Original Investigation 

Critical Care Medicine

Diagnostic Stewardship of Respiratory Cultures Using Clinical Decision Support in the PICU

Anna C. Sick-Samuels, Charlotte Z. Woods-Hill, Daniel P. Kelly, et al

JAMA Netw Open 2026;9;(7):e2626547. doi:10.1001/jamanetworkopen.2026.26547

Key Points

Question  What is the association of diagnostic stewardship of endotracheal aspirate cultures using clinical decision support with culture rates, antibiotic use, and patient outcomes in the pediatric intensive care unit (PICU)?

Findings  In this cohort study, a collaborative of 15 PICUs observed a statistically significant reduction in endotracheal aspirate culture rates. There were no significant changes in antibiotic utilization or balancing measures such as bronchoalveolar lavage culture rates, length of stay, readmissions, and ventilation duration, nor was patient harm detected.

Meaning  These findings suggest that diagnostic stewardship using clinical decision support to standardize testing indications and optimize endotracheal aspirate culture practices in patients without suspected ventilator-associated infection may reduce culture use in critically ill children without safety concerns.

Abstract

Importance  Endotracheal aspirate culture (EAC) practices for evaluation of ventilator-associated infections (VAI) vary widely across pediatric hospitals, and overuse can contribute to overdiagnosis and overtreatment for VAI. Diagnostic stewardship strategies to optimize EAC testing practices may reduce overtesting and unnecessary antibiotic treatment.

Objective  To evaluate the association of diagnostic stewardship of EACs using clinical decision support with culture rates, antibiotic use, and patient outcomes across a multicenter collaborative of pediatric intensive care units (PICUs).

Design, Setting, and Participants  This was a multicenter cohort study with a pre-post study design among the BrighT STAR (Testing Stewardship for Antibiotic Reduction) Quality Improvement (QI) Collaborative involving PICUs across the US between 2019 and 2023. Data were collected from the participating sites and from the Children’s Hospital Association Pediatric Health Information System and were analyzed from August to December 2025.

Exposure  Participating PICUs conducted local QI programs focused on optimizing EAC practices, facilitated by the BrighT STAR collaborative.

Main Outcomes and Measures  The primary outcome was the monthly rate of EACs per 100 ventilator-days. Secondary outcomes included rates of antibiotic initiations and antibiotic days of therapy, bronchoalveolar lavage cultures, readmissions, length of stay, ventilation duration, ventilation-free days, sepsis, and septic shock. Analysis included adjustment for seasonality.

Results  Across 15 sites (median [IQR] unit size, 30 [25-38] beds), the study captured 106 967 ventilator-days preimplementation and 92 167 ventilator-days postimplementation. Comparing 24 months in the preimplementation period with the 18 months in the postimplementation period, the mean monthly EAC rate declined by 16% from a preimplementation to postimplementation rate of 7.80 to 6.55 cultures per 100 ventilator-days (relative rate [RR], 0.84; 95% CI, 0.78-0.90). The rate of antibiotic initiations remained stable (RR, 0.98; 95% CI, 0.89-1.08), as well as the antibiotic days of therapy rate (RR, 1.03; 95% CI, 0.95-1.11). There were no significant changes in the rates of bronchoalveolar lavage cultures, PICU length of stay, PICU or hospital readmissions, sepsis, septic shock, ventilation duration, or ventilator-free days.

Conclusions and Relevance  In this multicenter cohort study, diagnostic stewardship of EACs using clinical decision support led by multidisciplinary teams was associated with reduced EAC use in the PICU without safety concerns. Future work will determine optimal implementation strategies, assess sustainability and the cost impact of EAC stewardship.