EDITORIAL

ADAM J. BROWN, MD, Associate Editor

Adam J. Brown, MD
Department of Rheumatologic and Immunologic
Disease, Cleveland Clinic, Cleveland, OH; Clinical
Instructor, Cleveland Clinic Lerner College of
Medicine of Case Western Reserve University,
Cleveland, OH

The history of blood cultures:

From the research laboratory
to the bedside
“In order to study the characters of any species of bacterium wasn’t until endocarditis became a recognized clinical
it is necessary to have it growing apart from every other entity in 1885 and the hunt began in earnest to prove
species. . . . When we have succeeded in separating it, and the etiology was bacterial that blood cultures were
have got it to grow on a medium which suits it, we are said brought to the bedside.
to have obtained a pure culture.”
Dr. Robert Muir, pathologist, Manual of Bacteriology, 18971 ■ FROM COMPLEX BEGINNINGS . . .
he case of endocarditis presented in this issue
T of Cleveland Clinic Journal of Medicine highlights
the heterogeneity of the cutaneous manifestations of
The Manual of Bacteriology, first published in 1897, is
a just over 500-page textbook of the knowledge at the
time of the rapidly expanding field of microbiology.1
this disease, as well as the importance of blood cultures The textbook walks the reader through the multiple
in making the diagnosis.2 A patient develops a fever, processes for culturing and isolating bacterial organ-
blood cultures are done, and Staphylococcus aureus isms, starting with sterilizing of equipment: dry heat in
grows. Next step is to check an echocardiogram to a hot air chamber, wet heat in Koch’s steam sterilizer, or
find the source of the bacteremia and, lo and behold, a high-pressure steam chamber. Next, the book outlines
vegetations are found and the boxes of the Duke crite- multiple practices for culturing bacteria with an amal-
ria for endocarditis are checked (2 major criteria). The gamation of recipes ranging from ox meat, horse meat,
patient had multiple rashes consistent with endocar- gelatin, agar, blood agar, potatoes, and bread paste.
ditis, but what cemented the diagnosis was the blood It took decades of trial and error to develop reci-
culture leading to the echocardiography findings. pes to create ideal culture media to isolate and grow
various organisms. Raw meat was the most popular
Associate Editor, Adam Brown, MD, discusses an angle culture medium, which isn’t surprising as bacteria that
related to the article “Skin manifestations in a patient infect human tissues were the most studied. Many of
with acute bacterial infective endocarditis” on page 657. the bacteria that infect human tissue are also capable
of colonizing horse and ox meat. Meat culture had a
We consider blood cultures to be an essential com- few negatives, however. For one, the preparation was
ponent of an infectious disease workup, especially in a complex and time consuming.
patient in whom bacterial endocarditis is suspected. It’s “It ought to be from an animal recently killed, and
reasonable to think culturing of blood was adopted rap- should therefore be markedly acid to litmus paper. It must
idly in clinical practice around the time of the micro- be freed from fat, and finely minced. For each pound of
biology revolution led by Koch, Pasteur, and Lister, but mince add 1000 cc distilled water, and mix thoroughly in
culturing of bacterial organisms was initially a complex a shallow dish. Skim off any fat present, removing the last
and labor-intensive process relegated to the research traces by stoking the surface of the fluid with pieces of filter
laboratories across the United States and Europe. It paper. Set aside in a cool place for twenty-four hours. Place
doi:10.3949/ccjm.91a.24091 a clean linen cloth over the mouth of a large filter funnel,
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 91 • NUMBER 11 NOVEMBER 2024 661

Downloaded from www.ccjm.org on November 20, 2024. For personal use only. All other uses require permission.
BLOOD CULTURES

