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Chiotos K, Fitzgerald JC, Hayes M, Dashefsky H, Metjian TA, Woods-Hill C, Biedron L, Stinson H, Ku BC, Robbins Tighe S, Weiss SL, Balamuth F, Schriver E, Gerber JS. Improving Vancomycin Stewardship in Critically Ill Children. Pediatrics 2022; 149:185402. [PMID: 35362066 PMCID: PMC9647566 DOI: 10.1542/peds.2021-052165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Inappropriate vancomycin use is common in children's hospitals. We report a quality improvement (QI) intervention to reduce vancomycin use in our tertiary care PICU. METHODS We retrospectively quantified the prevalence of infections caused by organisms requiring vancomycin therapy, including methicillin-resistant Staphylococcus aureus (MRSA), among patients with suspected bacterial infections. Guided by these data, we performed 3 QI interventions over a 3-year period, including (1) stakeholder education, (2) generation of a consensus-based guideline for empiric vancomycin use, and (3) implementation of this guideline through clinical decision support. Vancomycin use in days of therapy (DOT) per 1000 patient days was measured by using statistical process control charts. Balancing measures included frequency of bacteremia due to an organism requiring vancomycin not covered with empiric therapy, 30-day mortality, and cardiovascular, respiratory, and renal organ dysfunction. RESULTS Among 1276 episodes of suspected bacterial infection, a total of 19 cases of bacteremia (1.5%) due to organisms requiring vancomycin therapy were identified, including 6 MRSA bacteremias (0.5%). During the 3-year QI project, overall vancomycin DOT per 1000 patient days in the PICU decreased from a baseline mean of 182 DOT per 1000 patient days to 109 DOT per 1000 patient days (a 40% reduction). All balancing measures were unchanged, and all cases of MRSA bacteremia were treated empirically with vancomycin. CONCLUSION Our interventions reduced overall vancomycin use in the PICU without evidence of harm. Provider education and consensus building surrounding indications for empiric vancomycin use were key strategies.
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Affiliation(s)
- Kathleen Chiotos
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Division of Infectious Diseases, Department of Pediatrics,Antimicrobial Stewardship Program,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Address correspondence to Kathleen Chiotos, MD, MSCE, 3401 Civic Center Blvd, Wood Building, 6 Floor Room 6029, Philadelphia, PA 19104. E-mail:
| | - Julie C. Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Hannah Dashefsky
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Charlotte Woods-Hill
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren Biedron
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hannah Stinson
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brandon C. Ku
- Division of Emergency Medicine,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sheila Robbins Tighe
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Scott L. Weiss
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fran Balamuth
- Division of Emergency Medicine,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Jeffrey S. Gerber
- Antimicrobial Stewardship Program,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Sick-Samuels AC, Woods-Hill C. Diagnostic Stewardship in the Pediatric Intensive Care Unit. Infect Dis Clin North Am 2022; 36:203-218. [PMID: 35168711 PMCID: PMC8865365 DOI: 10.1016/j.idc.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the pediatric intensive care unit (PICU), clinicians encounter complex decision making, balancing the need to treat infections promptly against the potential harms of antibiotics. Diagnostic stewardship is an approach to optimize microbiology diagnostic test practices to reduce unnecessary antibiotic treatment. We review the evidence for diagnostic stewardship of blood, endotracheal, and urine cultures in the PICU. Clinicians should consider 3 questions applying diagnostic stewardship: (1) Does the patient have signs or symptoms of an infectious process? (2) What is the optimal diagnostic test available to evaluate for this infection? (3) How should the diagnostic specimen be collected to optimize results?
