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Diagnostic Stewardship Comes for Blood Cultures

Reviewed by Zachary Willis, MD, MPH; University of North Carolina, Chapel Hill

Given their higher specificity compared to cultures of nonsterile sites such as urine and endotracheal aspirates, blood cultures are a less obvious target for diagnostic stewardship. In this study, a Quality Improvement collaborative of 14 pediatric intensive care units (PICUs), termed the Bright STAR collaborative, implemented a QI intervention to standardize blood culture practices, with the aim of reducing unnecessary blood cultures. Each institution developed site-specific blood culture criteria and launched the initiative in 2018 or 2019. Each site contributed 24 months of pre-implementation and 18 months of post-implementation data.

Blood cultures fell 33%, from 149.4 to 100.5 blood cultures/1000 patient-days. Only one site did not observe a statistically significant decrease in blood culture utilization. There were concomitant reductions in CLABSI rates (36%) and broad-spectrum antibiotic use (13%). The effect on antibiotic utilization seems to be driven primarily by an 8% reduction in antibiotic initiations. Because blood cultures and antibiotic initiation are closely coupled in intensive care, a more measured approach to obtaining blood cultures also decreases antibiotic initiation. There was no change in incidence of C. difficile infection. There was no change from pre- to post-implementation in safety measures including mortality, PICU length of stay, PICU readmission, hospital readmission, sepsis, or severe sepsis/septic shock. This multicenter QI initiative demonstrates that PICUs can safely make substantial reductions in blood culture frequency, which may reduce overdiagnosis of CLABSI and overuse of broad-spectrum antibiotics without delaying diagnosis of important infections.

Reference:
Woods-Hill CZ, Colantuoni EA, Koontz DW, et al. 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. JAMA Pediatrics. Published online May 2, 2022. doi:10.1001/jamapediatrics.2022.1024

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