Diagnostic Stewardship of Respiratory Cultures Using Clinical Decision Support in the PICU

Endotracheal aspirate culture (EAC) practices for evaluation of ventilator-associated infections (VAI) vary widely across pediatric hospitals, and overuse can contribute to overdiagnosis and overtreatment for VAI. Diagnostic stewardship strategies to optimize EAC testing practices may reduce overtesting and unnecessary antibiotic treatment.

To evaluate the association of diagnostic stewardship of EACs using clinical decision support with culture rates, antibiotic use, and patient outcomes across a multicenter collaborative of pediatric intensive care units (PICUs).

This was a multicenter cohort study with a pre-post study design among the BrighT STAR (Testing Stewardship for Antibiotic Reduction) Quality Improvement (QI) Collaborative involving PICUs across the US between 2019 and 2023. Data were collected from the participating sites and from the Children's Hospital Association Pediatric Health Information System and were analyzed from August to December 2025.

Participating PICUs conducted local QI programs focused on optimizing EAC practices, facilitated by the BrighT STAR collaborative.

The primary outcome was the monthly rate of EACs per 100 ventilator-days. Secondary outcomes included rates of antibiotic initiations and antibiotic days of therapy, bronchoalveolar lavage cultures, readmissions, length of stay, ventilation duration, ventilation-free days, sepsis, and septic shock. Analysis included adjustment for seasonality.

Across 15 sites (median [IQR] unit size, 30 [25-38] beds), the study captured 106 967 ventilator-days preimplementation and 92 167 ventilator-days postimplementation. Comparing 24 months in the preimplementation period with the 18 months in the postimplementation period, the mean monthly EAC rate declined by 16% from a preimplementation to postimplementation rate of 7.80 to 6.55 cultures per 100 ventilator-days (relative rate [RR], 0.84; 95% CI, 0.78-0.90). The rate of antibiotic initiations remained stable (RR, 0.98; 95% CI, 0.89-1.08), as well as the antibiotic days of therapy rate (RR, 1.03; 95% CI, 0.95-1.11). There were no significant changes in the rates of bronchoalveolar lavage cultures, PICU length of stay, PICU or hospital readmissions, sepsis, septic shock, ventilation duration, or ventilator-free days.

In this multicenter cohort study, diagnostic stewardship of EACs using clinical decision support led by multidisciplinary teams was associated with reduced EAC use in the PICU without safety concerns. Future work will determine optimal implementation strategies, assess sustainability and the cost impact of EAC stewardship.