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Practices, Perceptions, and Attitudes in the Evaluation of Critically Ill Children for Bacteremia: A National Survey
Charlotte Z Woods-Hill1,2, Danielle W Koontz3, Anne F King3
1Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
Insights
Blood culture practices in pediatric intensive care units (PICUs) vary widely, often driven by fear of missing sepsis. This over-testing contributes to unnecessary antibiotic exposure and costs.
Area of Science:
- Pediatric critical care medicine
- Infectious disease diagnostics
- Antimicrobial stewardship
Background:
- Unnecessary blood cultures in low-risk children lead to increased antibiotic use, adverse effects, and costs.
- Variation in clinical practice and clinician beliefs can influence diagnostic testing in pediatric intensive care units (PICUs).
Purpose of the Study:
- To describe practice variations in blood culture testing among clinicians in PICUs.
- To understand clinician beliefs and attitudes regarding blood culture use in critically ill children.
- To identify barriers to optimizing blood culture testing in the PICU.
Main Methods:
- A cross-sectional electronic survey was distributed to clinicians in 15 PICUs participating in a collaborative focused on blood culture improvement.
- The survey assessed current blood culture practices, clinician beliefs, attitudes, and perceived barriers to reducing unnecessary testing.
- Data from 347 respondents were analyzed to determine median proportions and interquartile ranges for reported practices and beliefs.
Main Results:
- Significant variation exists in blood culture practices, including reflexive ordering (86%), lack of pre-ordering patient examination (71%), and culturing for any fever (90%).
- Clinicians frequently do not obtain peripheral cultures with indwelling catheters (33%) and sample multiple central venous catheter lumens (64%).
- Fear of missing sepsis (80%) was a primary barrier to reducing cultures, and certain practices varied by clinician type.
Conclusions:
- Practices surrounding blood culture use in PICUs are highly variable.
- Fear of missing sepsis and reflexive habits are significant drivers of blood culture over-testing.
- Optimizing blood culture utilization is crucial to reduce unnecessary antibiotic exposure and improve patient outcomes.
Objectives:
Sending blood cultures in children at low risk of bacteremia can contribute to a cascade of unnecessary antibiotic exposure, adverse effects, and increased costs. We aimed to describe practice variation, clinician beliefs, and attitudes about blood culture testing in critically ill children.
Design:
Cross-sectional electronic survey.
Setting:
Fifteen PICUs enrolled in the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children collaborative, an investigation of blood culture use in critically ill children in the United States.
Subjects:
PICU clinicians (bedside nurses, resident physicians, fellow physicians, nurse practitioners, physician assistants, and attending physicians).
Interventions:
None.
Measurement And Main Results:
Survey items explored typical blood culture practices, attitudes and beliefs about cultures, and potential barriers to changing culture use in a PICU setting. Fifteen of 15 sites participated, with 347 total responses, 15-45 responses per site, and an overall median response rate of 57%. We summarized median proportions and interquartile ranges of respondents who reported certain practices or beliefs: 86% (73-91%) report that cultures are ordered reflexively; 71% (61-77%) do not examine patients before ordering cultures; 90% (86-94%) obtain cultures for any new fever in PICU patients; 33% (19-61%) do not obtain peripheral cultures when an indwelling catheter is in place; and 64% (36-81%) sample multiple (vs single) lumens of central venous catheters for new fever. When asked about barriers to reducing unnecessary cultures, 80% (73-90%) noted fear of missing sepsis. Certain practices (culture source and indication) varied by clinician type. Obtaining surveillance cultures and routinely culturing all possible sources (each lumen of indwelling catheters and peripheral specimens) are positively correlated with baseline blood culture rates.
Conclusions:
There is variation in blood culture practices in the PICU. Fear and reflexive habits are common drivers of cultures. These practices may contribute to over-testing for bacteremia. Further investigation of how to optimize blood culture use is warranted.
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