Infection Control & Hospital Epidemiology
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Fig. 1. Monthly broad-spectrum antibi- otic days of therapy (panel A) and broad-spectrum antibiotic initiations (panel B) per 1,000 patient days in the pediatric intensive care unit. Antibiotic use depicted 12 months before and after implementation of a quality improvement initiative in April 2014 to optimize the use of blood cultures in the pediatric intensive care unit.
increase in antibiotic DOT with the reduction in blood culture obtainment. Prior diagnostic stewardship interventions to improve urine
culture testing have demonstrated a reduction in the frequency of urine cultures,6,7 and reduced urine culture utilization was associated with reduced antibiotic use.8,9 In contrast to these findings, we did not observe a decline in antibiotic DOT or ini- tiations associated with a reduction in blood culture utilization. The reasons for this are unclear; however, it is possible that the reduction in blood cultures was primarily driven by decreasing the number of cultures obtained from each patient rather than the number of patients from whom blood cultures were obtained. For example, obtaining only a peripheral culture instead of peripheral and central-line cultures from the same patient, or obtaining initial blood cultures but not daily follow-up cultures could have contributed to the findings. This study has several limitations. First, we used aggregate anti-
biotic data. As a result, we were unable to adjudicate indication or appropriateness of antibiotic treatment for individual patients. Perhaps there was a reduction of antibiotic use for the indication of ruling out bacteremia; however, this was coupled with an increase in the use of antibiotics for another indication leading to an overall equal rate of use. Alternatively, we may not have had the power to detect a small reduction in antibiotic use in this population given the variability in monthly use. Nevertheless, anti- biotic use related to changes in blood culture practice remains an
important balancing measure to evaluate. Additional larger, multi- center analyses are needed to better understand the association of improved blood culture use and antibiotic prescribing.
Author ORCIDs. Anna C. Sick-Samuels, 0000-0002-9247-9340.
Acknowledgements. We thank the staff of the Johns Hopkins Children’s Center Pediatric Intensive Care Unit. The content is solely the responsibility of the authors and does not necessarily represent the official views of the fund- ing agencies.
Financial support. This work was funded in part by National Institutes of Health (grant nos. T32-A1052071 to A.C.S. and K24AI141580 to A.M.), by the Agency for Healthcare Research and Quality (grant no. R18HS025642 to A.M.M.), and by the MITRE Corporation, an independent, not for profit organization that operates federally funded research and development centers.
Conflicts of interest. A.M. reports consulting for Becton Dickinson. All other authors report no conflicts of interest relevant to this article.
References
1. Lamy B, Dargere S, Arendrup MC, Parienti JJ, Tattevin P. How to optimize the use of blood cultures for the diagnosis of bloodstreaminfections?Astate- of-the art. Front Microbiol 2016;7:697.
2. Woods-Hill CZ, Fackler J, Nelson McMillan K, et al. Association of a clinical practice guideline with blood culture use in critically ill children. JAMA Pediatr 2017;171:157–164.
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