Diagnostic stewardship linked to fewer blood cultures and antibiotics in sick children

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A new study by a team of US researchers highlights the role that diagnostic management can play in reducing antibiotic use in hospitals.

the studypublished this week in JAMA Pediatrics, found that a national quality improvement collaboration to reduce the ordering of blood cultures to assess bloodstream infections in children in pediatric intensive care units (PICUs) was associated with both fewer blood cultures and unless broad-spectrum antibiotics are used, without increasing the risk of bacterial infection. sepsis or affecting mortality, readmission to hospital or time spent in hospital.

The study authors claim that the multicenter diagnostic management collaboration is the first, to their knowledge, to successfully reduce blood cultures and antibiotic use.

“Our study confirms that diagnostic stewardship is a promising strategy to augment antimicrobial stewardship programs and reduce antibiotic overuse,” they wrote.

Blood cultures and adverse consequences

The study evaluated the Bright STAR (Testing Stewardship for Antibiotic Reduction) collaboration, a quality improvement program implemented at 14 U.S. PICUs in 2017.

Guided by an expert steering committee and the results of a pre-implementation evaluation survey, each PICU created unique clinical decision support tools to guide the practice of blood culture. Implementation plans included training sessions, electronic clinical pathways, and targeted emails to PICU clinicians.

The goal of the intervention was to standardize practice and reduce variability in the decision to order blood cultures in PICUs, highlight patient safety considerations, and ultimately reduce blood cultures in children at low risk of sepsis. While blood cultures are the gold standard diagnostic test for sepsis caused by blood infection in critically ill children, ordering them can lead to a host of undesirable consequences, according to lead author Aaron Milstone, MD, MHS, pediatric infectious diseases at Johns Hopkins University School of Medicine.

“USIP patients are usually the sickest of the sick, and you want to do whatever you can to help,” Milstone said in a Johns Hopkins. Press release. “But when you perform a blood culture, anything can develop, whether it is the reason for the symptom concerned or possible contamination of the sample. Collecting a blood culture when it is not necessary can lead to unnecessary use of blood. antibiotics, unwanted side effects from additional medications, and additional blood tests.”

To evaluate Bright STAR, researchers analyzed data from each participating PICU and the Children’s Hospital Association Pediatric Health Information System, comparing 24 months before and 18 months after implementation on each. site. The primary outcome was blood culture levels (per 1000 patient days per month).

Secondary outcomes included broad-spectrum antibiotic use (total number of treatment days and re-initiation of broad-spectrum antibiotics), rates of central line-associated bloodstream infection (CLABSI), Clostridioides difficile infection, mortality, readmission, length of stay, sepsis and severe sepsis/septic shock.

Fewer blood cultures, less use of broad-spectrum antibiotics

In the 14 PICUs, the blood culture rate decreased from 149.4 per 1000 patient days per month before implementation to 100.5 after implementation, a relative reduction of 33% (confidence interval 95% [CI], 26% to 39%). The rate of broad-spectrum antibiotic use decreased from 506 to 440 days per 1000 patient-days/month, a relative reduction of 13% (95% CI, 7% to 19%), and the rate broad-spectrum antibiotic initiations decreased from 58.1 to 56.3 initiations per 1000 patient-days/month, representing a relative reduction of 8% (95% CI, 4% to 11%).

After program implementation, the rate of CLABSI at the 14 sites dropped by 36% (95% CI, 20% to 49%), from 1.79 to 1.14 per 1000 days of centralization/ months, while it’s hard the rates remained similar. PICU mortality rates, length of stay, readmissions (for hospital and PICU), and severe sepsis/septic shock were similar before and after implementation.

A review of 793 positive blood cultures after implementation revealed that 792 were collected in a timely manner and without any delays that could have been caused by the recommendation to avoid blood culture in certain settings.

“These results suggest that multidisciplinary efforts to standardize blood culture collection and avoid unnecessary testing at PICU can be performed successfully and safely in a variety of settings and that reduced blood culture use is associated with reduced blood culture use. reduction in the use of broad-spectrum antibiotics,” the authors wrote. .

Milstone and colleagues say the Bright STAR strategy may be particularly useful in settings such as PICUs, where children often present with nonspecific signs and symptoms of infection and are frequently given empiric antibiotics without definitive evidence of bacterial infection. . But they note that the program focuses on clinically stable patients in whom bloodstream infection and sepsis are considered unlikely.

“Bright STAR as an overall program and the clinical tools at each site intentionally make no recommendations to avoid blood cultures in patients with signs or symptoms of suspected sepsis,” they wrote.

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