Association of Diagnostic Stewardship for Blood Cultures in Critically Ill Children With Culture Rates, Antibiotic Use, and Patient Outcomes: Results of the Bright STAR Collaborative.

2022

690-698

05/2022

2168-6211

Importance: Blood culture overuse in the pediatric intensive care unit (PICU) can lead to unnecessary antibiotic use and contribute to antibiotic resistance. Optimizing blood culture practices through diagnostic stewardship may reduce unnecessary blood cultures and antibiotics.

Objective: To evaluate the association of a 14-site multidisciplinary PICU blood culture collaborative with culture rates, antibiotic use, and patient outcomes.

Design, Setting, and Participants: This prospective quality improvement (QI) collaborative involved 14 PICUs across the United States from 2017 to 2020 for the Bright STAR (Testing Stewardship for Antibiotic Reduction) collaborative. Data were collected from each participating PICU and from the Children's Hospital Association Pediatric Health Information System for prespecified primary and secondary outcomes.

Exposures: A local QI program focusing on blood culture practices in the PICU (facilitated by a larger QI collaborative).

Main Outcomes and Measures: The primary outcome was blood culture rates (per 1000 patient-days/mo). Secondary outcomes included broad-spectrum antibiotic use (total days of therapy and new initiations of broad-spectrum antibiotics ≥3 days after PICU admission) and PICU rates of central line-associated bloodstream infection (CLABSI), Clostridioides difficile infection, mortality, readmission, length of stay, sepsis, and severe sepsis/septic shock.

Results: Across the 14 PICUs, the blood culture rate was 149.4 per 1000 patient-days/mo preimplementation and 100.5 per 1000 patient-days/mo postimplementation, for a 33% relative reduction (95% CI, 26%-39%). Comparing the periods before and after implementation, the rate of broad-spectrum antibiotic use decreased from 506 days to 440 days per 1000 patient-days/mo, respectively, a 13% relative reduction (95% CI, 7%-19%). The broad-spectrum antibiotic initiation rate decreased from 58.1 to 53.6 initiations/1000 patient-days/mo, an 8% relative reduction (95% CI, 4%-11%). Rates of CLABSI decreased from 1.8 to 1.1 per 1000 central venous line days/mo, a 36% relative reduction (95% CI, 20%-49%). Mortality, length of stay, readmission, sepsis, and severe sepsis/septic shock were similar before and after implementation.

Conclusions and Relevance: Multidisciplinary diagnostic stewardship interventions can reduce blood culture and antibiotic use in the PICU. Future work will determine optimal strategies for wider-scale dissemination of diagnostic stewardship in this setting while monitoring patient safety and balancing measures.

10.1001/jamapediatrics.2022.1024

JAMA Pediatr

35499841

Association of Diagnostic Stewardship for Blood Cultures in Critically Ill Children With Culture Rates, Antibiotic Use, and Patient Outcomes: Results of the Bright STAR Collaborative.

2022

690-698

12/2022

2168-6211

Importance: Blood culture overuse in the pediatric intensive care unit (PICU) can lead to unnecessary antibiotic use and contribute to antibiotic resistance. Optimizing blood culture practices through diagnostic stewardship may reduce unnecessary blood cultures and antibiotics.

Objective: To evaluate the association of a 14-site multidisciplinary PICU blood culture collaborative with culture rates, antibiotic use, and patient outcomes.

Design, Setting, and Participants: This prospective quality improvement (QI) collaborative involved 14 PICUs across the United States from 2017 to 2020 for the Bright STAR (Testing Stewardship for Antibiotic Reduction) collaborative. Data were collected from each participating PICU and from the Children's Hospital Association Pediatric Health Information System for prespecified primary and secondary outcomes.

Exposures: A local QI program focusing on blood culture practices in the PICU (facilitated by a larger QI collaborative).

