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. 2022 Jul 1;176(7):690-698.
doi: 10.1001/jamapediatrics.2022.1024.

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

Charlotte Z Woods-Hill  1   2 , Elizabeth A Colantuoni  3 , Danielle W Koontz  4 , Annie Voskertchian  4 , Anping Xie  5   6 , Cary Thurm  7 , Marlene R Miller  8   9 , James C Fackler  5 , Aaron M Milstone  4   10 ; Bright STAR Authorship Group; Asya Agulnik  11 , J Elaine-Marie Albert  12 , Michael J Auth  13 , Erin Bradley  14 , Jason A Clayton  15 , Susan E Coffin  16 , Samantha Dallefeld  13 , Chidiebere P Ezetendu  17 , Nina A Fainberg  18 , Brian F Flaherty  19 , Charles B Foster  20 , Sarmistha B Hauger  21 , Sue J Hong  22 , Nicholas D Hysmith  23 , Aileen L Kirby  24 , Larry K Kociolek  25 , Gitte Y Larsen  26 , John C Lin  27 , William M Linam  28 , Jason G Newland  27 , Dawn Nolt  29 , Gregory P Priebe  30   31   32 , Thomas J Sandora  31 , Hayden T Schwenk  33 , Craig M Smith  25   34 , Katherine M Steffen  35 , Sachin D Tadphale  36 , Philip Toltzis  8 , Joshua Wolf  37   38 , Danielle M Zerr  39
Affiliations

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

Charlotte Z Woods-Hill et al. JAMA Pediatr. .

Abstract

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Woods-Hill reported grants from Agency for Healthcare Research and Quality (AHRQ) (the grant that funded the Bright STAR project) and grants from National Institutes of Health (NIH) (a training grant and then a career development award) during the conduct of the study. Drs Colantuoni, Koontz, Voskertchian, Xie, and Fackler reported grants from AHRQ during the conduct of the study. Dr Coffin reported grants from Merck (investigator-initiated study) and personal fees from Merck (member of data and safety monitoring board) outside the submitted work. Dr Kociolek reported grants from Merck outside the submitted work. Dr Priebe reported grants from AHRQ during the conduct of the study and grants from US Department of Defense W81XWH-19-1-0208 on Pseudomonas vaccines outside the submitted work. Dr Tadphale reported grants from Johns Hopkins University during the conduct of the study. Dr Wolf reported nonfinancial support from Karius Inc and in-kind support for investigator-initiated research outside the submitted work. Dr Zerr reported grants from a subcontract from the primary site during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Key Steps in the Bright STAR (Testing Stewardship for Antibiotic Reduction) Collaborative Time Line
JHCC indicates Johns Hopkins Children’s Center.
Figure 2.
Figure 2.. Monthly Blood Cultures per 1000 Patient-Days for Each of the 14 Bright STAR (Testing Stewardship for Antibiotic Reduction) Sites
Monthly blood cultures per 1000 patient-days for each of the 14 Bright STAR sites before and after implementation (24 and 18 months, respectively). The mean monthly average rate over time was estimated using a smoothing spline with 4 degrees of freedom.
Figure 3.
Figure 3.. Antibiotic Use for Each of the 11 Bright STAR (Testing Stewardship for Antibiotic Reduction) Sites That Participate in the Children’s Hospital Association Pediatric Health Information System
Rates of antibiotic use and new antibiotic initiation 3 or more days after pediatric intensive care unit admission, before and after implementation (24 and 18 months, respectively). The mean monthly average rate over time was estimated using a smoothing spline with 4 degrees of freedom.
See this image and copyright information in PMC

Comment in

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