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Affiliation(s)
- Anna C. Sick-Samuels
- The Johns Hopkins University School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD,The Johns Hopkins Hospital, Department of Hospital Epidemiology and Infection Control, Baltimore, MD
| | - Charlotte Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Weber MD, Conlon T, Woods-Hill C, Watts SL, Nelson E, Traynor D, Zhang B, Davis D, Himebauch AS. Retrospective Assessment of Patient and Catheter Characteristics Associated With Malpositioned Central Venous Catheters in Pediatric Patients. Pediatr Crit Care Med 2022; 23:192-200. [PMID: 34999641 PMCID: PMC8897221 DOI: 10.1097/pcc.0000000000002882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The primary objective was to determine the prevalence and characteristics associated with malpositioned temporary, nontunneled central venous catheters (CVCs) placed via the internal jugular (IJ) and subclavian (SC) veins in pediatric patients. DESIGN Single-center retrospective cohort study. SETTING Quaternary academic PICU. PATIENTS Children greater than 1 month to less than 18 years who had a CVC placed between January 2014 and December 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was the CVC tip position located on the first postprocedural radiograph. CVC tip was defined as follows: "recommended" (tip location between the carina and two vertebral bodies inferior to the carina), "high" (tip location between one and four vertebral bodies superior to the carina), "low" (tip position three or more vertebral bodies inferior to the carina), and "other" (tip grossly malpositioned). Seven hundred eighty-one CVCs were included: 481 (61.6%) were in "recommended" position, 157 (20.1%) were "high," 131 (16.8%) were "low," and 12 (1.5%) were "other." Multiple multinomial regression (referenced to "recommended" position) showed that left-sided catheters (adjusted odds ratio [aOR], 2.00, 95% CI 1.17-3.40) were associated with "high" CVC tip positions, whereas weight greater than or equal to 40 kg had decreased odds of having a "high" CVC tip compared with the reference (aOR, 0.45; 95% CI, 0.24-0.83). Further, weight category 20-40 kg (aOR, 2.42; 95% CI, 1.38-4.23) and females (aOR, 1.51; 95% CI, 1.01-2.26) were associated with "low" CVC tip positions. There was no difference in rates of central line-associated blood stream infection, venous thromboembolism, or tissue plasminogen activator usage or dose between the CVCs with tips outside and those within the recommended location. CONCLUSIONS The prevalence of IJ and SC CVC tips outside of the recommended location was high. Left-sided catheters, patient weight, and sex were associated with malposition. Malpositioned catheters were not associated with increased harm.
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Affiliation(s)
- Mark D. Weber
- Children’s Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, School of Nursing at the University of Pennsylvania, Philadelphia Pennsylvania
| | - Thomas Conlon
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Charlotte Woods-Hill
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie L. Watts
- Children’s Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, School of Nursing at the University of Pennsylvania, Philadelphia Pennsylvania
| | - Eileen Nelson
- Children’s Hospital of Philadelphia, Department of Nursing, Philadelphia Pennsylvania
| | - Danielle Traynor
- Children’s Hospital of Philadelphia, Department of Nursing, Philadelphia Pennsylvania
| | - Bingqing Zhang
- Children’s Hospital of Philadelphia, Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit
| | - Daniela Davis
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam S. Himebauch
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Chiotos K, Lee G, Sydney G, Wolfe H, Blumenthal J, Stinson H, McGowan N, Harab J, Traynor D, Dudhia A, Piccione J, Burke J, Doll A, Keim G, Woods-Hill C, Jennings M, Harris R, Gerber J. 1139. Reducing Collection of Tracheal Aspirate Bacterial Cultures: A Diagnostic Test Stewardship Intervention. Open Forum Infect Dis 2021. [PMCID: PMC8644428 DOI: 10.1093/ofid/ofab466.1332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Tracheal aspirate (TA) bacterial cultures are often collected in mechanically ventilated children to evaluate for ventilator-associated infections (VAI), including tracheitis and pneumonia. However, frequent bacterial colonization of tracheal tubes results in poor specificity of positive TA cultures for distinguishing bacterial infection from colonization, which contributes to antibiotic overuse for VAI. We performed a quality improvement project to reduce collection of TA cultures through implementation of a consensus guideline to standardize culture ordering, and measured its impact on antibiotic use in a tertiary PICU.
