We read with interest the quality report by Kurowski et al, titled “Improvement Methodology Increases Guideline Recommended Blood Cultures in Children With Pneumonia.” We applaud the authors for their successful implementation and description of a complex project using quality improvement methods. The first question in the model for improvement is: “What are we trying to accomplish?” Perhaps a second question should be added: “Why?” Kurowski et al cite compliance with the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America guidelines and “to standardize management” to support their aim. In their project, they increased the percent of blood cultures performed in children admitted for community-acquired pneumonia (CAP) from 53% to 79%.
Although the CAP guideline recommends blood cultures in children admitted with moderate to severe CAP, the evidence cited for this recommendation is weak. In fact, as Kurowski et al acknowledge, research published since guideline release further questions the utility of blood cultures. One thing, however, on which all these studies agree is that the percent of pathogenic bacteria recovery is usually <5%, and in most, the actionable information obtained is even lower. Most telling is the authors’ comparison of their study to Heine et al.1 In that article, researchers studied the effectiveness of institutional guidelines in decreasing the frequency of unnecessary blood cultures compared with national CAP guidelines. They studied a similar number of patients, 330; found the same ratio of pathogens to contaminants, 1:1; and an almost identical rate of true bacteremia, 1.5%. All 5 patients with bacteremia had radiographic evidence of effusion or empyema and were admitted to intensive care or described as being septic, thus meeting their institutional criteria to obtain blood culture. Adoption of institutional guidelines could have reduced the frequency of blood cultures from 47% to 26% without missing any true-positives.
Interestingly, the authors of the current study had institutional guidelines similar to the ones proposed in Heine et al, and they were working! In fact the authors, through their intervention, managed to decrease their percent of true-positive blood cultures from an unusually high rate of 6.3% preintervention to a negligible rate of 1.3% by drawing more blood cultures.
After adjusting for covariates, the authors did not find an increased length of stay in patients with blood cultures versus those without; thus, we assume they conclude lack of harm. However, there are other harms of obtaining unnecessary blood cultures: increased pain and discomfort (the authors do not describe how many extra venipunctures it took to improve compliance), costs, possible exposure to broad-spectrum antibiotics, and increased testing including repeat cultures.
Again we applaud the authors for demonstrating how a multimodal, complex quality improvement project to increase adherence to national guidelines can be successfully implemented and described. We question however, the value of this particular endeavor. The authors have managed to increase costs at the expense of dubious patient benefit. They have exposed some of the weaknesses of the current enthusiasm for quality improvement, and remind us to consider value before embarking on that next plan-do-study-act endeavor.
Conflict of Interest:None declared
- Heine D,
- Cochran C,
- Moore M,
- Titus MO,
- Andrews AL
- Copyright © 2015 by the American Academy of Pediatrics