Main Outcomes and Measures: The primary outcome was blood culture rates (per 1000 patient-days/mo). Secondary outcomes included broad-spectrum antibiotic use (total days of therapy and new initiations of broad-spectrum antibiotics ≥3 days after PICU admission) and PICU rates of central line-associated bloodstream infection (CLABSI), Clostridioides difficile infection, mortality, readmission, length of stay, sepsis, and severe sepsis/septic shock.

Results: Across the 14 PICUs, the blood culture rate was 149.4 per 1000 patient-days/mo preimplementation and 100.5 per 1000 patient-days/mo postimplementation, for a 33% relative reduction (95% CI, 26%-39%). Comparing the periods before and after implementation, the rate of broad-spectrum antibiotic use decreased from 506 days to 440 days per 1000 patient-days/mo, respectively, a 13% relative reduction (95% CI, 7%-19%). The broad-spectrum antibiotic initiation rate decreased from 58.1 to 53.6 initiations/1000 patient-days/mo, an 8% relative reduction (95% CI, 4%-11%). Rates of CLABSI decreased from 1.8 to 1.1 per 1000 central venous line days/mo, a 36% relative reduction (95% CI, 20%-49%). Mortality, length of stay, readmission, sepsis, and severe sepsis/septic shock were similar before and after implementation.

Conclusions and Relevance: Multidisciplinary diagnostic stewardship interventions can reduce blood culture and antibiotic use in the PICU. Future work will determine optimal strategies for wider-scale dissemination of diagnostic stewardship in this setting while monitoring patient safety and balancing measures.

10.1001/jamapediatrics.2022.1024

JAMA Pediatr

35499841

Consensus Recommendations for Blood Culture Use in Critically Ill Children Using a Modified Delphi Approach.

2021

2021 Apr 23

1529-7535

<p><strong>OBJECTIVES: </strong>Blood cultures are fundamental in evaluating for sepsis, but excessive cultures can lead to false-positive results and unnecessary antibiotics. Our objective was to create consensus recommendations focusing on when to safely avoid blood cultures in PICU patients.</p>

<p><strong>DESIGN: </strong>A panel of 29 multidisciplinary experts engaged in a two-part modified Delphi process. Round 1 consisted of a literature summary and an electronic survey sent to invited participants. In the survey, participants rated a series of recommendations about when to avoid blood cultures on five-point Likert scale. Consensus was achieved for the recommendation(s) if 75% of respondents chose a score of 4 or 5, and these were included in the final recommendations. Any recommendations that did not meet these a priori criteria for consensus were discussed during the in-person expert panel review (Round 2). Round 2 was facilitated by an independent expert in consensus methodology. After a review of the survey results, comments from round 1, and group discussion, the panelists voted on these recommendations in real-time.</p>

<p><strong>SETTING: </strong>Experts' institutions; in-person discussion in Baltimore, MD.</p>

<p><strong>SUBJECTS: </strong>Experts in pediatric critical care, infectious diseases, nephrology, oncology, and laboratory medicine.</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>Of the 27 original recommendations, 18 met criteria for achieving consensus in Round 1; some were modified for clarity or condensed from multiple into single recommendations during Round 2. The remaining nine recommendations were discussed and modified until consensus was achieved during Round 2, which had 26 real-time voting participants. The final document contains 19 recommendations.</p>

<p><strong>CONCLUSIONS: </strong>Using a modified Delphi process, we created consensus recommendations on when to avoid blood cultures and prevent overuse in the PICU. These recommendations are a critical step in disseminating diagnostic stewardship on a wider scale in critically ill children.</p>

10.1097/PCC.0000000000002749

Pediatr Crit Care Med

33899804

Practices, Perceptions, and Attitudes in the Evaluation of Critically Ill Children for Bacteremia: A National Survey.

