BrighT STAR was a diagnostic stewardship collaborative of 14 pediatric intensive care units (PICUs) across the United States designed to standardize and reduce unnecessary blood cultures and study the impact on patient outcomes and broad-spectrum antibiotic use. We now examine the implementation process in detail to understand how sites facilitated this diagnostic stewardship program in their PICUs.

A multi-center electronic survey of the 14 BrighT STAR sites, based on qualitative data about the implementation process collected during the primary phase of BrighT STAR.

14 PICUs enrolled in BrighT STAR.

Site leads at each enrolled site.

An electronic survey guided by implementation science literature and based on data collected during BrighT STAR was administered to all 14 sites after completion of the primary phase of the collaborative.

10 specific tasks appear critical to implementing blood culture diagnostic stewardship, with variability in site-level strategies employed to accomplish those tasks. Sites rated certain tasks and strategies as highly important. Strategies used in top-performing sites were distinct from those used in lower-performing sites. Certain strategies may link to drivers of culture overuse and represent key targets for changing clinician behavior.

BrighT STAR offers important insights into the tasks and strategies used to facilitate successful diagnostic stewardship in the PICU. More work is needed to compare specific strategies and optimize stewardship outcomes in this complex environment.

Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children (Bright STAR). NCT03441126. https://www.clinicaltrials.gov/study/NCT03441126?term=Bright%20STAR&aggFilters=status:com&checkSpell=false&rank=1

To evaluate the effect of 70% isopropyl alcohol–impregnated central venous catheter caps on ambulatory central-line–associated bloodstream infections (CLABSIs) in pediatric hematology-oncology patients.

This study was a 24-month, cluster-randomized, 2 period, crossover clinical trial.

The study was conducted in 15 pediatric healthcare institutions, including 16 pediatric hematology-oncology clinics.

All patients with an external central line followed at 1 of the 16 hematology-oncology clinics.

Usual ambulatory central-line care per each institution using 70% isopropyl alcohol–impregnated caps at home compared to usual ambulatory central-line care in each institution without using 70% isopropyl alcohol–impregnated caps.

Of the 16 participating clinics, 15 clinics completed both assignment periods. As assigned, there was no reduction in CLABSI incidence in clinics using 70% isopropyl alcohol–impregnated caps (1.23 per 1,000 days) compared with standard practices (1.38 per 1,000 days; adjusted incidence rate ratio [aIRR], 0.83; 95% CI, 0.63–1.11). In the per-protocol population, there was a reduction in positive blood culture incidence in clinics using 70% isopropyl alcohol-impregnated caps (1.51 per 1,000 days) compared with standard practices (1.88 per 1,000 days; aIRR, 0.72; 95% CI, 0.52–0.99). No adverse events were reported.

Isopropyl alcohol–impregnated central-line caps did not lead to a statistically significant reduction in CLABSI rates in ambulatory hematology-oncology patients. In the per-protocol analysis, there was a statistically significant decrease in positive blood cultures. Larger trials are needed to elucidate the impact of 70% isopropyl alcohol–impregnated caps in the ambulatory setting.

ClinicalTrials.gov; NCT02351258