Implementing Diagnostic Stewardship to Reduce Antibiotic Use and Resistance in Critically Ill Children

项目摘要 脓毒症约占儿科重症监护病房（PICU）入院的8%，其中住院患者中 在美国，死亡率为25%，估计每年的费用为40 - 50亿美元。延迟抗菌剂 治疗与儿科败血症的不良结局相关，但败血症的初始体征可能是非特异性的 和微妙。临床医生经常要求血培养来帮助诊断细菌性败血症，但普遍 没有可接受的标准或指南来指导何时获得血培养的决定。 与未能及时诊断败血症的潜在灾难性后果相比， 血培养通常被认为是一种低风险的筛查试验。然而，血培养的产量是 低（5-15%）和高达一半是假阳性。假阳性培养物通过额外的 住院天数，不必要的抗生素，以及增加的成本。不必要的抗生素使用是导致 抗生素耐药性正在成为全球人类健康的严重威胁。最近，一种新的临床 实践指南旨在规范危重儿童血培养方法， 血培养使用率为46%。此外，广谱抗生素的使用减少了15%， 干预随后在另外两个PICU实施该计划，降低了血培养 使用.本提案的长期目标是确定诊断管理，特别是 适当使用血培养，可以安全地减少抗生素的使用和抗生素耐药性， 不同的医院。具体目标是：目标1）实施循证临床实践 评估有脓毒症体征和症状的患者以减少PICU中血培养使用的指南， 目的2）评估临床实践是否会减少抗生素的使用、抗生素耐药性和梭菌 艰难梭菌感染，目的3）以确定本临床实践指南是否具有非预期的 患者伤害的后果。一项前瞻性多中心质量改进计划将在 10家医院，并将使用准实验设计进行评估，比较治疗前和治疗后的结局数据。 后经期。这些发现可以提供证据表明，围绕血培养的诊断管理可以 通过减少不必要的抗生素使用和抗生素耐药性来减少对患者的伤害。

PROJECT SUMMARY Sepsis accounts for approximately 8% of pediatric intensive care unit (PICU) admissions, with an in-hospital mortality of 25% and an estimated annual cost of $4-5 billion in the United States. Delayed antimicrobial therapy is associated with worse outcomes for pediatric sepsis, but initial signs of sepsis can be non-specific and subtle. Clinicians frequently order blood cultures to aid in diagnosing bacterial sepsis, but universally accepted standards or guidelines to guide decisions around when to obtain blood cultures are not available. Weighed against the potentially disastrous consequences of failing to diagnose sepsis in a timely fashion, blood cultures are generally perceived to be a low-risk screening test. The yield of blood cultures, however, is low (5-15%) and up to half are falsely positive. False positive cultures contribute to patient harm via additional hospital days, unnecessary antibiotics, and increased costs. Unnecessary antibiotic use is a primary driver of antibiotic resistance, which is emerging as a grave threat to human health worldwide. Recently, a novel clinical practice guideline designed to standardize approach to blood cultures in critically ill children safely reduced blood culture use by 46%. In addition, there was a 15% reduction in broad spectrum antibiotic use post- intervention. Subsequent implementation of this program in two other PICUs yielded reductions in blood culture use. The long term objective of this proposal is to determine whether diagnostic stewardship, specifically the appropriate use of blood cultures, can safely reduce antibiotic use and antibiotic resistance in a large and diverse group of hospitals. The specific aims are Aim 1) to implement an evidence-based, clinical practice guideline for evaluation of patients with signs and symptoms of sepsis to decrease blood culture use in PICUs, Aim 2) to evaluate whether a clinical practice will reduce antibiotic use, antibiotic resistance, and Clostridium difficile infection, and Aim 3) to determine whether this clinical practice guideline has an unintended consequence of patient harm. A prospective multicenter quality improvement program will be implemented at 10 hospitals, and will be evaluated using a quasi-experimental design comparing outcome data in pre- and post-periods. The findings could provide evidence that diagnostic stewardship around blood cultures can decrease harm to patients by reducing unnecessary antibiotic use and antibiotic resistance.