JOURNAL OF CLINICAL MICROBIOLOGY, Aug. 2007, p. 2711–2715 Vol. 45, No.

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0095-1137/07/$08.00⫹0 doi:10.1128/JCM.00059-07
Copyright © 2007, American Society for Microbiology. All Rights Reserved.

Relevance of Routine Use of the Anaerobic Blood Culture Bottle䌤

Patrick Grohs,1,5 Jean-Luc Mainardi,1,3,4,5* Isabelle Podglajen,1,4,5 Xavier Hanras,2,5
C. Eckert,1,4,5 A. Buu-Hoı̈,1,5 E. Varon,1,5 and Laurent Gutmann1,4,5
AP-HP, Hôpital Européen Georges Pompidou, Service de Microbiologie,1 Département d’Informatique Hospitalière,2 and
Unité Mobile de Microbiologie Clinique,3 Paris F-75015, France; INSERM, U872, LRMA Pôle 4-Equipe 12,
Paris F-75006, France4; and Université Paris-Descartes, Faculté de Médecine René Descartes,
Paris F-75006, France5
Received 8 January 2007/Returned for modification 23 February 2007/Accepted 7 June 2007

Using the BacT/Alert automated system, we conducted a 1-year retrospective study on blood cultures,
focusing on the relevance of routine use of the anaerobic bottle. The rate of patients with positive blood cultures
was 19.7%. Among these, 13.5% had a positive anaerobic bottle in the absence of any aerobic bottle, and 2/3 of
these grew with nonobligate anaerobes. These patients were hospitalized in 20 out of 26 wards of the hospital
group. For 65.4% of the monomicrobial-positive blood cultures growing Enterobacteriaceae, the anaerobic bottle
detected growth earlier than the corresponding aerobic bottle. These data suggest that, in our institution, the
use of an anaerobic bottle is still relevant.

Blood cultures remain the cornerstone for the diagnosis of Thus, using the BacT/Alert system and FAN bottles, we
bacteremia. Classically, two bottles are collected routinely: an conducted a 1-year retrospective study to evaluate whether
aerobic bottle, allowing preferential growth of aerobic and putative gains existed in terms of detection of the most com-
facultative anaerobic microorganisms, and an anaerobic bottle, mon microorganisms by use of both aerobic and anaerobic
allowing preferential growth of strict anaerobic bacteria. BacT/ bottles and also in terms of time of detection of positivity
Alert (bioMérieux, Lyon, France) is an automated system used between the two bottles when the same blood culture grew
for the incubation and detection of positive blood cultures with the same organism.
(16). The main improvements introduced with this system were The study was conducted in a 750-bed, acute-care teaching
the replacement of glass with plastic bottles and the introduc- hospital including 23 wards (12 medical wards, six surgical
tion of FAN medium containing charcoal and Fuller’s earth. wards, and five intensive care units) accounting for approxi-
These components were supposed to adsorb antibiotics present in mately 35,000 admissions and three long-term-care hospitals
blood samples but showed additional properties improving recov- corresponding to 850 beds. All of the blood cultures sampled in
ery of microorganisms (9, 10, 15, 17). 2004 were incubated in a BacT/Alert system with 40 ml FAN
Different parameters have been evaluated to improve the aerobic and anaerobic media (17). Since the recommendation
performance and the cost related to usage of blood cultures. was always to collect aerobic and anaerobic bottles concomi-
For pediatric patients, since anaerobic bacteria are rarely im- tantly, only pairs of aerobic and anaerobic bottles inoculated
plicated, the usefulness of the anaerobic bottle seemed limited simultaneously were taken into account to compare recovery
and it was recommended that the entire blood volume should
and rapidity of growth of the different organisms in each bottle.
be collected only in aerobic bottles (20). For adults, it was also
Using an aliquot of ca. 20 ml blood from patients with sus-
shown that the frequency of obligate anaerobic bacteremia
pected bacteremia, 10 ml of blood was introduced in each
declined significantly and that, with the exception of obligate
bottle. After comparison of 200 pairs of blood cultures, no
anaerobic bacteria, many organisms grew preferentially in aer-
statistical difference was found between the quantities of blood
obic bottles (5, 12, 14). Taking into account these results and
introduced in the aerobic and the anaerobic bottles (data not
the comparison of bacteriological and clinical data (13), the
shown). All bottles were placed at 37°C in the BacT/Alert
routine use of two aerobic blood cultures with only selective
use of anaerobic bottles was proposed previously (12). system for a 7-day incubation period and monitored in accor-
On the other hand, although different studies have com- dance with the manufacturer’s recommendations. All positive
pared the times of detection between different automatic sys- bottles were systematically plated on Columbia blood-sheep
tems or different media (18, 21), few studies have compared, agar and incubated under aerobic and anaerobic conditions.
using the same system, the time differences for growth detec- Bacterial identification was performed using standard proce-
tion between the aerobic and anaerobic bottles according to dures (3). Coagulase-negative staphylococci, Corynebacterium
the microorganism isolated. spp., Bacillus spp., and Propionibacterium spp. were not con-
sidered clinically significant if isolated in only one bottle or if
the same bacterium isolated in several bottles showed different
* Corresponding author. Mailing address: Department of Microbi- antibiotic-resistant phenotypes. The number of hours needed
ology, Université Paris-Descartes, Faculté de Médecine, AP-HP Hô- for automatic detection of the microbial growth for each bottle
pital Européen Georges Pompidou, 20 rue Leblanc, Cedex 15, 75908
was flagged by the instrument (Bactview software, interface
Paris, France. Phone: 33 1 56 09 39 51. Fax: 33 1 56 09 24 46. E-mail:
jlmainar@bhdc.jussieu.fr. between BacT/Alert incubators and laboratory information
䌤
Published ahead of print on 20 June 2007. system).

