcare Safety Network defines a contaminated blood culture (false positive) as one in which species typical of the commensal microbiota of the skin or those typical of the environment are isolated: coagulase-negative staphylococci, other microorganisms of low or zero virulence, such as Aerococcus spp., Micrococcus spp., Propionibacterium acnes, most species of the genera Bacillus and Corynebacterium and some of the viridans group streptococci. However, before considering an isolation of these microorganisms a contaminant, the patient's clinical characteristics and the number of blood cultures in which they are isolated should be carefully analysed as, in some cases, these microorganisms may be involved in bacteraemia. In the case of children, this differentiation is particularly difficult because normally only one draw is performed. Measures should thus be taken to prevent the contamination of the bottles and, in case of doubt, a second sample should be taken.<a class="elsevierStyleCrossRef" href="#bib0165">13</a> The detection of Staphylococcus aureus, Streptococcus pneumoniae, Enterobacteriaceae, Pseudomonas aeruginosa and Candida albicans generally translates to true bacteraemia.Optimal interpretation of the results of positive blood cultures requires knowledge of the patient's clinical situation, their underlying disease, predisposing factors for infection and, if possible, the antimicrobial treatments which have been administered to the patient. This makes it necessary to review patients’ medical histories, particularly nowadays, when they tend to be computerised and easy to access, with close communication with the physician responsible for the patient being highly recommended in order to report the findings at an early stage and assess the process jointly. Fluid communication channels should therefore be established, using new technological developments. It has been repeatedly demonstrated that rapid communication of the results to multidisciplinary teams which apply this information for proper patient management means that the results provided by the Microbiology Department acquire value in the clinical management of these processes and improve their cost-effectiveness. It is therefore important to strengthen these groups in each hospital and to establish rapid and effective information exchange channels, using all available resources.<a class="elsevierStyleCrossRef" href="#bib0170">14</a>Aetiological diagnosis through non-culture based proceduresMost of the available techniques are based on detecting the DNA of the microorganism causing the bacteraemia/fungaemia. The advantage of these techniques, in addition to their speed, is that they are very helpful when dealing with microorganisms which cannot be cultured or are difficult to grow, and when samples are taken after the antimicrobial treatment has been established. In addition, some allow information to be provided on the aetiology of the infection and on the antibiotic susceptibility of the microorganism involved by detecting some resistance determinants. However, they are expensive and require interpretation by experts as they measure DNAaemia rather than bacteraemia and can detect DNA of non-viable bacteria. It must be taken into account that blood has a large quantity of human DNA compared to bacterial DNA and may present normal inhibitory substances (haemoglobin, heparin, etc.) which affect the efficacy of the reaction, producing both invalid results (due to inhibition of the detection technique) and false negative results. In addition, with respect to the sensitivity analysis of molecular techniques, the number of genomic copies of a microorganism present in a sample has to be considered, rather than the determination of the bacterial load in CFU/ml. This concept would also take into consideration the DNA of dead bacteria or those captured by circulating phagocytic cells. According to this option, it is estimated that in an episode of bacteraemia the number of circulating genetic copies would be between 103 and 104 copies of DNA/ml of blood, a value that would be above the limit of detection of most amplification techniques.<a class="elsevierStyleCrossRef" href="#bib0175">15</a>The application of mass spectrometry (matrix-assisted laser desorption/ionisation time-of-flight [MALDI-TOF]) to Clinical Microbiology has resulted in a revolution in the working protocols of centres that possess this technology. This new method can provide aetiological information at an early stage, a few minutes after performing the Gram stain, and therefore enables early adjustment of the antimicrobial therapy, particularly if local epidemiology of antibiotic resistance is available at the centre.<a class="elsevierStyleCrossRef" href="#bib0180">16</a>There are two groups of techniques: the first is made up of those applied to bottles of positive blood cultures, in order to obtain information faster than traditional culture-based methods. These techniques are becoming increasingly more widespread as they are of great use in routine clinical practice and correlate closely with the classic methods. A second group of techniques comprises those that are applied directly using the patient's blood, in order to provide information at an even earlier stage. There is less experience with these techniques so they are used to a lesser extent in routine clinical practice<a class="elsevierStyleCrossRef" href="#bib0185">17</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Antimicrobial susceptibility testing methods for microorganismsPhenotypic studies for the determination of antibiotic susceptibility performed directly on positive blood culture bottles are not endorsed by the EUCAST, CLSI or ASM recommendations, but many studies have reported an excellent correlation between the results obtained from the positive blood culture and those provided by the reference method, which generates the antibiogram using the bacteria colony isolated in solid medium. The use of new automated continuous reading systems in the majority of Microbiology Departments could facilitate the standardisation of the inoculum. With the direct system, the response time is reduced to 24h, with the susceptibility of the bacterium being reported on the same day as the positive blood culture. In any event, considering the preliminary results and subsequently confirming these with standardised methods is recommended.<a class="elsevierStyleCrossRef" href="#bib0190">18</a>Another interesting approach to offer preliminary information is the use of sub-culture plates with chromogenic media for the detection of methicillin-resistant S. aureus, vancomycin-resistant enterococci and extended-spectrum beta-lactamase and carbapenemase-producing Enterobacteriaceae. These media have good sensitivity and specificity, but the results also have to always be confirmed by standardised susceptibility testing methods, so in principle they should only be used when justified by the epidemiological situation.In relation to non-culture-based methods which provide information on the antimicrobial susceptibility of the microorganism involved in the bacteraemia based on the positive blood culture, new technologies are emerging which must be properly validated before they can be applied to clinical practice. In general, they provide results shortly after the Gram stain has been observed and their data are therefore very useful from a clinical perspective. In order to regulate requests and reduce healthcare costs, it is important for them to be performed in a context of constant communication with the multidisciplinary hospital team responsible for managing bacteraemia/fungaemia at each centre<a class="elsevierStyleCrossRef" href="#bib0195">19</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).ConclusionsThe rapid and correct diagnosis of bacteraemia/fungaemia should be one of the strategic priorities of all Clinical Microbiology Departments and should form part of a multidisciplinary management system for these diseases, established at each hospital so that all patients can benefit from the results at an early stage. Furthermore, the rapid and correct diagnosis of these processes will contribute to improving antibiotic use, meaning that, as well as reducing healthcare costs, they will help to control antimicrobial resistance.The necessary measures should be implemented so as much information as possible is available in less than 6h after the blood culture is found to be positive. This information should be passed on urgently to the rest of the multidisciplinary team so that it has a real clinical impact. Indeed, when rapid and efficient communication systems have been applied, they have been shown to have an impact on patients’ progress. In this sense, it is very important that the continuous care model (24h, seven days a week) is advanced in Microbiology Departments, as the impact of an early aetiological diagnosis on patient prognosis is now widely demonstrated.<a class="elsevierStyleCrossRef" href="#bib0200">20</a>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1183838" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results and conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1104261" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1183837" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Resultados y conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1104262" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Microbiological diagnosis" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Biomarkers" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Processing of blood cultures" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Aetiological diagnosis through non-culture based procedures" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Antimicrobial susceptibility testing methods for microorganisms" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-02-28" "fechaAceptado" => "2018-03-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1104261" "palabras" => array:4 [ 0 => "Bacteraemia" 1 => "Fungaemia" 2 => "Microbiological diagnosis" 3 => "Blood cultures" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1104262" "palabras" => array:4 [ 0 => "Bacteriemia" 1 => "Fungemia" 2 => "Diagnóstico microbiológico" 3 => "Hemocultivos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveIn this review we try to update the new procedures applicable in the microbiological diagnosis of bacteriemia and fungemias. MethodReview of scientific literature. Results and conclusionsAfter defining the process and indicating its fundamental principles, the main biomarkers used in clinical practice are reviewed. Subsequently, the particularities of the pre-analytical phase (collection and transport of samples) are highlighted and the steps to follow for the microbiological identification by classical methods are detailed, based on the culture of the blood samples. In the following section, we review the diagnostic methods not culture based, including those that detect the presence of the genome of the microorganism and those based on the study of proteome by mass spectrometry. The last section describes the procedures more frequently used for the study of antibiotic susceptibility, both by phenotypic and genotypic methods." "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results and conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoEn esta revisión se pretende actualizar los nuevos procedimientos aplicables en el diagnóstico microbiológico de las bacteriemias y fungemias. MétodoRevisión de la literatura científica. Resultados y conclusionesTras definir el proceso e indicar sus principios fundamentales, se revisan los principales biomarcadores utilizados en la práctica clínica. Posteriormente, se resaltan las particularidades de la fase preanalítica (recogida y transporte de las muestras) y se detallan los pasos a seguir para la identificación microbiológica por métodos clásicos, basados en el cultivo de las muestras de sangre. En el siguiente apartado, se revisan los métodos diagnósticos no basados en el cultivo, incluyendo los que detectan la presencia del genoma del microorganismo y los basados en el estudio del proteoma mediante espectrometría de masas. En el último apartado se describen los procedimientos a seguir para el estudio de la sensibilidad antibiótica, tanto por métodos fenotípicos como genotípicos." "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Resultados y conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Guna Serrano MR, Larrosa Escartín N, Marín Arriaza M, Rodríguez Díaz JC. Diagnóstico microbiológico de la bacteriemia y la fungemia: hemocultivos y métodos moleculares. Enferm Infecc Microbiol Clin. 2019;37:335–340." