Improving Appropriateness and Timeliness of Antibiotic Delivery in Pediatric Intestinal Failure

BACKGROUND: Children with pediatric intestinal failure (PIF) on parenteral nutrition through central venous catheters are at high risk for central line-associated bloodstream infections (CLABSI), a major cause of morbidity and mortality. Current guidelines recommend prompt empiric antibiotic therapy, yet limited data exist on quality improvement initiatives in this population. OBJECTIVE: To increase appropriate antibiotics ordered in the emergency department (ED) for febrile PIF patients by 50% and increase antibiotics administered within 60 minutes by 50% within 2 years. METHODS: This single-center quality improvement project included PIF patients on home parenteral nutrition presenting to the ED with fever from February 2020 through August 2023. Interventions included electronic health record alerts, provider education, standardized CLABSI cards for families, antibiotic order sets, and ensuring cefepime availability in the ED. RESULTS: Ninety-five encounters were analyzed (43 preprotocol, 52 postprotocol). Postintervention, cefepime orders increased from 2.3% to 90.4% (P<0.0001), while ceftriaxone orders decreased from 88.4% to 23.1% (P<0.0001). Vancomycin orders increased from 76.7% to 98.1% (P<0.001). Both recommended antibiotics were ordered in 55.8% preintervention versus 80.8% postintervention (P<0.01). Median time to cephalosporin administration decreased 58%, from 94.5 to 39.5 minutes (P<0.05); vancomycin administration time decreased 56%, from 178 to 78 minutes (P<0.05). Cephalosporins were administered within 60 minutes in 30.2% preintervention versus 72.6% postintervention (P<0.05). CONCLUSIONS: This quality improvement initiative significantly improved appropriateness and timeliness of antibiotic delivery in children with PIF presenting with suspected CLABSI through multidisciplinary interventions targeting provider awareness, process standardization, and system-level barriers.