Implementation of a Tracheal Aspirate Clinical Practice Guideline: A Quality Improvement Project

Infants in the Neonatal Intensive Care Unit (NICU) are prone to infection, due to immature immune systems and exposure to nosocomial infections. Antibiotics are the most- prescribed medications in the NICU, and are overprescribed, partially caused by nonspecific infection symptoms in neonates. Because of the high risks of unnecessary antibiotic prescription, the need for antibiotic stewardship is increasingly acknowledged in neonatal medicine. Local Problem: In NICU patients with endotracheal tubes (ETT) and tracheostomies, the primary diagnostic tool to screen for pneumonia is the tracheal aspirate (TA) culture. TA cultures sample from the ETT or tracheostomy tube rather than the lung tissue, which can lead to an overidentification of bacteria, and potentially an overprescription of antibiotics. TA interpretation is subjective and isolation of pneumonia from tube colonization is difficult, indicating a need for provider guidance on prescribing antibiotics for pneumonia. Methods: Current practices regarding the use of TA cultures were assessed conducting a chart review of all TA cultures performed in a single urban NICU. Confidence in the ability to interpret TA cultures and attitudes about prescription of antibiotics for pneumonia were assessed by surveying all advanced practice providers (APPs) in the NICU. Best practice for the guideline was determined by consulting with experts in infectious disease, pharmacology, pulmonology, and neonatology; and by conducting an extensive literature review. Interventions: A chart review involving the examination of clinical status, culture results, and antibiotic use was conducted on NICU patients with positive TA cultures to determine if the current antibiotic prescription process was evidence-based. A survey was sent to NICU APPs to determine confidence and knowledge of TA cultures. Data from the chart review and survey was described using descriptive statistics. A guideline was then developed and implemented, and education was presented to providers. A sustainability plan was created, and an executive summary was provided to the NICU Antibiotic Stewardship team with recommendations for the next phase of this project. Results: In the pre-implementation survey, 55.6% (n=5) of APPs thought antibiotics were overprescribed, and in a case vignette outlining a patient with colonization, 77.8% (n=7) of APPs recommended treatment for pneumonia. Chart review of 166 patients with at least one positive TA culture indicated that of those who received antibiotics, 64% did not have both signs of inflammation and respiratory changes consistent with pneumonia. Although patients with tracheostomies and ETTs had similar rates of inflammation and respiratory changes, patients with tracheostomies were likelier to receive antibiotics than patients with ETTs. Conclusion: Prior to intervention, NICU APPs had low confidence and knowledge in the correct interpretation of TA cultures and antibiotic usage. Many patients that were treated with antibiotics lacked clinical, laboratory, and radiographical signs of pneumonia and were inappropriately given antibiotics. APPs were also more likely to prescribe antibiotics to patients with tracheostomies, regardless of clinical status. Phase two of this project, which will occur outside the timeframe of the current project, will evaluate the success of the guideline by analyzing antibiotic use as well as APP attitudes about the TA guideline and its usability, feasibility, and satisfaction.