Respiratory Culture Stewardship to Reduce Antibiotic Use in Critically Ill Children

项目摘要 在美国，每年有超过15万名患者死于多重耐药感染，而耐药感染 与超过200亿美元的医疗成本相关。医疗保健相关感染(HAI)突出了这种影响 抗生素耐药性，因为超过40%的人类免疫缺陷病毒是由具有抗生素耐药性的生物引起的。儿童需要 机械通气有发生呼吸机相关性感染(VAI)的风险。VAI负责 23%-53%的儿童感染了禽流感。高达87%的儿科重症监护病房(PICU)患者接受 抗生素和疑似炎的治疗占PICU抗生素使用量的50%。为了努力 为诊断Vais，临床医生通常从机械通气患者那里获得呼吸道培养。 然而，这些培养物是从非无菌场所获得的，超过50%的气管内培养物将 无论临床症状如何，在插管后3天内培养出可能致病的微生物。呼吸性 细菌培养不能区分细菌定植和感染，尽管对细菌的特异性较低 提示感染，阳性培养促使临床医生使用抗生素治疗。安全减少测试，请参阅 作为诊断管理，是减少检测过度使用和潜在的抗生素过度使用的一种新兴战略。 最近，约翰霍普金斯儿童中心设计了一项新的临床实践指南，以标准化 危重儿童呼吸道培养的方法安全地减少了41%的呼吸道培养使用。长的- 这项提案的任期目标是开发一个可定制的诊断管理计划，该计划可以改善 在易受感染的儿童中使用抗生素和预防抗生素耐药性。具体目标是目标1) 评估机械通气儿童呼吸道培养的诊断管理 减少呼吸道培养和抗生素的使用，而不会对患者造成意外伤害，目标2)确定 实施诊断管理质量改进计划的障碍和促进者 14个儿科重症监护病房机械通气患者的呼吸道培养使用情况，目的3) 使用德尔菲法，包括一个在全国具有代表性的小组，以达成共识 告知机械通气儿童何时进行呼吸道培养的建议。十四 参与多中心质量改进倡议的医院Bright Star Collaborative，是 实施当地质量改进计划，提高呼吸道培养使用率。这项提议将 评估当地诊断管理计划的实施情况，并确定这些计划是否 代表了一种有效和安全的战略，以减少脆弱人群中抗生素的使用。建议的目标 将收集工具和证据，广泛传播诊断管理，作为减少 抗生素的使用和提供高价值的护理，并在非ICU儿童和成人人口中催化类似的工作。

Project Summary In the U.S. over 150,000 patients die annually from multidrug-resistant infections, and resistant infections are associated with over $20 billion in healthcare costs. Healthcare-associated infections (HAI) highlight the impact of antibiotic resistance, as more than 40% of HAIs are due to antibiotic-resistant organisms. Children requiring mechanical ventilation are at risk for developing ventilator-associated infections (VAI). VAIs are responsible for 23-53% of all HAIs among children. Up to 87% of pediatric intensive care unit (PICU) patients are treated with antibiotics and treatment for suspected VAIs accounts for 50% of antibiotic use in the PICU. In an effort to inform the diagnosis of VAIs, clinicians often obtain respiratory cultures from mechanically ventilated patients. However, these cultures are obtained from a non-sterile site and more than 50% of endotracheal cultures will grow a potentially pathogenic organism within 3 days of intubation regardless of clinical symptoms. Respiratory cultures cannot distinguish between bacterial colonization and infection, and despite the low specificity to indicate infection, positive cultures prompt clinicians to treat with antibiotics. Safely reducing testing, referred to as diagnostic stewardship, is an emerging strategy to reduce testing overuse and potentially antibiotic overuse. Recently, a novel clinical practice guideline designed at the Johns Hopkins Children’s Center to standardize approach to respiratory cultures in critically ill children safely reduced respiratory culture use by 41%. The long- term objective of this proposal is to develop a customizable diagnostic stewardship program that can improve antibiotic use and prevent antibiotic resistance among vulnerable children. The specific aims are Aim 1) evaluate whether diagnostic stewardship of respiratory cultures among mechanically ventilated children decreases respiratory culture use and antibiotic use without leading to unintended patient harm, Aim 2) identify barriers and facilitators to implementation of diagnostic stewardship quality improvement programs to reduce respiratory culture use among mechanically ventilated patients in 14 pediatric intensive care units, and Aim 3) use a Delphi method, including a panel with nationwide representation, to develop consensus recommendations informing when to obtain respiratory cultures in mechanically ventilated children. Fourteen hospitals participating in a multicenter quality improvement initiative, the Bright STAR Collaborative, are implementing local quality improvement programs to improve respiratory culture use. This proposal will evaluate the implementation of local diagnostic stewardship programs and determine whether these programs represent an effective and safe strategy to reduce antibiotic use in a vulnerable population. The proposed aims will assemble the tools and evidence to broadly disseminate diagnostic stewardship as a strategy to reduce antibiotic use and deliver high value care, and catalyze similar work in non-ICU pediatric and adult populations.