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Wear gloves and a mask \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Clean the vial caps with chlorhexidine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Select the site from which the blood is to be drawn (do not collect blood through the catheter) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Disinfect the skin with chlorhexidine and leave it to work \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Perform the puncture without touching the patient's skin with your hand \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Do not allow the needle to come into contact with the cotton wool \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7. Draw the blood required so that 10ml of blood can be added to each bottle for adults, and between 1 and 5ml to the paediatric bottle \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8. Inoculate the anaerobic bottle first, preventing the entry of air \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9. Inoculate the aerobic bottle afterwards; it is not necessary to add air \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10. Inoculate the remaining tubes if applicable (biochemistry, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11. Gently agitate the two bottles \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12. Take urgently to the Microbiology Department \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13. If this is not possible, keep at room temperature preferably for no more than 2h \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2017912.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Methodology to be followed for collecting a blood culture." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "+ Bottle: blood culture bottle with bacterial growth." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Trade name \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bacteria \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fungi \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antimicrobial susceptibility \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sample \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LightCycler SeptiFast® Test MGRADE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C. albicans C. tropicalis C. parapsilosis C. glabrata C. krusei A. fumigatus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">mecA in additional test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SepsiTest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Most clinically relevant species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Many \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8–12h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2MR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Under development \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C. albicans C. tropicalis C. glabrata C. krusei C. parapsilosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3–5h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">iDTECT Dx Blood \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">800 species and 400 viruses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2–3 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LDI BSI test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Most clinically relevant species  \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Many \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Magicplex Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Gram-pos: 73 species Gram-neg: 12 species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">mecA vanA and vanB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VYOO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">mecA vanA, vanB blaSHV and blaCTX-M type ESBL (SHV, CTX-M) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IRIDICA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">780 species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Many species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">mecA vanA, vanB Carbapenemase KPC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AccuProbe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureus S. pneumoniae, Enterococcus spp. Streptococcus spp. groups A and B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottlea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30min. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GenomEra(™) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. pneumoniae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Min. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GenomEra(™) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Methicillin resistance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Min. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PNA-FISH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureus Coagulase-neg staphylococci E. faecalis Enterococcus spp. E. coli K. pneumoniae P. aeruginosa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C. albicans C. parapsilosis C. tropicalis C. glabrata C. krusei \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Min. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MALDI-TOF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Most clinically relevant species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yeasts Filamentous fungi \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Still undergoing validation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Min. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BinaxNOW S. pneumoniae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. pneumoniae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Min. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FilmArray \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 species and 15 genera of Gram-positive and Gram-negative bacteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 species of yeast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">mecA, vanA/B and blaKPC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GenoType Blood Culture (Hain Lifescience) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 Gram-positive bacteria and 15 Gram-negative species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Methicillin and vancomycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GeneXpert \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">mecA Carbapenemases (KPC, NDM, VIM, IMP and OXA-48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Verigene \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Gram-positive: 9 species and 4 genera Gram-negative: 5 species and 4 genera \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">mecA and vanA/B CTX-M type ESBL Carbapenemases (KPC, NDM, VIM, IMP and OXA) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BD GeneOhm StaphSR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Methicillin resistance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.5h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BD MAX StaphSR Assay (BD Diagnostics) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Methicillin resistance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Eazyplex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CTX-M type ESBL Carbapenemases (VIM, NDM, KPC and OXA-48) S. aureus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30min. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AID \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ESBL (TEM, SHV and CTX-M) Carbapenemases KPC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LightMix \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Carbapenemases (KPC, NDM, VIM, IMP and OXA-48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Check-Direct CPE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Carbapenemases (KPC, NDM, VIM and OXA-48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MyCycler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ESBL (CTX-M, TEM and SHV) Carbapenemases (KPC, NDM, IMP, VIM and OXA-48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.5h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ImmuLex S. pneumoniae Omni \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. pneumoniae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Min. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sepsis Flow Chip \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Listeria Staphylococci Streptococci Enterococcus spp. Enterobacteriaceae P. aeruginosa A. baumannii S. maltophilia N. meningitidis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Some species of yeast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">mecA vanA, vanB ESBL Carbapenemases (most of those described) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3–4h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Check-Points \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ESBL AmpC Carbapenemases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prove-It Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">mecA, vanA and vanB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">β LACTA test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ESBL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Minutes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ACCELERATE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 species and 6 bacterial genera \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple antibiotics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Identification: 90min Antibiogram: 7h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alfred AST \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple antibiotics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ Bottle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5h \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2017913.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Available commercial systems for the detection of bacteraemia and fungaemia." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Population-based epidemiology and microbiology of community-onset bloodstream infections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K.B. 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Review article