2711
2712 NOTES J. CLIN. MICROBIOL.

FIG. 1. Rates of positive blood culture bottles. ⫹, positive; ⫺, negative.

Positive rate of blood cultures. Only blood cultures for TABLE 1. Numbers of significant bacterial isolates recovered from
which simultaneous pairs of aerobic and anaerobic bottles patients with positive anaerobic bottles without a
were collected were counted in this study, corresponding to positive aerobic bottle and vice versa
95% of all blood cultures sampled. A total of 19,677 blood No. of isolates from No. of isolates from
cultures (39,354 bottles) were collected from 5,040 patients anaerobic bottles aerobic bottles
during the study period (Fig. 1), corresponding to an average Organism(s) without a positive without a positive
aerobic bottle anaerobic bottle
of four pairs of blood cultures per patient. A total of 2,108 (no. of patients) (no. of patients)
positive blood cultures (10.7%), a number within the range
(8.9% to 11.6%) of those determined by previous studies (6, Anaerobic bacteria 50 (46) 1 (1)
Strict aerobic bacilli 1 (1) 48 (47)
17, 20), were obtained from 994 patients, corresponding to Enterobacteriaceae 38 (38) 32 (32)
19.7% of patients. Eighty-four percent of patients had a posi- Streptococcus/Enterococcus 26 (26) 22 (21)
tive aerobic bottle, while 69.7% had a positive anaerobic bot- Staphylococcus spp. 14 (14)a 14 (14)b
tle. Among all positive blood cultures, aerobic or anaerobic Yeast 0 22 (22)
Other 10 (10) 8 (8)
bottles alone were detected positive in 30.6% (collected from
454 patients) and 19.1% (collected from 315 patients) of cases, Anaerobic bacteria ⫹ 4 (2) 0
respectively (Fig. 1). Streptococcus spp.
Positive anaerobic bottle(s) without any concomitant posi- Strict aerobic bacilli ⫹ 0 2 (1)
tive aerobic bottle(s). For 137 patients, representing 13.7% of Streptococcus spp.
Strict aerobic bacilli ⫹ 0 4 (2)
the patients with positive blood cultures (2.7% of all sampled Enterobacteriaceae
patients), significant organisms were isolated only in an anaer- Strict aerobic bacilli ⫹ yeast 0 2 (1)
obic bottle(s) without any concomitant positive aerobic bottle Staphylococcus spp. ⫹ 0 2 (1)
(Table 1). These 137 patients were localized in 20 out of 26 Streptococcus spp.
Streptococcus spp. ⫹ 0 4 (1)
wards of the hospital group. Fifty-two obligate anaerobic bac-
Enterobacteriaceae
teria were isolated from 48 patients, but most interestingly 91
nonobligate anaerobic bacteria, absent in all aerobic bottles
collected for each patient, were isolated from the remaining 91 Total 143 (137) 161 (151)
patients. a
Including 13 S. aureus isolates.
Since 13 additional patients had positive cultures with obli- b
Including 11 S. aureus isolates.
VOL. 45, 2007 NOTES 2713

