Infection Control & Hospital Epidemiology (2019), 40,482–490 doi:10.1017/ice.2019.10
Research Brief
Association of a blood culture utilization intervention on antibiotic use in a pediatric intensive care unit Anna C. Sick-Samuels MD, MPH1
Sybil A. Klaus MD, MPH5, Elizabeth E. Colantuoni PhD6 and Aaron M. Milstone MD, MHS1 1Division of Pediatric Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, 2Division of Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, 3Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, 4Division of Pediatric Anesthesia and Critical Care, Johns Hopkins School of Medicine, Baltimore, Maryland, 5MITRE Corporation, McLean, Virginia and 6Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
Blood cultures are essential for the evaluation of
sepsis.However, they may sometimes be obtained inappropriately, leading to high false-positive rates, largely due to contamination.1 As a quality improvement project, clinician decision-support tools for evalu- ating patients with fever or signs and symptoms of sepsis were implemented in April 2014 in our pediatric intensive care unit (PICU).This initiative resulted in a 46% decrease in blood culture obtainment2 and has been replicated in other institutions.3 It is important to evaluate antibiotic use as a balancing measure because a reduction in blood cultures could lead to an increase in antibiotic treatment days if clinicians continued empiric treat- ment in scenarios when blood culture results were not available. The objective of this study was to evaluate whether antibiotic useinthePICU changedinassociationwithareductionin blood culture utilization.
Methods
We conducted a retrospective observational study examining anti- biotics administered to children admitted to the PICU at The Johns Hopkins Hospital during the 12 months before and during the implementation of a locally developed blood culture clinical prac- tice guideline.2 The antibiotic data reflect medication administered to patients while admitted to the PICU. Broad-spectrum antibiot- ics (BSA) commonly administered for the empiric treatment of sepsis were evaluated: cefepime, piperacillin-tazobactam, merope- nem, imipenem-cilastatin, and vancomycin. The intervention primarily targeted hospital-onset events, for which ceftriaxone or fluoroquinolones were not typically prescribed. Antibiotic use was evaluated as (1) monthly antibiotic days of therapy (DOT) per 1,000 patient days (PD),4 and (2)monthly number of antibiotic initiations per 1,000 PD. Initiations were defined as the start of a BSA with at least 48 hours elapsed from the last time the patient received a BSA. The rate of antibiotic DOT per 1,000 PD and antibiotic
initiations per 1,000 PD before and after the intervention were compared using a standard incident rate ratio (IRR) and by an interrupted time-series (ITS) model using log-transformed
Author for correspondence: Anna Sick-Samuels, Email:
asick1@jhmi.edu Cite this article: Sick-Samuels AC, et al. (2019). Association of a blood culture
utilization intervention on antibiotic use in a pediatric intensive care unit. Infection Control & Hospital Epidemiology, 40: 482–484,
https://doi.org/10.1017/ice.2019.10
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
monthly antibiotic DOT and antibiotic initiations.5 An existing preapproval antibiotic stewardship program restricted all the anti- biotics evaluated, and there were no notable changes in antibiotic stewardship practices during the study period. The Johns Hopkins Institutional Review Board acknowledged this evaluation as part of a quality improvement project.
Results
In the year preceding implementation of the guideline, there were 11,196 PD, 6,255 antibiotic DOT and 701 initiations. The propor- tion of total antibiotic DOT contributed by each medication were as follows: cefepime (36%), vancomycin (31%), piperacillin- tazobactam (23%), meropenem (10%), and imipenem-cilastatin (0.6%). The distributions of antibiotics were similar in the preim- plementation and postimplementation years. Compared to the preimplementation year, there were no changes in the overall anti- biotic DOT per 1,000 PD (559 vs 556; IRR, 0.99; 95% CI, 0.96– 1.03). In the ITS analysis (Fig. 1, panel A), the monthly rate of anti- bioticDOTper 1,000PDduring the year preceding (IRR, 1.00; 95% CI, 0.98–1.02) and the year during implementation (IRR, 1.00; 95% CI, 0.97–1.02) were similar (P = .90). No changes occurred in overall antibiotic initiations per 1,000
PD (63 vs 62; IRR, 0.98; 95% CI, 0.89–1.10) in the postimplemen- tation year. Similarly, in the ITS analysis (Fig. 1, panel B), there was no change in the monthly rate of initiations during the year prior (IRR, 1.00; 95% CI, 0.99–1.02) or the year during implementation (IRR, 1.00; 95% CI, 0.98–1.02; P = .66).
Discussion
We examined broad-spectrum antibiotic use in the setting of a quality improvement project to optimize blood culture use. Despite a 46% decline in blood cultures following program imple- mentation, there was no change in antibiotic use. A priori, there was concern that some clinicians who complied with the guidelines may have feared “missing” bacteremia and thus increased empiric antibiotic prescribing in scenarios when blood cultures were not obtained. Similarly, there was concern that clinicians would initiate empiric antibiotic therapy and, in the absence of blood culture results to follow, that they would not discontinue therapy after 48–72 hours. Our findings indicate that there was not a significant
, Charlotte Z. Woods-Hill MD2,3, James C. Fackler MD4, Pranita D. Tamma MD, MHS1,
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