Microbiological diagnosis of bacteraemia and fungaemia: Blood cultures and molecular methods

Diagnóstico microbiológico de la bacteriemia y la fungemia: hemocultivos y métodos moleculares

María Remedio Guna Serranoa, Nieves Larrosa Escartínb, Mercedes Marín Arriazac, Juan Carlos Rodríguez Díazd,

Corresponding author

rodriguez_juadia@gva.es

Corresponding author.

a Servicio de Microbiología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain

b Servicio de Microbiología, Hospital Universitario Vall d’Hebron, Barcelona, Spain

c Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain

d Servicio de Microbiología, Hospital General Universitario de Alicante, Instituto Sanitario y Biomédico de Alicante (ISABIAL), Alicante, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The detection of bacteraemia and fungaemia is one of the priorities of the Clinical Microbiology Department&#44; given its diagnostic and prognostic relevance&#46; These infections are associated with increased mortality that can range between 10 and 30&#37; according to the series and the type of patient&#44; the source and the initial management&#46; The severity of this clinical entity requires the rapid administration of empirical antimicrobial treatment&#44; based on clinical data and the local epidemiology of resistance&#46; Despite this&#44; the percentage of inadequate treatments may reach up to 25&#8211;30&#37;&#44; with this data being especially key in patients with underlying diseases&#44; severe conditions or in centres with high rates of multidrug-resistant microorganisms&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Bacteraemia is defined as the presence of bacteria in the blood&#44; which is revealed by isolating bacteria from blood cultures&#46; The source of bacteraemia can be diverse depending on the patient&#39;s clinical characteristics&#46; The term fungaemia is used to denote the presence of fungi in the blood&#44; generally yeasts from the genus <span class="elsevierStyleItalic">Candida</span> spp&#46; which&#44; although may stem from similar foci to those that cause bacteraemia&#44; frequently occur as a result of catheter infections&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Currently&#44; sepsis is defined as life-threatening organ dysfunction in a patient caused by the individual&#39;s dysregulated response to infection&#46; A new scale has been designed&#44; known as the quick Sepsis-Related Organ Failure Assessment &#40;qSOFA&#41;&#44; which exclusively includes clinical criteria&#44; meaning that it is easy to apply at any care level &#40;not only in hospitals&#41;&#46; Septic shock is defined as sepsis symptoms which develop with circulatory and cellular abnormalities&#44; as well as metabolic abnormalities which are severe enough to substantially increase mortality to figures above 40&#37;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The creation of a specific code for the management of sepsis&#44; code sepsis&#44; stems from the fact that this entity is the main infectious cause of death&#44; affecting 100&#8211;150 in every 100&#44;000 inhabitants&#47;year&#44; which accounts for more than 50&#44;000 patients&#47;year in Spain&#44; of whom more than a third may die&#46; Sepsis-related mortality may be combated with correct diagnosis and adequate management within the first few hours of onset&#46; Implementing the package of measures recommended by the Surviving Sepsis Campaign successfully reduces morbidity and mortality to figures of around 25&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Microbiological diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">It should be taken into account that the limited number of microorganisms present in the blood during an episode of bacteraemia&#44; which tends to range between 10 colony-forming units &#40;CFU&#41;&#47;ml and 10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU&#47;ml&#44; may be even lower than 0&#46;1<span class="elsevierStyleHsp" style=""></span>CFU&#47;ml in 20&#37; of cases&#46; This characteristic means that only very sensitive techniques can be used in the rapid diagnosis of this infection&#46; Currently&#44; blood culture continues to be the main diagnostic method for bacteraemia&#44; although its practical value is undermined by the delay in obtaining results and because results are not positive in all patients&#46; Its performance is lower in patients on antibiotic treatment or if the infection is caused by fungi&#44; slow-growing bacteria or bacteria with specific requirements&#46; Another key factor is the high proportion of blood cultures contaminated by microorganisms belonging to the skin microbiota&#46; This can result in diagnostic errors&#44; inadequate treatments and lead to high economic costs for the health system&#46; The sensitivity of blood cultures is largely related to the type of microorganism&#44; as well as the volume of the sample&#44; the timing of collection and the absence of previous antibiotic treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Biomarkers</span><p id="par0030" class="elsevierStylePara elsevierViewall">Nowadays&#44; we cannot discuss the diagnosis of sepsis without taking into consideration the detection of biomarkers&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> There are some better known biomarkers such as procalcitonin&#44; C-reactive protein&#44; interleukin-6 and mid-regional pro-adrenomedullin&#44; and this is being investigated in a large number of other molecules of diverse origins&#44; including those which reflect changes in the metabolome and some genetic markers of the host &#40;RNA biosignatures&#41; present in serum as a response to bacterial infections&#46; Ideally&#44; these molecules should allow the antimicrobial treatment to be de-escalated or even discontinued in some situations&#44; help establish the severity of the patient&#39;s condition and allow their progress to be monitored&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Processing of blood cultures</span><p id="par0035" class="elsevierStylePara elsevierViewall">There is no universal recommendation as regards the indications for taking blood cultures&#44; although it is generally recommended that they be collected in the presence of chills&#44; fever &#40;body temperature &#8805;38<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; or hypothermia in neonates and elderly patients&#46; They are also recommended in case of leukocytopenia&#44; leukocytosis or thrombocytopenia not related to haematological processes&#44; in other signs of focal infection or sepsis&#44; as well as in case of suspected endocarditis&#46; Blood culture draws are likewise indicated in small children or elderly patients with a sudden decline in vitality&#44; as these populations may not present with the typical signs and symptoms of bacteraemia&#46; Furthermore&#44; they should always be collected when a catheter tip is sent for seeding due to being suspected as the source of bacteraemia as&#44; if this is not done&#44; it is not possible to differentiate it from catheter colonisation&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">When infection is suspected&#44; blood cultures should be collected from patients who are susceptible to meningitis&#44; osteomyelitis&#44; pyelonephritis&#44; intra-abdominal infection&#44; arthritis&#44; severe skin and soft-tissue infections&#44; pneumonia&#44; endocarditis and fever of unknown origin &#40;occult abscess&#44; typhoid fever&#44; brucellosis&#44; tularaemia&#44; etc&#46;&#41;&#46; The blood culture should be accompanied by samples from other sites to try to determine the focus of the infection&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Samples for blood cultures should be collected by venipuncture &#40;peripheral collection&#41; and draws performed with intravascular devices should be avoided&#44; as recommended by the American College of Physicians&#44; with the equipment and anatomical site being changed in each blood culture draw&#46; Draws through a catheter should only be performed if they are intended to diagnose a catheter infection&#44; and this should be accompanied by another draw by peripheral venipuncture&#46; In exceptional circumstances&#44; blood can be collected through a catheter in paediatric patients with haematological cancers&#46; Furthermore&#44; blood should be drawn before antibiotic treatment is initiated and&#44; where this is not possible&#44; when the antibiotic is at its trough concentration &#40;just before the next dose&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The volume of blood is the most important factor for increasing the diagnostic performance of the blood culture&#46; In general&#44; the recommendations of the Infectious Diseases Society of America&#47;American Society for Microbiology &#40;ASM&#41; are followed&#44; according to which the volume