A quality improvement initiative to optimize diagnostic and antimicrobial stewardship of ventilator-associated tracheitis in the pediatric intensive care unit

OBJECTIVE: To reduce frequency of endotracheal aspirate culture (EAC) collection and decrease antibiotic days of therapy (DOT) for ventilator-associated tracheitis (VAT). DESIGN: Quality improvement intervention. SETTING: Tertiary-care pediatric intensive care unit (PICU). PATIENTS: Admitted to the PICU with an endotracheal tube (ETT) or tracheostomy. INTERVENTIONS: A clinical decision-support tool was implemented to provide clinical criteria for culture collection and microbiologic criteria for diagnosis, and to reduce treatment duration to 3 days. Key stakeholders were engaged, a nurse champion was identified, and a protocol was implemented. Culture rates (overall and serially repeated) and antibiotic DOT for VAT, each per 100 ETT/tracheostomy days, were analyzed. The proportion of VAT episodes treated for 3 days was also evaluated. Balancing measures included PICU mortality, ventilator-associated events, ventilator days, and length of stay. Statistical process control methods were used to analyze the data. RESULTS: Across 1072 EACs sent and 213 VAT cases diagnosed, interventions led to a 23% reduction in monthly cultures (9.2 to 7.1 per 100 ETT/tracheostomy days) and a 53% reduction in serial culture use (1.5 to 0.7 per 100 ETT/tracheostomy days). There was a 53% reduction in monthly antibiotic DOT for VAT (10.8 to 5.1 per 100 ETT/tracheostomy days) and a 13-fold increase in the proportion of 3-day antibiotic prescriptions (5 to 65%). There was no increase in mortality, ventilator-associated events, ventilator days, or length of stay. CONCLUSIONS: Standardized VAT guidelines in critically ill children can safely and effectively decrease culture and antibiotic use.