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Original Investigation
February 2017

Association of a Clinical Practice Guideline With Blood Culture Use in Critically Ill Children

Author Affiliations
  • 1Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
  • 2Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 3Department of Pediatrics, Johns Hopkins Nursing, Baltimore, Maryland
  • 4Department of Emergency Medicine, The Johns Hopkins University, Baltimore, Maryland
  • 5Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 6Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 7MITRE Corporation, Mclean, Virginia
  • 8Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 9Department of Civil Engineering, The Johns Hopkins University, Baltimore, Maryland
  • 10Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA Pediatr. 2017;171(2):157-164. doi:10.1001/jamapediatrics.2016.3153
Key Points

Question  Can a quality improvement initiative safely reduce unnecessary blood culture use in critically ill children?

Findings  In this cohort study, introduction of education and decision support tools for caregivers was associated with a reduction in blood culture use, and focused attention on blood culture collection site was associated with fewer cultures being collected from central venous catheters after vs before intervention. In-hospital mortality, readmissions, and rates of episodes defined as “suspected infection” and “suspected septic shock” did not increase after intervention.

Meaning  Education and decision support tools that standardize approach to fever can safely reduce blood culture use in hospitalized children.


Importance  Sepsis and septic shock are common and, at times, fatal in pediatrics. Blood cultures are often obtained when clinicians suspect sepsis, yet are low-yield with a false-positive rate up to 50%.

Objectives  To determine whether a novel, 2-part, clinical practice guideline could decrease the rates of total blood cultures and cultures collected from central venous catheters in critically ill children and to examine the effect of the guideline on patient outcomes.

Design, Setting, and Participants  A retrospective cohort study was performed to determine the effect of a new clinical practice guideline on blood culture practices in a 36-bed, combined medical/surgical pediatric intensive care unit of an urban, academic, tertiary care center from April 1, 2013, to March 31, 2015. All patients admitted to the pediatric intensive care unit with length of stay of 4 hours or more were evaluated (4560 patient visits: 2204 preintervention, 2356 postintervention visits).

Interventions  Two documents were developed: (1) fever/sepsis screening checklist and (2) blood culture decision algorithm. Clinicians consulted these documents when considering ordering blood cultures and for guidance about the culture source.

Main Outcomes and Measures  Primary outcome was the total number of blood cultures collected per 100 patient-days.

Results  Of the 2204 children evaluated before the intervention, 1215 were male (55.1%); median (interquartile range) age was 5 (1-13) years. Postintervention analysis included 2356 children; 1262 were male (53.6%) and median (interquartile range) age was 6 (1-13) years. A total of 1807 blood cultures were drawn before the intervention during 11 196 patient-days; 984 cultures were drawn after the intervention during 11 204 patient-days (incidence rate, 16.1 vs 8.8 cultures per 100 patient-days). There was a 46.0% reduction after the intervention in the blood culture collection rate (incidence rate ratio, 0.54; 95% CI, 0.50-0.59). After the intervention, there was an immediate 25.0% reduction in the rate of cultures per 100 patient-days (95% CI, 4.2%-39.7%; P = .02) and a sustained 6.6% (95% CI, 4.7%-8.4%; P < .001) monthly decrease in the rate of cultures per 100 patient-days. Significantly fewer cultures were collected from central venous catheters after vs before the intervention (389 [39.5%] vs 1321 [73.1%]; P < .001). Rates of episodes defined as suspected infection and suspected septic shock decreased significantly after the intervention, but patients meeting these criteria underwent cultures at unchanged frequencies before vs after the intervention (52.1% vs 47.0%, P = .09, compared with 56.7% vs 55.0%, P = .75). In-hospital mortality (45 [2.0] vs 37 [1.6]; P = .23) and hospital readmissions (107 [4.9] vs 103 [4.4]; P = .42) were unchanged after the intervention.

Conclusions and Relevance  A systematic approach to blood cultures decreased the total number of cultures and central venous catheter cultures, without an increase in rates of mortality, readmission, or episodes of suspected infection and suspected septic shock.