(1281) Blood Culture Stewardship in a Large Clinically Cohorted Pediatric ICU

Introduction: Practice variation in obtaining blood cultures (BC) exists in critically ill children where sepsis and non-specific sepsis like symptoms are prevalent. Unnecessary BCs that entail avoidable central line entries and antibiotic overuse can be safely reduced [BrightSTAR collaborative]. We hypothesized that adopting this evidence-based clinical decision support (CDS) tool could safely reduce excessive BC, antibiotic use and CLABSI (Central line associated blood stream infections) in our large PICU with multiple diagnostic patient cohorts.

Methods: In October 2022 we adapted and implemented the BC stewardship tool to standardize decision, ordering and frequency of BC in our 84-bed PICU with 6 patient cohorts (Surgery, Neurology, Pulmonology, Oncology, general and technology dependent ICUs) across four floors. The CDS tool was based on presence of new vs persistent fever, central line, and immune status. Usual care and cultures (blood, urine, respiratory and other potential sources) were recommended for suspected sepsis. Measures tracked per month (mo) were: Primary- BC and antibiotic days per 1000 patient days (PD), Secondary-CLABSI per 1000-line days, %positive BC; Balancing- deaths, readmissions, and severe sepsis per 100 admissions. Data over 6 mo pre and post intervention were compared with student’s t-test, *p < 0.05.

Results: Pre and Post data were- total admissions: 1814 and 1884, BC: 369 and 334, Mean BCs/1000 PD/ mo: 173 and 141 [p=0.07], Antibiotic days: 704 and 669 [p=0.3] and CLABSI rates: 3.3 and 1.8 [p=0.08]. Percent positive cultures (9.9 to 8.9), readmissions (0.8 to 0.5) and severe sepsis (8 to 7.3) were unchanged. Death rates were 3 and 2 [p=0.04].
Pulmonary and oncology patients had high BC/1000PD/mo with no change (245 to 210) [p=0.5]. Lowest BC rates were in general and technology dependent ICUs. Surgical and neuro ICU patients had significantly decreased pre-post BC/1000 PD/mo from 267 to 194 [p < 0.05] with similar line days and % positive rates.

Conclusions: Practice standardization thru evidence based diagnostic stewardship reduced unnecessary BC and assisted with CLABSI prevention practices. The significant impact seen in surgical-neuro patients (likely with intact immune function) can guide future interventions and resource allocation in other patients.