Association of Diagnostic Stewardship for Blood Cultures in Critically Ill Children With Culture Rates, Antibiotic Use, and Patient Outcomes

Abstract

and the Bright STAR Authorship Group 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 MEASURESThe 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 Ն3 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 canreduce 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.

Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention

“…Microbiologic diagnostic test stewardship, in which the practice of ordering cultures is modified to reduce the number of cultures that are ordered absent evidence of infection, have consistently reduced culture utilization, with inconsistent reductions in antimicrobial use. [7][8][9][10] Several studies have evaluated the determinants of uptake of antimicrobial stewardship interventions, but few have focused on diagnostic test stewardship interventions, particularly in the PICU setting. [11][12][13][14][15][16] These data are fundamental to optimizing the implementation of diagnostic test stewardship interventions.…”

Leveraging diagnostic stewardship within antimicrobial stewardship programmes

“…Consensus recommendations for when to avoid blood cultures in patients in the PICU were developed by an expert panel, and then subsequently studied with a quality improvement intervention in 14 PICUs. 76 , 77 This resulted in a 33% relative reduction in blood cultures and a 13% relative reduction in the use of broad-spectrum antimicrobials, with no increase in mortality, length of stay, readmission, or clinical diagnoses such as sepsis/severe sepsis.…”

Diagnostic Stewardship to Prevent Diagnostic Error

“…By correcting for overtesting and misdiagnosis of colonization as infection, diagnostic stewardship can help reduce unnecessary antibiotic use. Diagnostic stewardship has improved diagnosis and antibiotic use for C difficile , urinary tract infection (UTI), and sepsis …”