and strain the fluid through it into a flask. Pour the minced could be added to cultivate the famously fastidious
meat into the cloth, and gathering [sic] up the edges of the Mycobacterium tuberculosis, whereas glucose could be
cloth in the left hand, squeeze out the juice still held back added for diphtheriae. Pfeiffer influenza bacillus (later
in the contained meat. Finish this expression by putting the recognized to not cause influenza) had a predilection
cloth and its contents into a meat press . . . squeeze out for human or ox blood added to agar plates, inspiring
the last drops.”1 its future name Haemophilus (heme-loving) influen-
Even when prepared correctly, the meat-based zae. Even bacteria that had a deep disdain for oxygen
culture media presented challenges when used to could be grown by combining sulfuric acid with pure
culture bacteria, as, not surprisingly, meat is opaque zinc to create hydrogen, which is then passed over
and colonies of bacteria could not be observed growing the culture to bind and expel the oxygen and make a
within. An advancement in culture technology was the comfy anerobic environment for certain organisms.1
recognition that gelatin could be sterilized and added Decades of work, trial, and error led to an assortment
to the culture mixture to make it clearer and allow the of culture media to isolate and grow bacteria in the
viewer to see bacterial growth within the meat culture. research laboratory.
Gelatin was also popular as an additive because it
could be purchased ready-made (Gold label from Paris ■ BRINGING BLOOD CULTURE TO THE BEDSIDE
was mentioned in the textbook as being particularly IN THE PURSUIT OF ENDOCARDITIS
high quality). Challenges with gelatin were noted,
however, as at human body temperature—the optimal For centuries endocarditis was an enigmatic disease. It
temperature for growing organisms that affect humans— is debatable when the first description of endocarditis
gelatin is a liquid, making it unstable and potentially occurred. Dr. Jean-Nicolas Corvisart in the late 1700s
leading to a plate full of soupy minced meat.1 was the first to use the term vegetation to describe a
A substitution for gelatin came from discovering lesion on the mitral valve of a patient who died, but
agar’s stability and ability to cultivate bacterial organ- there was no clear overarching disease known to cause
isms. Although agar now is most associated with the these valvular changes.4 Corvisart surmised that the
thing you made to grow bacteria in your Biology 101 vegetations were caused by syphilis.
lab, originally agar had nothing to do with bacteriology. Other medical heavyweights had hypotheses
Agar-agar is a southeast Asian term for seaweed. In about the cause of the vegetations. None other than
the late 1600s it was noted that seaweed and algae Dr. René-Théophile Hyacinthe Laënnec, the inventor
when ground and left to dry in the sun turned into a of the stethoscope, hypothesized that vegetations were
semi-solid jelly and could be used as a food additive. caused by thrombus formation.4
Agar began to be used in research laboratories in The “clinical entity” endocarditis made its debut
the late 19th century, when Dr. Walther Hesse, then on the international stage in 1885 when Dr. William
a researcher working in Dr. Robert Koch’s laboratory, Osler reviewed more than 200 cases of the disease in a
was having difficulty with the gelatin culture he was Gulstonian lecture series in London.5 Osler synthesized
applying to the inside of a test tube to grow bacteria, as the data, describing signs and symptoms to look for
the gelatin persistently melted in the summertime heat. like fever, joint pain, rash, and splenomegaly. Osler
Legend has it his wife Fanny Hesse, who was working as also made the critical observation that a history of
his unpaid laboratory assistant, suggested using the food valvular abnormalities, such as those resulting from
additive agar as a culture medium because it is stable rheumatic fever, predisposes to the development of
at higher temperatures.3 Not only was agar solid at a endocarditis.4,6 What was the cause? Osler hypothesized
wide range of temperatures, but it was also clear and it was infectious but couldn’t prove it. It would take
able to grow various bacteria. Agar has been a staple another 3 decades to prove the infectious etiology of
in research and Biology 101 labs ever since. endocarditis.
It wasn’t until 1910 that Dr. Hugo Schottmüller
■ DIFFERENT MIXTURES FOR DIFFERENT BACTERIA cultured viridans streptococci from a patient with
endocarditis.4,7 That same year, Dr. Emanuel Libman,
Not all bacteria, it turns out, are fans of plain, dried- practicing at Mount Sinai in New York City, pub-
out, pulverized seaweed. Through much trial and error, lished a paper with the confident title “The etiology
different additives or formulations of culture media of subacute infective endocarditis,” along with Herbert
were created to cultivate and isolate certain, more Louis Celler.8 Libman described 43 patients who died
discerning organisms.1 For example, glycerine broth of endocarditis. Blood cultures were done in 36 of these
662 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 91 • NUMBER 11 NOVEMBER 2024

