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. 2020 Jan;21(1):e23-e29.
doi: 10.1097/PCC.0000000000002176.

Practices, Perceptions, and Attitudes in the Evaluation of Critically Ill Children for Bacteremia: A National Survey

Charlotte Z Woods-Hill  1   2 , Danielle W Koontz  3 , Anne F King  3 , Annie Voskertchian  3 , Elizabeth A Colantuoni  4 , Marlene R Miller  5   6   7 , James C Fackler  8 , Christopher P Bonafide  9 , Aaron M Milstone  3 , Anping Xie  8   10 ; Bright Star Authorship group
Collaborators, Affiliations

Practices, Perceptions, and Attitudes in the Evaluation of Critically Ill Children for Bacteremia: A National Survey

Charlotte Z Woods-Hill et al. Pediatr Crit Care Med. 2020 Jan.

Abstract

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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Conflict of interest statement

Copyright form disclosure: Drs. Woods-Hill and Colantuoni’s institution received fundingfrom the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ). Dr. Woods-Hill received honorarium for giving grand rounds at St Jude Children's Research Hospital, which was a discussion about the Bright Star project. Drs. Woods-Hill and Miller received support for article research from the NIH. Drs. Koontz, Voskertchian,and Milstone received support for article research from the AHRQ. Drs. King, Milstone, and Xie’s institutions received funding from the AHRQ. The remaining authors have disclosed thatthey do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
Perception, attitudes and typical practices for blood cultures in the pediatric intensive care unit (median proportion of respondents across sites, and interquartile ranges) CVC = central venous catheter
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