Decision-support guidelines cut unnecessary respiratory cultures in pediatric ICUs without harm

Researchers from Johns Hopkins Children's Center analyzed endotracheal aspirate culture (EAC) practices across 15 U.S. pediatric intensive care units participating in the BrighT STAR respiratory collaborative. The study, published in JAMA Network Open, evaluated a clinical decision-support intervention designed to replace reflexive culture ordering with deliberate, symptom-based testing.

Clinicians routinely collect EACs from ventilated children to detect bacterial pneumonia, but the respiratory tract in these patients is not sterile, making it difficult to distinguish true infection from harmless colonization. Overuse of cultures can lead to unnecessary antibiotics, increased resistance, and added cost.

The intervention provided bedside algorithms and checklists that prompted clinicians to consider specific signs of infection — such as fever, changes in ventilation support, or declining oxygen saturation — before ordering a culture. The approach built on a 2021 single-center study that achieved a 40% reduction in culture use without safety concerns.

In the current analysis, investigators compared the 24 months before the intervention with the 18 months after implementation across 14 additional health systems (median PICU size 30 beds) from 2019 to 2023. The monthly EAC rate fell from 7.80 to 6.55 cultures per 100 ventilator-days, a 16% decline.

No significant changes were observed in antibiotic prescribing rates, duration of mechanical ventilation, hospital length of stay, or readmission rates. The authors conclude that reducing respiratory cultures in children without clinical signs of infection is feasible and not associated with patient harm.

The findings support broader adoption of diagnostic stewardship programs in pediatric critical care to standardize testing practices and limit unnecessary antimicrobial exposure.