Downloaded from www.ccjm.org on November 20, 2024. For personal use only. All other uses require permission.
 BROWN

patients, and “atypical” nonhemolytic streptococci laboratories around the globe. The skills Dr. Emanuel
grew in 35.4 Libman attained working directly with Dr. Escherich
Libman also reviewed more than 3,000 blood cul- allowed him to establish the bacterial cause of endo-
tures over the preceding 10 years during his studies carditis, paving the way for use of bacterial culture in
on the “bacteriology of the blood,” recognizing other the clinic to help establish the diagnosis of bacteremia
causes of endocarditis such as Staphylococcus.6 He and potentially, endocarditis. Once the antibiotic era
was particularly inclined to make this discovery, as opened in the 1940s, there was an even greater desire
he had previously worked under the mentorship of
to diagnose bacteremia, as it was recognized that the
Dr. Theodor Escherich in Vienna, a famous pediatri-
rapid introduction of antibiotics could reduce the risk
cian who first isolated a bacterium from the intestines
of multiple children he termed Bacterium coli commune of septic shock and death. Techniques for culturing
and who would later have his name attached to the blood improved, becoming less time intensive, and,
ever-difficult-to spell Escherichia coli. Dr. Escherich was thankfully for the horse and ox, less reliant on raw
particularly known for his skills of bacterial culture and meat. In the 1970s automated growth systems were
passed these skills to Dr. Libman.4 introduced, detecting evidence of bacterial metabolism
With blood cultures, Dr. Libman showed the bac- and division instead of relying on the naked eye of a
terial etiology of infectious endocarditis and how, in human.9
the right clinical context, the diagnosis of endocarditis Blood cultures have become standard practice for
could be made in a living, breathing person. Half a evaluating a patient for suspected infection. Next time
century before the development of echocardiography, you’re on the hospital wards and you’re alerted to fever
blood culture gave us 1 of the 2 major Duke criteria to in a patient with an unknown cause and you go to click
diagnose infectious endocarditis. Before Dr. Libman’s the blood culture button, remember the oxen sacrificed,
paper, the diagnosis of endocarditis was mostly rele- the melted gelatin, and the pursuit of endocarditis that
gated to the pathologist at autopsy.
gave us this valuable clinical tool. ■
■ CONCLUSION
■ DISCLOSURES
Culturing and isolating bacteria was a labor-intensive Dr. Brown has disclosed consulting and teaching and speaking for
process developed through decades of toil in research Amgen and Chemocentryx.

■ REFERENCES 6. Hook EW Jr. Emanuel Libman and infective endocarditis: comments

on the etiology of subacute infective endocarditis. Am J Med Sci
1. Muir R. Manual of Bacteriology. Edinburgh and London: Young J. 1995; 309(2):71–73. doi:10.1097/00000441-199502000-00002
Pentland; 1897/2012. 7. Schottmuller J. Endocarditis lenta. Zugleich ein Beitrag zur
2. Aykent B, Yilmaz O. Skin manifestations in a patient with acute Artunterscheidung der pathogenen Streptokokken. Munch Med
bacterial infective endocarditis. Clev Clin J Med 2024; 91(11): Wochenschr 1910; 57:617–620. German.
657–659. doi:10.3949/ccjm.91a.24066 8. Libman E, Celler HL. The etiology of subacute infective endocarditis.
3. Hesse W. Walther and Angelina Hesse-early contributors to bacteri- Am J Med Sci 1910; 4:516–527.
9. Cross AJ, Haworth E, Spencer RC. A re-evaluation of the pour plate
ology. ASM News 1992; 58(8):425–428.
blood culture method for the detection of Candida and other septi-
4. Geller SA. Infective endocarditis: a history of the development of its
caemias. J Hosp Infect 1986; 7(1):74–77.
understanding. Autops Case Rep 2013; 3(4):5–12.
doi:10.1016/0195-6701(86)90029-0
doi:10.4322/acr.2013.033
5. Osler W. The Gulstonian lectures, on malignant endocarditis. Br Address: Adam J. Brown, MD, Department of Rheumatologic and Immu-
Med J 1885; 1(1262):467–470. nologic Disease, A50, Cleveland Clinic, 9500 Euclid Avenue, Cleveland,
doi:10.1136/bmj.1.1262.467 OH 44195; [email protected]

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 91 • NUMBER 11 NOVEMBER 2024 663

Downloaded from www.ccjm.org on November 20, 2024. For personal use only. All other uses require permission.