Background: The 2011 the updated IDSA guideline on Community Acquired Pneumonia (CAP) in children recommends a blood culture in children with moderate to severe bacterial CAP requiring hospitalization. This recommendation was included in the Seattle Children’s Hospital (SCH) Clinical Standard Work (CSW) CAP pathway, for several reasons: (1) blood culture results would drive treatment decisions, (2) since SCH is a tertiary referral center, blood culture results would provide information regarding regional bacterial surveillance and antimicrobial sensitivities, and (3) there was a belief that it is was already part of our local culture. Our QI initiative analyzed blood culture results over a 3-year period, to determine the utility of this recommendation.
Methods: Our CSW pathway for uncomplicated CAP was launched in September 2012. Patients were pathway eligible if they were suspected to have CAP and were >60 days old. Pathway exclusion criteria included: underlying immunodeficiency, risk for aspiration pneumonia, known lung disease other than asthma, malignancy, prior/current tracheostomy, prior/current ventilator dependence, neuromuscular disease, empyema and lung abscess. Blood culture results from October 1, 2012 to September 30, 2015 were reviewed.
Results: During this 3-year period, 470 patients met our definition for an uncomplicated CAP and qualified for inclusion on our pathway. Blood cultures were obtained in 293 (62%) encounters with a total of 540 blood cultures obtained (range 1-16 blood cultures per encounter). There were only 5 positive blood culture results, for a ~1% positivity rate: (1) one patient encounter was coded incorrectly and the patient had bacteremia due to Streptococcus pneumoniae without evidence of pneumonia, (2) two blood cultures were determined to be contaminants, and (3) two blood cultures grew pan sensitive Streptococcus pneumoniae that did not impact or change patient care.
Conclusions: Blood cultures were not routinely obtained in children with moderate CAP, despite pathway recommendations. Positive blood culture results were very uncommon and did not drive treatment decisions or provide significant information regarding regional bacterial susceptibilities. The CSW team is now in the process of reversing the initial mandate to routinely obtain blood cultures on all children hospitalized with moderate to severe CAP.