Optimizing Duration of Empiric Management of Suspected Central Line-Associated Bloodstream Infections in Pediatric Intestinal Failure Patients

Abstract

Purpose: In pediatric patients requiring long-term home parenteral nutrition (PN) due to intestinal failure (IF), central line-associated bloodstream infections (CLABSI) are potentially life-threatening illnesses. Yet, there are no evidence-based guidelines for empiric management of patients who present to the emergency department. The purpose of this study was to determine the optimal length of time for empiric management of pediatric IF patients on PN who present for suspected CLABSI. Methods: Pediatric IF patients at Boston Children’s Hospital were prospectively observed from 7/1/2015 to 6/30/2018 for presentations to the emergency department for suspected CLABSIs. The primary endpoint was time to positive blood cultures. Secondary endpoints included vital signs, exam findings, laboratory studies, and responses to a symptom survey. Results: Seventy-three patients were enrolled in the study, with 35 patients presenting for CLABSI rule-out at least once during the study period. There were 49 positive blood cultures over 128 CLABSI rule-out presentations, and the median time to positive blood cultures was 11.1 hours. The probability of a blood culture becoming positive beyond 24 hours was 2.3%. Elevated C-reactive protein and neutrophil predominance on CBC correlated with positive blood cultures. Conclusions: All blood cultures that became positive did so within 48 hours and most became positive within 24 hours (46/49). This suggests that the current 48-hour rule-out used as a standard of practice at many institutions is a safe length of time to empirically manage patients with suspected CLABSI. However, the 3 patients who had positive blood cultures beyond the 24-hour mark developed fevers over the first 24 hours of hospitalization and would not have been discharged regardless of culture results. This suggest that a 24-hour rule-out would be safe with proper risk stratification. Minimizing the time of empiric management may reduce unnecessary antibiotic exposure, nosocomial complications, healthcare costs, and the burden placed on patients and their families.