of blood to be cultured is related to the patient&#39;s weight&#46; Therefore&#44; in small children&#44; between 1 and 5<span class="elsevierStyleHsp" style=""></span>ml &#40;dilution 1&#58;5&#41; will be required&#44; inoculated in a single aerobic bottle&#44; while the accepted volume of blood to be cultured for older children and adults will be 10&#8211;20<span class="elsevierStyleHsp" style=""></span>ml &#40;dilution 1&#58;10&#41;&#44; divided between two bottles &#40;anaerobic and aerobic&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The likelihood of recovering the causative agent increases in relation to the number of blood cultures collected from the patient&#46; It is close to 60&#8211;80&#37; in the first blood culture&#44; 80&#8211;90&#37; when two blood cultures are collected&#44; and 95&#8211;99&#37; in case of a third blood culture&#46; There is no universal recommendation on the interval to be respected between each draw and&#44; although in general it is advised that they be separated by 10&#8211;30<span class="elsevierStyleHsp" style=""></span>min&#44; this interval can be shortened in situations of extreme urgency and&#44; in these cases&#44; blood cultures can even be drawn simultaneously from different limbs so as not to delay the antibiotic treatment&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Blood for blood cultures should be drawn under maximal aseptic conditions&#44; scrupulously disinfecting the skin at the site where the venipuncture is going to be performed&#44; as well as the rubber stoppers of the blood culture bottles&#44; preferably with alcoholic 2&#37; chlorhexidine in patients older than two months of age&#46; In all hospitals&#44; the percentage of contaminated blood cultures should be regularly monitored and training activities should be carried out periodically among the staff in charge of blood draws to raise awareness that they should be done in accordance with the protocol established at each centre&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the method to be followed for collecting blood cultures&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In cases where the bacteraemia source is suspected to be the catheter and it is not easy to replace or do without it&#44; using the differential time to positivity technique is recommended to confirm the diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Once the sample has been obtained and the blood culture bottles have been inoculated&#44; they should be suitably identified in terms of the patient&#39;s data and the pairs of bottles corresponding to each of the blood draws&#46; They should be quickly sent to the laboratory and kept at room temperature at all times&#46; The bottles should not be stored in an oven&#44; as it may be that&#44; when they are placed in the smart incubator&#44; they have already reached the stationary growth phase and are thus not detected as positive&#46; It has been reported that there is a significant reduction in pathogen recovery if&#44; instead of placing the bottles immediately in the incubator&#44; they are kept at room temperature over a long period of time&#46; Therefore&#44; the CLSI guidelines recommend that blood culture bottles be placed in the incubator within 2<span class="elsevierStyleHsp" style=""></span>h of when they are drawn&#46; The need to have satellite incubators in places which cannot comply with this requirement should also be assessed&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The development of new automated methods &#40;BacT&#47;Alert<span class="elsevierStyleSup">&#174;</span> VIRTUO&#8482; &#91;bioM&#233;rieux&#93; and BD BACTEC&#8482; FX &#91;Becton Dickinson&#93;&#41; for processing blood cultures has resulted in a substantial breakthrough&#44; as the bottles are placed in automated incubation systems which keep them at a temperature of around 36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; These systems consist in a series of individual cells with continuous agitation to facilitate the multiplication of bacteria&#44; and perform regular monitoring to detect positive bottles&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In addition&#44; each of these companies develops different bottles with particular specifications&#46; Generally speaking&#44; there are bottles designed for the isolation of aerobic bacteria and facultative anaerobes&#44; and bottles for the isolation of facultative and obligate anaerobes&#46; There are also bottles optimised for small volumes of blood&#44; useful in paediatrics&#44; and those selective for mycobacteria &#40;Middlebrook 7H9 broth&#41; or fungi&#44; which can be used in specific cases&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Although the usefulness of the bottles for anaerobes has been questioned due to the low number of obligate anaerobic bacteria responsible for bacteraemia&#44; currently they continue to be recommended in adults as their use helps to locate the focus of the infection and&#44; in addition&#44; 10&#37; of facultative anaerobic bacteria are more quickly recovered in this type of bottle&#46; This is not applicable to the paediatric population&#44; in which the risk of developing bacteraemia due to these microorganisms is much lower&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A total of 85&#8211;90&#37; of the blood cultures are positive in less than 48<span class="elsevierStyleHsp" style=""></span>h&#44; except in the event of fungaemia or bacteraemia caused by a slow-growing bacterium&#46; In general&#44; the bottles are incubated for five days before being reported as negative&#46; This time tends to be sufficient for the recovery of most microorganisms&#44; including the fastidious bacteria belonging to the HACEK &#40;<span class="elsevierStyleItalic">Haemophilus</span> spp&#46;&#44; <span class="elsevierStyleItalic">Aggregatibacter</span> spp&#46;&#44; <span class="elsevierStyleItalic">Cardiobacterium</span> spp&#46;&#44; <span class="elsevierStyleItalic">Eikenella</span> spp&#46; and <span class="elsevierStyleItalic">Kingella</span> spp&#46;&#41; group&#46; Incubation should be prolonged in diseases such as endocarditis&#44; which can be caused by slow-growing bacteria&#44; or when the presence of fungi&#44; mycobacteria&#44; <span class="elsevierStyleItalic">Legionella</span> spp&#46;&#44; <span class="elsevierStyleItalic">Brucella</span> spp&#46;&#44; <span class="elsevierStyleItalic">Bartonella</span> spp&#46; or <span class="elsevierStyleItalic">Nocardia</span> spp&#46; is suspected&#46; It must be taken into account that prolonging the incubation time favours the recovery of contaminants&#44; which is why late findings should be assessed with great caution&#44; always considering the isolated microorganism&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">If the clinical professional and microbiologist must always work together&#44; this is even more the case in light of a suspected infection where the aetiological agent is difficult to isolate and grow&#46; The majority of these bacteria need special culture media due to their nutritional requirements and&#44; in some cases&#44; their incubation should be prolonged because of their slow growth&#46; In some of these infectious processes&#44; serological testing and molecular microbiology techniques are essential procedures for diagnosis&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Yeasts grow well in routine blood culture bottles&#46; However&#44; this test is only positive in approximately half of patients in whom fungaemia is suspected due to the fact that monocytes and other cells of the immune system lyse the fungal cells&#44; there may be a very low inoculum or fungaemia may be transitory or intermittent&#46; In order to improve the technique&#39;s sensitivity&#44; the volume of blood cultured is a crucial factor&#46; The usefulness of performing an additional draw for a fungi-specific bottle is disputed&#44; although some authors have reported that they improve recovery rates&#44; particularly for infections associated with <span class="elsevierStyleItalic">Candida glabrata&#46;</span></p><p id="par0105" class="elsevierStylePara elsevierViewall">In relation to the incubation time of the blood culture bottles with suspected fungal infections due to yeasts&#44; the vast majority of these microorganisms are isolated within the first three days of incubation&#44; with <span class="elsevierStyleItalic">C&#46; glabrata</span> and <span class="elsevierStyleItalic">Cryptococcus neoformans</span> being the pathogens which exhibit the slowest growth&#46; Despite this&#44; due to the low profitability of this diagnostic method in this process&#44; it is advised to extend the incubation time of these bottles if after five days they remain negative and there is a high clinical suspicion of fungaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">A