effect on the test results. Genetic testing can be used for rapid detection of certain antimicrobial resistance markers. Methods such as PCR and microarrays, which can be performed directly on positive blood culture samples, detect DNA sequences associated with genes that confer resistance, such as the mecA gene found in methicillin-resistant Staphylococcus aureus or the vanA and vanB genes of vancomycin-resistant enterococci. MALDI-TOF has been explored as a rapid antimicrobial sensitivity testing method; principles involve measuring microbial growth in the presence of antibiotics, identifying the breakdown of antibiotics by microbial enzymes, and detecting protein spectra associated with bacterial strains that exhibit antibiotic resistance. Some of these methods can be performed on pellets from positive blood culture bottles. However, the lack of established methodologies for AST by MALDI-TOF limits its use in clinical practice, and direct AST by MALDI-TOF, unlike genetic testing methods, had not been approved by the Food and Drug Administration as of 2018. Limitations Blood cultures are subject to both false positive and false negative errors. In automated culture systems, identification of positive bottles is based on the detection of gases produced by cellular metabolism, so samples with high numbers of white blood cells may be reported as positive when no bacteria are present. Inspection of the growth curve produced by the instrument can help to distinguish between true and false positive cultures, but Gram staining and subculturing are still necessary for any sample that is flagged as positive. Blood cultures can become contaminated with microorganisms from the skin or the environment, which multiply inside the culture bottle, giving the false impression that those organisms are present in the blood. Contamination of blood cultures can lead to unnecessary antibiotic treatment and longer hospital stays. The frequency of contamination can be reduced by following established protocols for blood culture collection, but it cannot be eliminated; for instance, bacteria can survive in deeper layers of the skin even after meticulous disinfection of the blood draw site. The CLSI defines an acceptable contamination rate as no greater than 3% of all blood cultures. The frequency of contamination varies widely between institutions and between different departments in the same hospital; studies have found rates ranging from 0.8 to 12.5 percent. When faced with a positive blood culture result, clinicians must decide whether the finding represents contamination or genuine infection. Some organisms, such as S. aureus or Streptococcus pneumoniae, are usually considered to