Methods
A multidisciplinary team including PICU, pulmonary, and ID clinicians developed the consensus guideline in November 2019-February 2020. The first Plan-Do-Study-Act (PDSA) cycle occurred in August 2020 and included provider education, providing a link to the guideline in the TA culture order, and signs and screensavers highlighting key guideline recommendations. The second PDSA cycle occurred in October-December 2020 and included weekly emails to on service PICU clinicians. Statistical process control charts were used to measure the number of TA cultures collected/100 ventilator days and broad-spectrum antibiotic DOT/100 ventilator days. The number of patients treated for VAI/100 ventilator days and guideline compliance were also measured.
Results
The baseline rate of TA culture collection was 4.58/100 ventilator days. A centerline shift to 3.33 cultures/100 ventilator days occurred in March 2020. Following PDSA 1 and 2 in October 2020, a second downward centerline shift to 2.22 cultures/100 ventilator days occurred (Figure 1). Broad-spectrum antibiotic days of therapy/100 ventilator days decreased in November 2019 coincident with the start of the project, but no further reductions occurred after PDSA 1 and 2 (Figure 2). The number of patients treated for VAI decreased from a baseline of 1.24/100 ventilator days to 0.66/100 ventilator days. Finally, the proportion of TA cultures ordered that were non-compliant with the guideline recommendations was unchanged throughout the study period (Table 1).
Conclusion
A consensus guideline reduced collection of TA cultures, with a modest reduction in the rate of antibiotic treatment for VAI.
Disclosures
All Authors: No reported disclosures
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Affiliation(s)
| | - Giyoung Lee
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Guy Sydney
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heather Wolfe
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Hannah Stinson
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nancy McGowan
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julie Harab
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Aaditya Dudhia
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph Piccione
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennalyn Burke
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ashley Doll
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Garrett Keim
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Megan Jennings
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rebecca Harris
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeffrey Gerber
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Hoops KEM, Fackler JC, King A, Colantuoni E, Milstone AM, Woods-Hill C. How good is our diagnostic intuition? Clinician prediction of bacteremia in critically ill children. BMC Med Inform Decis Mak 2020; 20:144. [PMID: 32616046 PMCID: PMC7330962 DOI: 10.1186/s12911-020-01165-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/24/2020] [Indexed: 02/02/2023] Open
Abstract
Background Clinical intuition and nonanalytic reasoning play a major role in clinical hypothesis generation; however, clinicians’ intuition about whether a critically ill child is bacteremic has not been explored. We endeavored to assess pediatric critical care clinicians’ ability to predict bacteremia and to evaluate what affected the accuracy of those predictions. Methods We conducted a retrospective review of clinicians’ responses to a sepsis screening tool (“Early Sepsis Detection Tool” or “ESDT”) over 6 months. The ESDT was completed during the initial evaluation of a possible sepsis episode. If a culture was ordered, they were asked to predict if the culture would be positive or negative. Culture results were compared to predictions for each episode as well as vital signs and laboratory data from the preceding 24 h. Results From January to July 2017, 266 ESDTs were completed. Of the 135 blood culture episodes, 15% of cultures were positive. Clinicians correctly predicted patients with bacteremia in 82% of cases, but the positive predictive value was just 28% as there was a tendency to overestimate the presence of bacteremia. The negative predictive value was 96%. The presence of bandemia, thrombocytopenia, and abnormal CRP were associated with increased likelihood of correct positive prediction. Conclusions Clinicians are accurate in predicting critically ill children whose blood cultures, obtained for symptoms of sepsis, will be negative. Clinicians frequently overestimate the presence of bacteremia. The combination of evidence-based practice guidelines and bedside judgment should be leveraged to optimize diagnosis of bacteremia.
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Affiliation(s)
- Katherine E M Hoops
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - James C Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anne King
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charlotte Woods-Hill
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Woods-Hill C, Papili K, Nelson E, Watts S, Quinn D, Davis D, Priestley M. 1306: IMPROVING ICU PHYSICIAN ENGAGEMENT REDUCES PEDIATRIC CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS. Crit Care Med 2018. [DOI: 10.1097/01.ccm.0000529309.89415.85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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