key issue when establishing the clinical significance of microbiological findings is to successfully differentiate between contamination and infection&#46; The United States National Healthcare Safety Network defines a contaminated blood culture &#40;false positive&#41; as one in which species typical of the commensal microbiota of the skin or those typical of the environment are isolated&#58; coagulase-negative staphylococci&#44; other microorganisms of low or zero virulence&#44; such as <span class="elsevierStyleItalic">Aerococcus</span> spp&#46;&#44; <span class="elsevierStyleItalic">Micrococcus</span> spp&#46;&#44; <span class="elsevierStyleItalic">Propionibacterium acnes</span>&#44; most species of the genera <span class="elsevierStyleItalic">Bacillus</span> and <span class="elsevierStyleItalic">Corynebacterium</span> and some of the <span class="elsevierStyleItalic">viridans</span> group streptococci&#46; However&#44; before considering an isolation of these microorganisms a contaminant&#44; the patient&#39;s clinical characteristics and the number of blood cultures in which they are isolated should be carefully analysed as&#44; in some cases&#44; these microorganisms may be involved in bacteraemia&#46; In the case of children&#44; this differentiation is particularly difficult because normally only one draw is performed&#46; Measures should thus be taken to prevent the contamination of the bottles and&#44; in case of doubt&#44; a second sample should be taken&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> The detection of <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; Enterobacteriaceae&#44; <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> and <span class="elsevierStyleItalic">Candida albicans</span> generally translates to true bacteraemia&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Optimal interpretation of the results of positive blood cultures requires knowledge of the patient&#39;s clinical situation&#44; their underlying disease&#44; predisposing factors for infection and&#44; if possible&#44; the antimicrobial treatments which have been administered to the patient&#46; This makes it necessary to review patients&#8217; medical histories&#44; particularly nowadays&#44; when they tend to be computerised and easy to access&#44; with close communication with the physician responsible for the patient being highly recommended in order to report the findings at an early stage and assess the process jointly&#46; Fluid communication channels should therefore be established&#44; using new technological developments&#46; It has been repeatedly demonstrated that rapid communication of the results to multidisciplinary teams which apply this information for proper patient management means that the results provided by the Microbiology Department acquire value in the clinical management of these processes and improve their cost-effectiveness&#46; It is therefore important to strengthen these groups in each hospital and to establish rapid and effective information exchange channels&#44; using all available resources&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Aetiological diagnosis through non-culture based procedures</span><p id="par0120" class="elsevierStylePara elsevierViewall">Most of the available techniques are based on detecting the DNA of the microorganism causing the bacteraemia&#47;fungaemia&#46; The advantage of these techniques&#44; in addition to their speed&#44; is that they are very helpful when dealing with microorganisms which cannot be cultured or are difficult to grow&#44; and when samples are taken after the antimicrobial treatment has been established&#46; In addition&#44; some allow information to be provided on the aetiology of the infection and on the antibiotic susceptibility of the microorganism involved by detecting some resistance determinants&#46; However&#44; they are expensive and require interpretation by experts as they measure DNAaemia rather than bacteraemia and can detect DNA of non-viable bacteria&#46; It must be taken into account that blood has a large quantity of human DNA compared to bacterial DNA and may present normal inhibitory substances &#40;haemoglobin&#44; heparin&#44; etc&#46;&#41; which affect the efficacy of the reaction&#44; producing both invalid results &#40;due to inhibition of the detection technique&#41; and false negative results&#46; In addition&#44; with respect to the sensitivity analysis of molecular techniques&#44; the number of genomic copies of a microorganism present in a sample has to be considered&#44; rather than the determination of the bacterial load in CFU&#47;ml&#46; This concept would also take into consideration the DNA of dead bacteria or those captured by circulating phagocytic cells&#46; According to this option&#44; it is estimated that in an episode of bacteraemia the number of circulating genetic copies would be between 10<span class="elsevierStyleSup">3</span> and 10<span class="elsevierStyleSup">4</span> copies of DNA&#47;ml of blood&#44; a value that would be above the limit of detection of most amplification techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The application of mass spectrometry &#40;matrix-assisted laser desorption&#47;ionisation time-of-flight &#91;MALDI-TOF&#93;&#41; to Clinical Microbiology has resulted in a revolution in the working protocols of centres that possess this technology&#46; This new method can provide aetiological information at an early stage&#44; a few minutes after performing the Gram stain&#44; and therefore enables early adjustment of the antimicrobial therapy&#44; particularly if local epidemiology of antibiotic resistance is available at the centre&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">There are two groups of techniques&#58; the first is made up of those applied to bottles of positive blood cultures&#44; in order to obtain information faster than traditional culture-based methods&#46; These techniques are becoming increasingly more widespread as they are of great use in routine clinical practice and correlate closely with the classic methods&#46; A second group of techniques comprises those that are applied directly using the patient&#39;s blood&#44; in order to provide information at an even earlier stage&#46; There is less experience with these techniques so they are used to a lesser extent in routine clinical practice<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Antimicrobial susceptibility testing methods for microorganisms</span><p id="par0135" class="elsevierStylePara elsevierViewall">Phenotypic studies for the determination of antibiotic susceptibility performed directly on positive blood culture bottles are not endorsed by the EUCAST&#44; CLSI or ASM recommendations&#44; but many studies have reported an excellent correlation between the results obtained from the positive blood culture and those provided by the reference method&#44; which generates the antibiogram using the bacteria colony isolated in solid medium&#46; The use of new automated continuous reading systems in the majority of Microbiology Departments could facilitate the standardisation of the inoculum&#46; With the direct system&#44; the response time is reduced to 24<span class="elsevierStyleHsp" style=""></span>h&#44; with the susceptibility of the bacterium being reported on the same day as the positive blood culture&#46; In any event&#44; considering the preliminary results and subsequently confirming these with standardised methods is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Another interesting approach to offer preliminary information is the use of sub-culture plates with chromogenic media for the detection of methicillin-resistant <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; vancomycin-resistant enterococci and extended-spectrum beta-lactamase and carbapenemase-producing Enterobacteriaceae&#46; These media have good sensitivity and specificity&#44; but the results also have to always be confirmed by standardised susceptibility testing methods&#44; so in principle they should only be used when justified by the epidemiological situation&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In relation to non-culture-based methods which provide information on the antimicrobial susceptibility of the microorganism involved in the bacteraemia based on the positive blood culture&#44; new technologies are emerging which must be properly validated before they can be applied to clinical practice&#46; In general&#44; they provide results shortly after the Gram stain has been observed and their data are therefore very useful from a clinical perspective&#46; In order to regulate requests and reduce healthcare costs&#44; it is important for them to be performed in a context of constant communication with the multidisciplinary hospital team responsible for managing bacteraemia&#47;fungaemia at