Optimizing Duration of Empiric Management of Suspected Central Line-Associated Bloodstream Infections in Pediatric Patients with Intestinal Failure

J Pediatr. 2020 Dec;227:69-76.e3. doi: 10.1016/j.jpeds.2020.07.044. Epub 2020 Jul 17.

Abstract

Objectives: To assess whether a 24-hour length of hospitalization and empiric antibiotic therapy to exclude central line-associated bloodstream infection (CLABSI) in children with intestinal failure is potentially as safe as 48 hours, which is the duration most commonly used but not evidence based.

Study design: A prospective single-institution observational cohort study was conducted among pediatric patients with intestinal failure from July 1, 2015, through June 30, 2018, to identify episodes of suspected CLABSI. The primary end point was time from blood sampling to positive blood culture. Secondary end points included presenting symptoms, laboratory test results, responses to a parent/legal guardian-completed symptom survey, length of inpatient stay, costs, and charges.

Results: Seventy-three patients with intestinal failure receiving nutritional support via central venous catheters enrolled; 35 were hospitalized with suspected CLABSI at least once during the study. There were 49 positive blood cultures confirming CLABSI in 128 episodes (38%). The median time from blood sampling to positive culture was 11.1 hours. The probability of a blood culture becoming positive after 24 hours was 2.3%. Elevated C-reactive protein and neutrophil predominance in white blood cell count were associated with positive blood cultures. Estimated cost savings by transitioning from a 48-hour to a 24-hour admission to rule-out CLABSI was $4639 per admission.

Conclusions: A 24-hour duration of empiric management to exclude CLABSI may be appropriate for patients with negative blood cultures and no clinically concerning signs. A multi-institutional study would more robustly differentiate patients safe for discharge after 24 hours from those who warrant longer empiric treatment.

Keywords: antibiotics; blood culture; central venous line; parenteral nutrition.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anti-Bacterial Agents / administration & dosage*
  • Anti-Bacterial Agents / adverse effects
  • C-Reactive Protein / analysis
  • Case-Control Studies
  • Catheter-Related Infections / blood
  • Catheter-Related Infections / diagnosis
  • Catheter-Related Infections / economics
  • Catheter-Related Infections / prevention & control*
  • Catheterization, Central Venous / adverse effects*
  • Catheterization, Central Venous / instrumentation
  • Catheters, Indwelling / microbiology
  • Child
  • Child, Preschool
  • Female
  • Humans
  • Infant
  • Intestinal Diseases / economics
  • Intestinal Diseases / therapy*
  • Length of Stay / economics
  • Length of Stay / statistics & numerical data
  • Male
  • Parenteral Nutrition / adverse effects
  • Parenteral Nutrition / methods
  • Prospective Studies
  • Surveys and Questionnaires
  • Time Factors

Substances

  • Anti-Bacterial Agents
  • C-Reactive Protein