O2114: Reduction of Broad-Spectrum Antimicrobial Use through Standardization of Blood Culture Decision Making in a Pediatric Cardiac Intensive Care Unit (CICU)

Purpose/Objectives: Pediatric patients requiring CICU care are at high risk for life threatening infection. Early recognition and adequate treatment are crucial. While the etiology of fevers is broad, the vulnerability of this patient population, especially in combination with common presence of central venous lines, creates a low threshold for work up for bacterial etiology, often with routine initiation of broad-spectrum antibiotics. Initiation of antibiotics is associated with monetary and other costs including discomfort and complications of intra-venous access and prolonged hospital stay. The rise in antimicrobial resistance makes heightened antimicrobial stewardship imperative.
We aimed to reduce blood culture rates and associated broad-spectrum antibiotic use in the CICU through implementation of a standardized blood culture decision support algorithm. Delay in treatment of sepsis was tracked as balancing measure.

Design/Methods: After a thorough literature review, an algorithm to assist with decision making for blood culture necessity in CICU patients with fever without signs of sepsis or clinical deterioration was developed and implemented by a stakeholder team. A 33% decrease from baseline of 17.56 blood cultures / 100 patient days to 11.7 within six months of implementation was set as the reduction target. Rate of blood cultures per 100 patient days was tracked using control charts and standard rules to identify special cause variation. All charts of patients with positive cultures were reviewed to identify any potential delay in treatment. Broad-spectrum antibiotic utilization was tracked and defined as total days of therapy per 1,000 CICU inpatient days.

Results: Blood culture rate decreased from 17.56 to 10.40 / 100 patient days within six months of implementation of algorithm, demonstrating a 41% reduction from baseline. No missed sepsis events were identified during the study period. A concurrent reduction in blood cultures and broad-spectrum antimicrobial use was demonstrated with a decrease of approximately 30% during the intervention period. The reduction in broad-spectrum antibiotic use was greatest in vancomycin (45% reduction), followed by cefepime (20% reduction).

Conclusion/Discussion: Standardizing the clinical decision-making process for blood culture screening in febrile patients in the CICU is an effective and safe tool to reduce blood culture rates and broad-spectrum antibiotic exposure without delaying adequate identification and treatment of sepsis.