409 - Reducing unnecessary endotracheal aspirate cultures and excess antibiotic days of therapy in patients who are intubated or who have chronic tracheostomies

Publication Number: 2397.409

Talla Bitar, Childrens National Hospital, Arlington, TX, United States; Shamily Jadhav, George Washington University School of Medicine and Health Sciences, Washington, DC, United States; Aimee Dassner, Thermo Fisher Scientific, Washington, DC, United States; Kevin LLoyd, Children's National Hospital, Washington, DC, United States; Esther Esadah, Children's National Health System, Washington, DC, United States; Miriam Bloom, Children's National Health System, Washington, DC, United States; Nicola Brodie, Children's National Health System, Washington, DC, DC, United States; Lexi M. Crawford, George Washington University School of Medicine and Health Sciences, Washington, DC, United States; Enrique Escalante, Children's National Health System, Washington, DC, United States; Hani Fanous, Children's National Health System, Washington, DC, United States; Monika Geslak, Children's National Health System, Washington, DC, United States; Andrea Hahn, Children's National Hospital, Washington, DC, United States; Nneka Nzegwu, George Washington University School of Medicine and Health Sciences, Washington, DC, United States; Margaret Rush, Children's National Health System, Washington, DC, United States; Matthew P. Sharron, Nationwide Children's Hospital, Washington, DC, United States; Caleb E. Ward, Children's National Medical Center, Washington, DC, United States; Rana F. Hamdy, Children's National Health System, Washington, DC, United States

Background: Intubated patients and patients with chronic tracheostomies are at risk for ventilator-associated infections (VAIs) including ventilator-associated tracheitis (VAT) and pneumonia (VAP). (Endo)tracheal aspirate (ETA) cultures can guide antibiotic therapy for infections in these patients. However, bacterial growth from (E)TA culture does not differentiate between colonization and infection and can lead to antibiotic overuse.

Objective: This quality improvement project aims to decrease 1) unnecessary ETA cultures sent and 2) excess antibiotic days of therapy in patients who are intubated or have chronic tracheostomies by 25% by June 2025 and sustain for 1 year.

Design/Methods: A multidisciplinary team of key stakeholders identified 4 key drivers and 7 interventions to affect these drivers (Fig 1). Primary outcome measures were number and rate (per 100 ventilator days) of ETA cultures/month and antibiotic days of therapy for associated VAI treatment. Process measures included number and rate of ETA cultures sent in patients not meeting clinical criteria for a VAI (≥1 respiratory symptom + ≥1 systemic symptom) and repeat ETA cultures within 72 hours. Balancing measures included ICU length of stay and total ventilator days. Statistical process charts were used to evaluate changes in measures over time.

Results: During the baseline period Jan to Dec 2023, the number of ETA cultures sent ranged from 37 to 107 (mean:72/month; 9 tests/100 vent days). Post-intervention (Jan 2024 - Jan 2025), ETA cultures sent ranged from 69 to 136 (mean: 95/month; 11.5 tests/100 vent days) (Fig 2). ETA cultures sent from patients having met clinical criteria were 156/243 (64.2%) at baseline vs 333/536 (62.1%) post-intervention (Table 1). The rate of ETA cultures sent did not change over time (Fig 2). Mean duration of antibiotic therapy among patients who did not meet clinical criteria for VAT or VAP decreased significantly by 31% following the interventions (6.4 vs 4.4 days; p=0.01).

Conclusion(s): Nearly 40% of all ETA cultures were sent on patients who did not meet clinical criteria for a VAI. Implementing a clinical algorithm supplemented with regular educational initiatives led to a significant reduction in the mean duration of therapy for patients who did not meet clinical criteria for a VAT or VAP, but had no effect on number of ETA cultures ordered. More effective diagnostic stewardship initiatives are needed.

Table 1: Presenting signs and symptoms: Baseline vs Post-intervention


Key Driver Diagram


Statistical process charts: ETA cultures sent per 100 ventilator days
Figure 2: ETA cultures sent per 100 vent days (2A) and Repeat ETA cultures sent within 72 hours of a previous ETA culture sent on the same patient, per 100 vent days (2B)