Outcomes of Blood Culture Best Practice Implementation in Immunocompromised Children: A Multi-Center Study

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Abstract Background Febrile neutropenia (FN) affects 10-45% of pediatric oncology patients, with bacteremia identified in 10-30% of cases. Blood cultures are a standard component of FN evaluation but are frequently overused, contributing to unnecessary antibiotics, false positives, prolonged hospitalization, and increased costs. Evidence indicates that cultures drawn >48 hours after fever onset provide limited diagnostic value, with positivity rates declining from 12.3-21% before empiric antibiotics to 4.2-4.4% thereafter. The national blood culture bottle shortage (July-October 2024) prompted stewardship protocols across institutions, providing an opportunity to assess the clinical effects of reduced culture frequency. We aim to evaluate the clinical outcomes of hospitalized immunocompromised children with fever who receive only one set of blood cultures at fever onset, without daily repeats within 2 days if clinically stable, compared to those who traditionally received daily cultures, and to characterize factors related to repeat blood culture positivity. Methods This multi-center, retrospective cohort study included 441 unique patients and 584 encounters of immunocompromised pediatric patients hospitalized with fever or clinical change at five New York institutions from March-November 2024. Data were extracted from electronic medical records and stratified by interval between cultures (<2 days or ≥2 days from initial culture). T-test and Wilcoxon signed-rank test were used for continuous variables; chi-squared and Fisher test were used for categorical comparisons. Results 261 encounters met inclusion criteria, representing cases where repeat cultures were obtained <2 days or ≥2 days after an initial negative culture. Among these encounters, no significant associations were found between the timing of repeat cultures and outcomes such as need for noninvasive ventilation, volume repletion, inotropic support, PICU admission, or mortality. Positivity of first and second repeat blood cultures was not statistically different between the two groups. Data show a tendency, although does not reach statistical significance, to repeat culture <2 days after the initial with malignancy or stem cell transplant (SCT) history (p = .06) and lower WBC (p = .06). However, these variables were associated with first-to-second repeat culture interval <2 days (Table 1). Positive first or second repeat blood cultures after an initial negative blood culture were all retrieved from central line of neutropenic cancer patients (Table 2). Conclusion Reducing the frequency of repeat blood cultures to ≥2 days after the initial culture decreased culture utilization in immunocompromised children without adversely affecting clinical outcomes. These findings support adherence to blood culture stewardship best practices in managing stable pediatric patients with FN.

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