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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.

Authors
  • Woods-Hill, Charlotte Z1, 2
  • Colantuoni, Elizabeth A3
  • Koontz, Danielle W4
  • Voskertchian, Annie4
  • Xie, Anping5, 6
  • Thurm, Cary7
  • Miller, Marlene R8, 9
  • Fackler, James C5
  • Milstone, Aaron M4, 10
  • Agulnik, Asya11
  • Albert, J Elaine-Marie12
  • Auth, Michael J13
  • Bradley, Erin14
  • Clayton, Jason A15
  • Coffin, Susan E16
  • Dallefeld, Samantha13
  • Ezetendu, Chidiebere P17
  • Fainberg, Nina A18
  • Flaherty, Brian F19
  • Foster, Charles B20
  • And 19 more
  • 1 Division of Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia.
  • 2 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.
  • 3 Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.
  • 4 Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
  • 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
  • 6 Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland.
  • 7 Children's Hospital Association, Lenexa, Kansas.
  • 8 Rainbow Babies and Children's Hospital, Cleveland, Ohio.
  • 9 Case Western Reserve University School of Medicine, Cleveland, Ohio.
  • 10 Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland.
  • 11 Department of Global Pediatric Medicine, Division of Critical Care, St Jude Children's Research Hospital, Memphis, Tennessee.
  • 12 Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle.
  • 13 Division of Pediatric Critical Care, Department of Pediatrics, Dell Medical School, University of Texas at Austin.
  • 14 Children's Healthcare of Atlanta, Atlanta, Georgia. , (Georgia)
  • 15 University Hospitals, Rainbow Babies and Children's Hospital, Cleveland, Ohio.
  • 16 Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia.
  • 17 Cleveland Clinic Children's Hospital, Cleveland, Ohio.
  • 18 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
  • 19 University of Utah, Department of Pediatrics, Division of Critical Care, Salt Lake City.
  • 20 Center for Pediatric Infectious Diseases, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
  • 21 Division of Pediatric Infectious Disease, Dell Medical School, University of Texas at Austin.
  • 22 Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois.
  • 23 Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis.
  • 24 Division of Pediatric Critical Care, Doernbecher Children's Hospital, Oregon Health & Science University, Portland.
  • 25 Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
  • 26 Division of Critical Care Medicine, Department of Pediatrics, Intermountain Primary Children's Hospital, University of Utah, Salt Lake City.
  • 27 Washington University School of Medicine, St Louis, Missouri.
  • 28 Emory School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia. , (Georgia)
  • 29 Doernbecher Children's Hospital, Oregon Health & Science University, Portland.
  • 30 Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.
  • 31 Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.
  • 32 Department of Anesthesia, Harvard Medical School, Boston, Massachusetts.
  • 33 Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California.
  • 34 Department of Neurology, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
  • 35 Stanford University Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford, California.
  • 36 Division of Pediatric Critical Care and Cardiology, Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis.
  • 37 Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee.
  • 38 Department of Pediatrics, University of Tennessee Health Science Center, Memphis.
  • 39 Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle.
Type
Published Article
Journal
JAMA pediatrics
Publication Date
Jul 01, 2022
Volume
176
Issue
7
Pages
690–698
Identifiers
DOI: 10.1001/jamapediatrics.2022.1024
PMID: 35499841
Source
Medline
Language
English
License
Unknown

Abstract

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. To evaluate the association of a 14-site multidisciplinary PICU blood culture collaborative with culture rates, antibiotic use, and patient outcomes. 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. A local QI program focusing on blood culture practices in the PICU (facilitated by a larger QI collaborative). 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. 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. 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.

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