Respiratory Culture Stewardship to Reduce Antibiotic Use in Critically Ill Children

项目摘要 在美国，每年有超过150，000名患者死于多药耐药感染，并且耐药感染是一种常见的疾病。 与超过200亿美元的医疗费用相关。卫生保健相关感染（HAI）突出了 抗生素耐药性，因为超过40%的HAI是由于抗生素耐药生物体。儿童需要 机械通气有发生呼吸机相关感染（VAI）的风险。VAI负责 23-53%的儿童HAI。高达87%的儿科重症监护病房（PICU）患者接受以下治疗： 抗生素和疑似VAIs的治疗占PICU抗生素使用的50%。为了努力 为了告知VAIs的诊断，临床医生经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部位获得的，并且超过50%的气管内培养物将 无论临床症状如何，插管后3天内培养出潜在致病微生物。呼吸 培养物不能区分细菌定植和感染，尽管对细菌定植和感染的特异性低， 表明感染，阳性培养物提示临床医生用抗生素治疗。安全减少测试，参考 作为诊断管理，是一种新兴的战略，以减少测试过度使用和潜在的抗生素过度使用。 最近，约翰霍普金斯儿童中心设计了一个新的临床实践指南， 在重症儿童中使用呼吸道培养方法安全地减少了41%的呼吸道培养使用。很长的- 该提案的长期目标是开发一个可定制的诊断管理程序， 抗生素的使用和预防脆弱儿童的抗生素耐药性。具体目标为：目标1） 评估是否对机械通气儿童的呼吸道培养进行诊断管理 减少呼吸道培养和抗生素的使用，而不会导致非预期的患者伤害，目的2）识别 实施诊断管理质量改进计划的障碍和促进因素， 在14个儿科重症监护病房的机械通气患者中使用呼吸道培养，以及目标3） 采用德尔菲法，包括一个具有全国代表性的小组，以达成共识 建议告知机械通气儿童何时进行呼吸道培养。十四 参与多中心质量改进计划的医院，即Bright星星协作计划， 实施当地质量改进计划，以提高呼吸道培养物的使用。这项建议会 评估当地诊断管理计划的实施情况，并确定这些计划是否 这是一种有效和安全的策略，可以减少弱势群体的抗生素使用。拟议目标 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，并促进非ICU儿科和成人人群的类似工作。

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.