2019

2019 Nov 06

1529-7535

<p><strong>OBJECTIVES: </strong>Sending blood cultures in children at low risk of bacteremia can contribute to a cascade of unnecessary antibiotic exposure, adverse effects, and increased costs. We aimed to describe practice variation, clinician beliefs, and attitudes about blood culture testing in critically ill children.</p>

<p><strong>DESIGN: </strong>Cross-sectional electronic survey.</p>

<p><strong>SETTING: </strong>Fifteen PICUs enrolled in the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children collaborative, an investigation of blood culture use in critically ill children in the United States.</p>

<p><strong>SUBJECTS: </strong>PICU clinicians (bedside nurses, resident physicians, fellow physicians, nurse practitioners, physician assistants, and attending physicians).</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>MEASUREMENT AND MAIN RESULTS: </strong>Survey items explored typical blood culture practices, attitudes and beliefs about cultures, and potential barriers to changing culture use in a PICU setting. Fifteen of 15 sites participated, with 347 total responses, 15-45 responses per site, and an overall median response rate of 57%. We summarized median proportions and interquartile ranges of respondents who reported certain practices or beliefs: 86% (73-91%) report that cultures are ordered reflexively; 71% (61-77%) do not examine patients before ordering cultures; 90% (86-94%) obtain cultures for any new fever in PICU patients; 33% (19-61%) do not obtain peripheral cultures when an indwelling catheter is in place; and 64% (36-81%) sample multiple (vs single) lumens of central venous catheters for new fever. When asked about barriers to reducing unnecessary cultures, 80% (73-90%) noted fear of missing sepsis. Certain practices (culture source and indication) varied by clinician type. Obtaining surveillance cultures and routinely culturing all possible sources (each lumen of indwelling catheters and peripheral specimens) are positively correlated with baseline blood culture rates.</p>

<p><strong>CONCLUSIONS: </strong>There is variation in blood culture practices in the PICU. Fear and reflexive habits are common drivers of cultures. These practices may contribute to over-testing for bacteremia. Further investigation of how to optimize blood culture use is warranted.</p>

10.1097/PCC.0000000000002176

Pediatr Crit Care Med

31702704

Evaluating application of the National Healthcare Safety Network central line-associated bloodstream infection surveillance definition: a survey of pediatric intensive care and hematology/oncology units.

2013

663-70

2013 Jul

1559-6834

<p><strong>OBJECTIVE: </strong>To evaluate the application of the National Healthcare Safety Network (NHSN) central line-associated bloodstream infection (CLABSI) definition in pediatric intensive care units (PICUs) and pediatric hematology/oncology units (PHOUs) participating in a multicenter quality improvement collaborative to reduce CLABSIs; to identify sources of variability in the application of the definition.</p>

<p><strong>DESIGN: </strong>Online survey using 18 standardized case scenarios. Each described a positive blood culture in a patient and required a yes- or-no answer to the question "Is this a CLABSI?" NHSN staff responses were the reference standard.</p>

<p><strong>SETTING: </strong>Sixty-five US PICUs and PHOUs.</p>

<p><strong>PARTICIPANTS: </strong>Staff who routinely adjudicate CLABSIs using NHSN definitions.</p>

<p><strong>RESULTS: </strong>Sixty responses were received from 58 (89%) of 65 institutions; 78% of respondents were infection preventionists, infection control officers, or infectious disease physicians. Responses matched those of NHSN staff for 78% of questions. The mean (SE) percentage of concurring answers did not differ for scenarios evaluating application of 1 of the 3 criteria ("known pathogen," 78% [1.7%]; "skin contaminant, &gt;1 year of age," 76% [SE, 2.5%]; "skin contaminant, ≤1 year of age," 81% [3.8%]; [Formula: see text]). The mean percentage of concurring answers was lower for scenarios requiring respondents to determine whether a CLABSI was present or incubating on admission (64% [4.6%]; [Formula: see text]) or to distinguish between primary and secondary bacteremia (65% [2.5%]; [Formula: see text]).</p>

<p><strong>CONCLUSIONS: </strong>The accuracy of application of the CLABSI definition was suboptimal. Efforts to reduce variability in identifying CLABSIs that are present or incubating on admission and in distinguishing primary from secondary bloodstream infection are needed.</p>

10.1086/671005

Infect Control Hosp Epidemiol

23739069