Stewardship effort helps PICUs sustain lower blood culture rates

Key takeaways:

• A quality improvement program lowered blood culture rates in 14 PICUs.
• The reductions were sustained during a 2-year period following an initial study.

More than a dozen pediatric ICUs were able to sustain reductions in blood culture rates during a 2-year period following a diagnostic stewardship effort aimed at safely improving ordering practices, researchers reported in JAMA Pediatrics.

The initial study was part of the Testing Stewardship for Antibiotic Reduction collaborative, nicknamed Bright STAR. It collected data from PICUs and measured the change in rates of blood cultures per 1,000 patients each month when screening for bacterial infections.

“Bright STAR was a 14-site collaborative project that we did from 2017 to 2020,” Charlotte Z. Woods-Hill, MD, an attending physician in the division of critical care medicine at The Children’s Hospital of Philadelphia, told Healio.

“The idea was to see if we could facilitate diagnostic stewardship for blood cultures in the complex, fast-moving and often complicated world of pediatric intensive care,” Woods-Hill said. “What we wanted to do is see if we could help clinicians be better stewards of blood cultures.”

She said clinicians have been “trained to be worried” that an infection may be to blame if a child has a fever.

“Much of the time that we test a blood culture, the results are negative, but we are so worried [about a bad outcome] that we think about any fever, for example, as potentially a sign that a child could have a bacterial bloodstream infection,” Woods-Hill said.

The goal of the original Bright STAR initiative, Woods-Hill continued, was to help clinicians “be a little more thoughtful about when to send a test,” and to try to “figure out a way to safely reduce unnecessary instances of sending that test.”

“Maybe there were some reliable clinical signs that a different condition was present, like a virus instead of a bacterial infection, or no infection at all, since there are some causes of fever in children that are not infectious diseases,” Woods-Hill said. “That initial work is just trying to help clinicians get more comfortable with potentially not sending the test quite so often.”

Woods-Hill and colleagues also examined the impact of the approach on antibiotic use because sending a sample is often paired with starting broad-spectrum antibiotics.

According to results published last year in JAMA Pediatrics, the multidisciplinary diagnostic stewardship intervention — which involved strategies to influence blood culture practices and coaching calls from a coordinating center — reduced blood culture and broad-spectrum antibiotic use at 14 PICUs in the U.S. by 33% and 13%, respectively, from 2017 to 2020.

“For this new paper, we wanted to see how did those original 14 sites do?” Woods-Hill said. “Were they still able to sustain the reductions and improvements that we had seen the first time around, or did practices drift back to what they had done before? That was really sort of a trigger for doing this follow up paper, looking at the sustainability as a kind of a separate piece of the project.”

The researchers reached out to the 14 original sites and asked for the next 24 months of data.

“When you do this type of work in quality improvement, it’s not easy to ‘change practices,’” Woods-Hill said. “Initially, when you have a ton of resources and you’ve got a ton of energy and everybody’s really focused on fixing this thing. When all that goes away, how do people actually sustain the improvements?”

They found that all 14 sites maintained lower blood culture rates during the 24-month sustainability period compared with the preimplantation period. The average blood culture rate per 1,000 patient-days was 148.3 during the preimplantation period, 100.2 during the postimplementation period, and 108 during the sustainability period.

Although the blood culture rate increased around 8% during sustainability compared with the postimplementation period, it was still over 27% lower than the preimplementation average, which Woods-Hill said was a “pleasant surprise.”

“We were surprised by how low the rates remained,” Woods-Hill said. “Most of the sites had a bit of an increase in blood culture rates again, sort of suggesting that that rates were going back up, but then they stay significantly below what we saw in the baseline period, and I think to see that 2 years later is actually pretty great.”

Woods-Hill said she hopes clinicians will realize how crucial it is to “recognize that we can unintentionally contribute to harmful overuse of tested treatments,” and said she and her colleagues are planning a similar project to examine bacterial respiratory infections like tracheitis or pneumonia.

“We call that sort of Brightstar 2.0, or Brightstar Respiratory, [and we’re] trying to reduce unnecessary use of respiratory cultures in ICU patients, because that certainly also can drive a lot of unnecessary antibiotic use,” Woods-Hill said.

References:

Woods-Hill CZ, et al. JAMA Pediatr. 2022;doi:10.001/jamapediatrics.2022.1024.

Woods-Hill, CZ et al. JAMA Pediatr. 2023;doi:10.1001/jamapediatrics.2023.3229.