each centre<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0150" class="elsevierStylePara elsevierViewall">The rapid and correct diagnosis of bacteraemia&#47;fungaemia should be one of the strategic priorities of all Clinical Microbiology Departments and should form part of a multidisciplinary management system for these diseases&#44; established at each hospital so that all patients can benefit from the results at an early stage&#46; Furthermore&#44; the rapid and correct diagnosis of these processes will contribute to improving antibiotic use&#44; meaning that&#44; as well as reducing healthcare costs&#44; they will help to control antimicrobial resistance&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The necessary measures should be implemented so as much information as possible is available in less than 6<span class="elsevierStyleHsp" style=""></span>h after the blood culture is found to be positive&#46; This information should be passed on urgently to the rest of the multidisciplinary team so that it has a real clinical impact&#46; Indeed&#44; when rapid and efficient communication systems have been applied&#44; they have been shown to have an impact on patients&#8217; progress&#46; In this sense&#44; it is very important that the continuous care model &#40;24<span class="elsevierStyleHsp" style=""></span>h&#44; seven days a week&#41; is advanced in Microbiology Departments&#44; as the impact of an early aetiological diagnosis on patient prognosis is now widely demonstrated&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p></span></span>"
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          "titulo" => "Processing of blood cultures"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1104261"
          "palabras" => array:4 [
            0 => "Bacteraemia"
            1 => "Fungaemia"
            2 => "Microbiological diagnosis"
            3 => "Blood cultures"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1104262"
          "palabras" => array:4 [
            0 => "Bacteriemia"
            1 => "Fungemia"
            2 => "Diagn&#243;stico microbiol&#243;gico"
            3 => "Hemocultivos"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In this review we try to update the new procedures applicable in the microbiological diagnosis of bacteriemia and fungemias&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Review of scientific literature&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results and conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">After defining the process and indicating its fundamental principles&#44; the main biomarkers used in clinical practice are reviewed&#46; Subsequently&#44; the particularities of the pre-analytical phase &#40;collection and transport of samples&#41; are highlighted and the steps to follow for the microbiological identification by classical methods are detailed&#44; based on the culture of the blood samples&#46; In the following section&#44; we review the diagnostic methods not culture based&#44; including those that detect the presence of the genome of the microorganism and those based on the study of proteome by mass spectrometry&#46; The last section describes the procedures more frequently used for the study of antibiotic susceptibility&#44; both by phenotypic and genotypic methods&#46;</p></span>"
        "secciones" => array:3 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Method"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results and conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Objetivo</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En esta revisi&#243;n se pretende actualizar los nuevos procedimientos aplicables en el diagn&#243;stico microbiol&#243;gico de las bacteriemias y fungemias&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">M&#233;todo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n de la literatura cient&#237;fica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados y conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Tras definir el proceso e indicar sus principios fundamentales&#44; se revisan los principales biomarcadores utilizados en la pr&#225;ctica cl&#237;nica&#46; Posteriormente&#44; se resaltan las particularidades de la fase preanal&#237;tica &#40;recogida y transporte de las muestras&#41; y se detallan los pasos a seguir para la identificaci&#243;n microbiol&#243;gica por m&#233;todos cl&#225;sicos&#44; basados en el cultivo de las muestras de sangre&#46; En el siguiente apartado&#44; se revisan los m&#233;todos diagn&#243;sticos no basados en el cultivo&#44; incluyendo los que detectan la presencia del genoma del microorganismo y los basados en el estudio del proteoma mediante espectrometr&#237;a de masas&#46; En el &#250;ltimo apartado se describen los procedimientos a seguir para el estudio de la sensibilidad antibi&#243;tica&#44; tanto por m&#233;todos fenot&#237;picos como genot&#237;picos&#46;</p></span>"
        "secciones" => array:3 [
          0 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "M&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Resultados y conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guna Serrano MR&#44; Larrosa Escart&#237;n N&#44; Mar&#237;n Arriaza M&#44; Rodr&#237;guez D&#237;az JC&#46; Diagn&#243;stico microbiol&#243;gico de la bacteriemia y la fungemia&#58; hemocultivos y m&#233;todos moleculares&#46; Enferm Infecc Microbiol Clin&#46; 2019&#59;37&#58;335&#8211;340&#46;</p>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&#46; Wear gloves and a mask&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#46; Clean the vial caps with chlorhexidine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46; Select the site from which the blood is to be drawn &#40;do not collect blood through the catheter&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46; Disinfect the skin with chlorhexidine and leave it to work&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46; Perform the puncture without touching the patient&#39;s skin with your hand&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&#46; Do not allow the needle to come into contact with the cotton wool&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&#46; Draw the blood required so that 10<span class="elsevierStyleHsp" style=""></span>ml of blood can be added to each bottle for adults&#44; and between 1 and 5<span class="elsevierStyleHsp" style=""></span>ml to the paediatric bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&#46; Inoculate the anaerobic bottle first&#44; preventing the entry of air&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&#46; Inoculate the aerobic bottle afterwards&#59; it is not necessary to add air&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&#46; Inoculate the remaining tubes if applicable &#40;biochemistry&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11&#46; Gently agitate the two bottles&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12&#46; Take urgently to the Microbiology Department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13&#46; If this is not possible&#44; keep at room temperature preferably for no more than 2<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2017912.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Methodology to be followed for collecting a blood culture&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#43; Bottle&#58; blood culture bottle with bacterial growth&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Trade name&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fungi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antimicrobial susceptibility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sample&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LightCycler SeptiFast<span class="elsevierStyleSup">&#174;</span> Test MGRADE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">C&#46; albicans</span><br><span class="elsevierStyleItalic">C&#46; tropicalis</span><br><span class="elsevierStyleItalic">C&#46; parapsilosis</span><br><span class="elsevierStyleItalic">C&#46; glabrata</span><br><span class="elsevierStyleItalic">C&#46; krusei</span><br><span class="elsevierStyleItalic">A&#46; fumigatus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">mec</span>A in additional test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SepsiTest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Most clinically relevant species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Many&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#8211;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2MR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Under development&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">C&#46; albicans</span><br><span class="elsevierStyleItalic">C&#46; tropicalis</span><br><span class="elsevierStyleItalic">C&#46; glabrata</span><br><span