TABLE 3. Repartition of significant isolates recovered from

TABLE 2. Species of anaerobes isolated from blood cultures
patients for whom only one blood culture was sampled
between 2001 and 2004
No. of isolates (no. of patients)a
No. (%) of anaerobes isolated in yr: Group
Organism(s) Aer /Ana⫺
⫹
Aer⫹/Ana⫹ Aer⫺/Ana⫹
2001 2002 2003 2004
Strict aerobic bacilli 2 1 0
Gram-negative bacilli
Bacteroides spp. Anaerobic bacteria 0 1 8
B. caccae 2 Enterobacteriaceae 5 25 7
B. distasonis 1 1 1 Staphylococcus spp. 2 11 2
B. fragilis 12 18 14 32 Streptococcus/ 4 14 2
B. thetaiotaomicron 3 6 1 2 Enterococcus spp.
B. uniformis 1 2 Other 0 0 2
B. vulgatus 2
Other Bacteroides spp. 3 5 3 Total 13 (12) 52 (47) 21 (21)

Leptotrichia spp. 1 a
Aer⫹, positive aerobic bottle; Aer⫺, negative aerobic bottle; Ana⫹, positive
anaerobic bottle; Ana⫺, negative anaerobic bottle.
Prevotella spp.
P. loescheii 1
P. melaninogenica 1
P. oralis 1
Other Prevotella spp. 1 1 1 gate anaerobic bacteria in the two bottles, a total of 61 pa-
tients, corresponding to 1.2% of all the sampled patients, grew
Fusobacterium spp. blood cultures with obligate anaerobic bacteria, in accordance
F. mortiferum 1
F. naviforme 1 with previously published data (4, 13). Fifteen of those 61
F. necrophorum 1 2 patients belonged to medical and chirurgical digestive wards,
F. nucleatum 2 1
Other Fusobacterium spp. 1 1 1 2 while the others (46/61) were present in 15 out of the 26 wards
of the hospital group. These results suggest that the selective
Veillonella spp.
V. parvula 2 use of anaerobic bottles according to the type of medical or
V. ratti 1 surgical ward cannot generally be recommended and depends
Other Veillonella spp. 2
on the type of patient present in the different wards of the
Other gram-negative bacilli 4 1 5 1 hospital. Moreover, unanticipated sepsis with anaerobic bac-
teria could place patients at high risk for serious, life-threat-
All gram-negative bacilli 31 37 32 45
ening infection. No change in anaerobic bacteremia rate was
observed to occur between 2001 and 2004 (5.0% and 4.9%,
Gram-positive bacilli respectively) (Table 2). These rates, which are slightly superior
Clostridium spp.
C. bifermentans 1
to those of recent and older studies, which varied from 2.5 to
C. clostridioforme 1 3.3% (1, 11, 12), show that the proportion of positive anaerobic
C. difficile 1 blood cultures, which has decreased since the 1970s, has now
C. fimetarium 1
C. hastiforme 1 stabilized. Furthermore, a very recent study showed a rate that
C. innocuum 1 increased from 5.4% to 10.4% between 1993 and 2004, sug-
C. paraputrificum 1
C. perfringens 1 1 1 4 gesting a potential reemergence of anaerobic bacteremia (8).
C. ramosum 1 2 Moreover, no significant difference in anaerobic species repar-
C. tertium 1
Other Clostridium spp. 1 4 2 1 tition was noted for this period (Table 2). As found in recent
studies (1, 8, 19), Bacteroides spp. and Clostridium spp. remain
Peptococcus spp. 2 2 2
the anaerobes isolated most frequently from blood cultures
Peptostreptococcus spp. (Table 2).
P. micros 2 Mirroring the above-mentioned observation, for 151 pa-
Other Peptostreptococcus 4 4 4 4
spp. tients, corresponding to 14.9% of patients with positive blood
cultures, significant organisms were isolated only in aerobic
Eubacterium spp. bottles without any anaerobic bottles (Table 1). As expected,
E. aerofaciens 1
E. lentum 2 1 predominantly strictly aerobic bacteria or yeasts were isolated
Other Eubacterium spp. 2 from these aerobic bottles. Interestingly, somewhat similar
Other gram-positive bacilli 2 4 proportions of Enterobacteriaceae, staphylococci, and strepto-
cocci/enterococci were isolated either in an aerobic or in an
All gram-positive bacilli 10 13 17 22 anaerobic bottle alone (Table 1).
Repartition of positive aerobic and anaerobic bottles for
Unidentified anaerobic 11 2 4 1 patients sampled for only one blood culture. To evaluate
bacteria whether an advantage to collecting pairs of aerobic and anaer-
All anaerobic bacteria 52 (5.0) 52 (3.8) 53 (4.1) 68 (4.9)
obic bottles exists, patients for whom only a single pair of
isolated from blood bottles was sampled were analyzed. Out of 1,902 patients, 118
cultures (6.2%) had a positive blood culture. For 80 of them, a signif-
All bacteria isolated from 1,030 1,353 1,296 1,389 icant isolate grew in the blood culture (Table 3). Among those,
blood cultures for 12 and 21 patients, respectively, bacteria grew only in the
aerobic or the anaerobic bottle. These results emphasize the
2714 NOTES J. CLIN. MICROBIOL.

