79 - Less Is More: A Targeted Blood-Culture Protocol Reduces Testing and Costs in Pediatric Febrile Neutropenia

Publication Number: 4077.79

Muayad Alali, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, United States

Background: Pediatric oncology patients with febrile neutropenia (FN) represent some of the highest consumers of blood cultures in hospitals. Overuse of repeat cultures beyond 48 hours contributes to unnecessary testing, prolonged antibiotic exposure, and increased healthcare costs. Current guidelines recommend obtaining blood cultures from all central line lumens within the first 48 hours of fever, but provide limited direction beyond this period when initial cultures remain negative. This uncertainty has led to practice variability and excess utilization. To address this gap, we implemented a targeted institutional protocol at Riley Hospital for Children in January 2023, restricting repeat cultures after 48 hours to episodes with hemodynamic instability or recurrent fever (≥72 hours after defervescence).

Objective: Primary outcomes included (1) reduction in total repeat blood cultures, (2) repeat cultures per fever day after 48 hours, (3) culture sets per length of stay (LOS), and (4) yield of repeat cultures after 48 hours. Secondary outcomes included antibiotic days, contamination rate, and cost savings.

Design/Methods: We conducted a single-center mixed retrospective-prospective cohort study of pediatric hematology-oncology patients with FN episodes lasting ≥3 days (January 2019-December 2024). Episodes with positive cultures within 48 hours or fever duration ≤2 days were excluded. We compared a 4-year pre-implementation period (January 2019-December 2022) to a 2-year post-implementation period (January 2023-December 2024). Random-effects models accounted for patients with multiple admissions.

Results: Of 2,313 FN episodes screened, 1,285 met the inclusion criteria (834 pre- and 451 post-implementation). Among episodes with negative initial cultures, only 8 (0.62%) yielded new true pathogens after 48 hours (5 pre- and 3 post-intervention). Multivariable analysis showed significant reductions in antibiotic days (-33%), post-Day 2 culture sets per fever day (37%), post-Day 2 cultures per LOS (29%), and contamination rate (40%) (see Table 1) . Estimated cost savings over the two-year post-intervention period were approximately $1.5 million, primarily driven by reduced culture use, shorter hospitalizations, and decreased antibiotic exposure. These reductions were particularly impactful during the 2024 national blood-culture-bottle shortage.

Conclusion(s): A restrictive, targeted blood-culture protocol for persistent FN in pediatric oncology patients was safe, effective, and cost-saving. This pragmatic "less-is-more" strategy enhances diagnostic stewardship, reduces unnecessary testing.

Flow diagram of the study
Figure 1

Table 1: Primary and secondary outcomes (Multivariate Analysis)
Table 1

Figure 2. Trend in Post-Day 2 Blood Culture Sets per Fever Day Before and After Protocol Implementation
Figure2