class="elsevierStyleItalic">C&#46; krusei</span><br><span class="elsevierStyleItalic">C&#46; parapsilosis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#8211;5<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">iDTECT Dx Blood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">800 species and 400 viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#8211;3 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LDI BSI test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Most clinically relevant species<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Many&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Magicplex Sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gram-pos&#58; 73 species<br>Gram-neg&#58; 12 species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">mec</span>A<br><span class="elsevierStyleItalic">van</span>A and <span class="elsevierStyleItalic">van</span>B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VYOO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34 species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">mec</span>A<br><span class="elsevierStyleItalic">van</span>A&#44; <span class="elsevierStyleItalic">van</span>B<br><span class="elsevierStyleItalic">bla</span>SHV and<br><span class="elsevierStyleItalic">bla</span>CTX-M type ESBL<br>&#40;SHV&#44; CTX-M&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IRIDICA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">780 species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Many species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">mec</span>A<br><span class="elsevierStyleItalic">van</span>A&#44; <span class="elsevierStyleItalic">van</span>B<br>Carbapenemase KPC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AccuProbe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span><br><span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; <span class="elsevierStyleItalic">Enterococcus</span> spp&#46; <span class="elsevierStyleItalic">Streptococcus</span> spp&#46; groups A and B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30<span class="elsevierStyleHsp" style=""></span>min&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GenomEra&#40;&#8482;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Min&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GenomEra&#40;&#8482;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Methicillin resistance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Min&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PNA-FISH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span><br>Coagulase-neg staphylococci<br><span class="elsevierStyleItalic">E&#46; faecalis</span><br><span class="elsevierStyleItalic">Enterococcus</span> spp&#46;<br><span class="elsevierStyleItalic">E&#46; coli</span><br><span class="elsevierStyleItalic">K&#46; pneumoniae</span><br><span class="elsevierStyleItalic">P&#46; aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">C&#46; albicans</span><br><span class="elsevierStyleItalic">C&#46; parapsilosis</span><br><span class="elsevierStyleItalic">C&#46; tropicalis</span><br><span class="elsevierStyleItalic">C&#46; glabrata</span><br><span class="elsevierStyleItalic">C&#46; krusei</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Min&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MALDI-TOF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Most clinically relevant species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yeasts<br>Filamentous fungi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Still undergoing validation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Min&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BinaxNOW<br><span class="elsevierStyleItalic">S&#46; pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Min&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FilmArray&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 species and 15 genera of Gram-positive and Gram-negative bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 species of yeast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">mec</span>A&#44; <span class="elsevierStyleItalic">van</span>A&#47;B and <span class="elsevierStyleItalic">bla</span>KPC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GenoType Blood Culture &#40;Hain Lifescience&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17 Gram-positive bacteria and 15 Gram-negative species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Methicillin and vancomycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GeneXpert&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">mec</span>A<br>Carbapenemases &#40;KPC&#44; NDM&#44; VIM&#44; IMP and OXA-48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Verigene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gram-positive&#58; 9 species and 4 genera<br>Gram-negative&#58; 5 species and 4 genera&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">mec</span>A and <span class="elsevierStyleItalic">van</span>A&#47;B<br>CTX-M type ESBL<br>Carbapenemases &#40;KPC&#44; NDM&#44; VIM&#44; IMP and OXA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BD GeneOhm StaphSR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Methicillin resistance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;5<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BD&#160;MAX&#160;StaphSR Assay &#40;BD Diagnostics&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Methicillin resistance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Eazyplex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CTX-M type ESBL<br>Carbapenemases &#40;VIM&#44; NDM&#44; KPC and OXA-48&#41;<br><span class="elsevierStyleItalic">S&#46; aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30<span class="elsevierStyleHsp" style=""></span>min&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AID&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ESBL &#40;TEM&#44; SHV and CTX-M&#41;<br>Carbapenemases KPC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LightMix&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Carbapenemases &#40;KPC&#44; NDM&#44; VIM&#44; IMP and OXA-48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Check-Direct CPE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Carbapenemases &#40;KPC&#44; NDM&#44; VIM and OXA-48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MyCycler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ESBL &#40;CTX-M&#44; TEM and SHV&#41;<br>Carbapenemases &#40;KPC&#44; NDM&#44; IMP&#44; VIM and OXA-48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;5<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ImmuLex <span class="elsevierStyleItalic">S&#46; pneumoniae</span> Omni&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Min&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sepsis Flow Chip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Listeria</span><br>Staphylococci<br>Streptococci<br><span class="elsevierStyleItalic">Enterococcus</span> spp&#46;<br>Enterobacteriaceae<br><span class="elsevierStyleItalic">P&#46; aeruginosa</span><br><span class="elsevierStyleItalic">A&#46; baumannii</span><br><span class="elsevierStyleItalic">S&#46; maltophilia</span><br><span class="elsevierStyleItalic">N&#46; meningitidis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Some species of yeast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">mec</span>A<br><span class="elsevierStyleItalic">van</span>A&#44; <span class="elsevierStyleItalic">van</span>B<br>ESBL<br>Carbapenemases<br>&#40;most of those described&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#8211;4<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Check-Points&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ESBL<br>AmpC<br>Carbapenemases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prove-It Sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60 species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">mec</span>A&#44; <span class="elsevierStyleItalic">van</span>A and <span class="elsevierStyleItalic">van</span>B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#946; LACTA test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ESBL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Minutes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ACCELERATE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 species and 6 bacterial genera&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple antibiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Identification&#58; 90<span class="elsevierStyleHsp" style=""></span>min<br>Antibiogram&#58; 7<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alfred AST&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple antibiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43; Bottle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information

