Diagnostic Stewardship of Endotracheal Aspirate Cultures in a PICU

Abstract

BACKGROUND: Clinicians commonly obtain endotracheal aspirate cultures (EACs) in the evaluation of suspected ventilator-associated infections. However, bacterial growth in EACs does not distinguish bacterial colonization from infection and may lead to overtreatment with antibiotics. We describe the development and impact of a clinical decision support algorithm to standardize the use of EACs from ventilated PICU patients. METHODS: We monitored EAC use using a statistical process control chart. We compared the rate of EACs using Poisson regression and a quasi-experimental interrupted time series model and assessed clinical outcomes 1 year before and after introduction of the algorithm. RESULTS: In the preintervention year, there were 557 EACs over 5092 ventilator days; after introduction of the algorithm, there were 234 EACs over 3654 ventilator days (an incident rate of 10.9 vs 6.5 per 100 ventilator days). There was a 41% decrease in the monthly rate of EACs (incidence rate ratio [IRR]: 0.59; 95% confidence interval [CI] 0.51–0.67; P < .001). The interrupted time series model revealed a preexisting 2% decline in the monthly culture rate (IRR: 0.98; 95% CI 0.97–1.0; P = .01), immediate 44% drop (IRR: 0.56; 95% CI 0.45–0.70; P = .02), and stable rate in the postintervention year (IRR: 1.03; 95% CI 0.99–1.07; P = .09). In-hospital mortality, hospital length of stay, 7-day readmissions, and All Patients Refined Diagnosis Related Group severity and mortality scores were stable. The estimated direct cost savings was $26 000 per year. CONCLUSIONS: A clinical decision support algorithm standardizing EAC obtainment from ventilated PICU patients was associated with a sustained decline in the rate of EACs, without changes in mortality, readmissions, or length of stay.

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.…”

Diagnosis, management, and outcomes of pediatric tracheostomy‐associated infections: A scoping review

“…Over 70% of studies were retrospective in nature and accompanied by the limitations of data granularity and uncertain causal relationships of interest. Furthermore, the inclusion of large cohorts of patients from retrospective periods of time prohibits the consideration of institutional secular trends that may affect key outcomes related to TRAIN, such as efforts to reduce the number of respiratory cultures and other laboratory testing that may influence diagnostic and treatment decisions 81 . Of the prospective studies including only children with tracheostomy, the detection of bacterial or other pathogens was the primary outcome of interest.…”

“…Furthermore, the inclusion of large cohorts of patients from retrospective periods of time prohibits the consideration of institutional secular trends that may affect key outcomes related to TRAIN, such as efforts to reduce the number of respiratory cultures and other laboratory testing that may influence diagnostic and treatment decisions. 81 narrowing the spectrum of antimicrobial activity in only ~20% of patients. 25 No other studies explicitly examined duration of treatment and clinically relevant outcomes.…”

Principles of diagnostic stewardship: A practical guide from the Society for Healthcare Epidemiology of America Diagnostic Stewardship Task Force

“…Understanding healthcare providers' mental constructs and local drivers for testing and management (eg, setting in which they practice, anecdotal experience, patient preferences, peer prescribing practices, etc) are essential to the design and implementation of effective diagnostic stewardship interventions. 22 Interventions focusing on clinical decision making include traditional education and various clinical-decision support tools (Table 2). 3.…”