FIG. 2. For monomicrobial blood cultures, difference between time of detection of growth for the anaerobic bottles and their corresponding
aerobic bottles for Enterobacteriaceae (A), the Enterococcus/Streptococcus group (B), and S. aureus (C). P values correspond to the chi-square test
and were used to determine if the number of aerobic bottles positive before the anaerobic bottle was statistically different from the number of
anaerobic bottles positive before the aerobic bottle. The level of statistical significance was set at 0.05.

respective role of each type of bottle. If anaerobic bottles had possible advantage of growth in anaerobic or aerobic bottles.
not been sampled systematically, 25% of the single pair of Out of 2,108 positive blood cultures, 1,060 corresponded to a
positive blood cultures, among which 50% grew nonobligate positive pair of aerobic and anaerobic bottles, and for 894 of
anaerobic bacteria, would not have been diagnosed. them, the same unique organism grew in the two bottles: En-
Time of detection for aerobic and anaerobic positive bottles. terobacteriaceae in 289 pairs, Staphylococcus aureus in 257
Another question raised during this study was, as far as the pairs, either Streptococcus spp. or Enterococcus spp. in 138
time of detection before positivity was concerned, to find the pairs, and other microorganisms, mainly coagulase-negative
VOL. 45, 2007 NOTES 2715

staphylococci, in 210 pairs. The difference in the times of 2. Cockerill, F. R., III, J. W. Wilson, E. A. Vetter, K. M. Goodman, C. A.
Torgerson, W. S. Harmsen, C. D. Schleck, D. M. Ilstrup, J. A. Washington
detection of growth between the two bottles is represented in
II, and W. R. Wilson. 2004. Optimal testing parameters for blood cultures.
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Enterococcus group, and S. aureus, a gain of ⬎6 h of growth for 3. Comité de l’antibiogramme de la Société Française de Microbiologie. 2003.
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and 8.7% grew in the aerobic bottle first). A gain of ⬎2 h was sessment of the routine anaerobic culture and incubation time in the BacT/
found for 40.8% of the monomicrobial blood cultures (14.6% Alert FAN blood culture bottles. Diagn. Microbiol. Infect. Dis. 35:93–99.
5. Gransden, W. R., S. J. Eykyn, and I. Phillips. 1991. Anaerobic bacteremia:
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Enterobacteriaceae, 65.4% of the anaerobic bottles grew cul- mia by the continuously monitoring BacT/Alert system. J. Clin. Pathol.
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anaerobic bottles were raised in this study. (i) Only 13.7% of of increased sensitivity of BacT/Alert FAN aerobic and anaerobic blood
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4759.
anaerobic bottle than in the aerobic one. Such an advantage
16. Thorpe, T. C., M. L. Wilson, J. E. Turner, J. L. DiGuiseppi, M. Willert, S.
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We thank Vincent Jarlier for his relevant comments. 20. Zaidi, A. K., A. L. Knaut, S. Mirrett, and L. B. Reller. 1995. Value of routine
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