ISSN: 2529993X
Original language: English

DOI:10.1016/j.eimce.2018.03.018

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Year/Month	Html	Pdf	Total

2024 October	32	5	37
2024 September	75	23	98
2024 August	36	9	45
2024 July	42	5	47
2024 June	56	24	80
2024 May	75	18	93
2024 April	62	17	79
2024 March	98	10	108
2024 February	97	33	130
2024 January	143	28	171
2023 December	132	19	151
2023 November	197	14	211
2023 October	214	29	243
2023 September	74	28	102
2023 August	72	20	92
2023 July	100	24	124
2023 June	96	23	119
2023 May	93	12	105
2023 April	72	22	94
2023 March	78	47	125
2023 February	42	23	65
2023 January	82	9	91
2022 December	44	13	57
2022 November	52	12	64
2022 October	42	30	72
2022 September	38	17	55
2022 August	46	25	71
2022 July	37	26	63
2022 June	42	21	63
2022 May	38	15	53
2022 April	26	20	46
2022 March	42	13	55
2022 February	37	7	44
2022 January	84	24	108
2021 December	35	16	51
2021 November	40	12	52
2021 October	48	20	68
2021 September	63	18	81
2021 August	42	21	63
2021 July	35	13	48
2021 June	44	11	55
2021 May	48	18	66
2021 April	77	12	89
2021 March	47	19	66
2021 February	21	14	35
2021 January	18	13	31
2020 December	15	9	24
2020 November	20	11	31
2020 October	12	14	26
2020 September	18	8	26
2020 August	19	11	30
2020 July	12	10	22
2020 June	17	13	30
2020 May	36	20	56
2020 April	20	8	28
2020 March	16	13	29
2020 February	19	13	32
2020 January	23	20	43
2019 December	22	16	38
2019 November	10	11	21
2019 May	5	2	7
2019 April	2	0	2

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