A quasi-experimental study of a bundled diagnostic stewardship intervention for ventilator-associated pneumonia

Owen R Albin; Jonathan P Troost; Louis Saravolatz 2nd; Michael P Thomas; Robert C Hyzy; Mark A Konkle; Andrew J Weirauch; Robert P Dickson; Krishna Rao; Keith S Kaye

doi:10.1016/j.cmi.2023.12.023

A quasi-experimental study of a bundled diagnostic stewardship intervention for ventilator-associated pneumonia

Clin Microbiol Infect. 2024 Apr;30(4):499-506. doi: 10.1016/j.cmi.2023.12.023. Epub 2023 Dec 30.

Authors

Affiliations

¹ Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA. Electronic address: oalbin@med.umich.edu.
² Michigan Institute for Clinical & Health Research, University of Michigan, Ann Arbor, MI, USA.
³ Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA.
⁴ Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
⁵ Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
⁶ Department of Adult Respiratory Care, Michigan Medicine, Ann Arbor, MI, USA.
⁷ Department of Internal Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ, USA.

PMID: 38163481
DOI: 10.1016/j.cmi.2023.12.023

Abstract

Objectives: Diagnostic error in the use of respiratory cultures for ventilator-associated pneumonia (VAP) fuels misdiagnosis and antibiotic overuse within intensive care units. In this prospective quasi-experimental study (NCT05176353), we aimed to evaluate the safety, feasibility, and efficacy of a novel VAP-specific bundled diagnostic stewardship intervention (VAP-DSI) to mitigate VAP over-diagnosis/overtreatment.

Methods: We developed and implemented a VAP-DSI using an interruptive clinical decision support tool and modifications to clinical laboratory workflows. Interventions included gatekeeping access to respiratory culture ordering, preferential use of non-bronchoscopic bronchoalveolar lavage for culture collection, and suppression of culture results for samples with minimal alveolar neutrophilia. Rates of adverse safety outcomes, positive respiratory cultures, and antimicrobial utilization were compared between mechanically ventilated patients (MVPs) in the 1-year post-intervention study cohort (2022-2023) and 5-year pre-intervention MVP controls (2017-2022).

Results: VAP-DSI implementation did not associate with increases in adverse safety outcomes but did associate with a 20% rate reduction in positive respiratory cultures per 1000 MVP days (pre-intervention rate 127 [95% CI: 122-131], post-intervention rate 102 [95% CI: 92-112], p < 0.01). Significant reductions in broad-spectrum antibiotic days of therapy per 1000 MVP days were noted after VAP-DSI implementation (pre-intervention rate 1199 [95% CI: 1177-1205], post-intervention rate 1149 [95% CI: 1116-1184], p 0.03).

Discussion: Implementation of a VAP-DSI was safe and associated with significant reductions in rates of positive respiratory cultures and broad-spectrum antimicrobial use. This innovative trial of a VAP-DSI represents a novel avenue for intensive care unit antimicrobial stewardship. Multicentre trials of VAP-DSIs are warranted.

Keywords: Antimicrobial stewardship; Diagnostic stewardship; Hospital-acquired bacterial pneumonia; Nosocomial pneumonia; Ventilator-associated.

Publication types

Evaluation Study

MeSH terms

Anti-Bacterial Agents / therapeutic use
Feasibility Studies
Humans
Intensive Care Units
Pneumonia, Ventilator-Associated* / diagnosis
Pneumonia, Ventilator-Associated* / drug therapy
Pneumonia, Ventilator-Associated* / microbiology
Prospective Studies

Substances

Anti-Bacterial Agents