Expanding antimicrobial stewardship for long term care facility patients:Implemen

扩大对长期护理机构患者的抗菌药物管理：实施

• 批准号: 8014853
• 负责人: Jeffrey M Caterino
• 金额: $ 14.37万
• 依托单位: OHIO STATE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-09-30 至 2015-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8014853
• 关键词: Accident and Emergency department; Acute; Address; Adverse effects; Aging; Agreement; Algorithms; Antibiotic Therapy; Antibiotics; Antimicrobial Resistance; Biology of Aging; Caring; Chronic; Clinical; Clinical Research; Cohort Studies; Data; Development Plans; Diagnosis; Diagnostic; Dose; Educational Curriculum; Elderly; Ensure; Failure; Formularies; Functional disorder; Goals; Guidelines; Hepatic; Infection; Infection Control; Information Systems; Inpatients; Intervention; Kidney; Lead; Literature; Long-Term Care; Morbidity - disease rate; Nursing Homes; Online Systems; Outcome; Patients; Pharmacists; Phase; Physicians; Population; Positioning Attribute; Public Health; Recommendation; Renal function; Research; Research Personnel; Resistance; Resources; Site; Techniques; Testing; Time; Work; abstracting; antimicrobial; antimicrobial drug; base; career development; clinically significant; combat; design; diagnostic accuracy; experience; health information technology; high risk; improved; intervention program; meetings; microorganism; mortality; new technology; novel; prevent; programs; prospective; public health relevance; tool; treatment site

DESCRIPTION (provided by applicant): This proposal represents a five-year curriculum and research plan designed to transition the candidate to an independent investigator in clinical research. During the five years the candidate will complete coursework relevant to the project and will execute the research plan. Infection is one of the leading causes of morbidity and mortality in residents of long-term care facilities (LTCFs). As a result, LTCF residents are exposed to large numbers of antimicrobial agents but use of antimicrobials in LTCF residents is often suboptimal due to difficulty in distinguishing acute infection from colonization and due to the increased likelihood of inaccurate or inappropriate antibiotic prescribing in LTCF residents (for example due to increased presence of antimicrobial resistance). The emergency department (ED) is a common site for treatment of infection in LTCF residents, particularly those most severely ill. Comprehensive programs to address problems of antimicrobial use for LTCF residents in the ED are currently lacking. The conceptual framework for the study is borrowed from the literature on antimicrobial stewardship programs (ASPs), empiric antibiotic treatment, and LTCF infection control guidelines. ASPs have been successfully implemented in inpatient populations to improve antimicrobial prescribing practices and outcomes with resulting decreases in resistance and side effects. This study expands their use to a high-risk ED population with the goal of incorporating both improved diagnostic accuracy and empiric antimicrobial prescribing. Current LTCF infection control guidelines recommend that acute infection be diagnosed in LTCF patients only when they meet specific criteria in order to differentiate active infection from colonization and prevent overuse of antibiotics. These guidelines were developed for use in the LTCFs themselves and have not yet been studied in the ED or inpatient settings. As failure to differentiate acute infection from colonization in the ED may lead to inappropriate antibiotic use, validating diagnostic guidelines in the ED setting is an important step towards appropriate antimicrobial stewardship. Another key concept of these studies is efficiency, driven primarily by Health Information Technology (HIT). In an era of limited resources utilizing pre-existing HIT systems and information will allow extension of ASPs to novel clinical settings and populations. The majority of moderately- to severely-ill LTCF patients receive their initial diagnosis and initiation of antimicrobials in the ED. To improve care of this high-risk population, our overall objective is to develop and implement an antimicrobial stewardship program (ASP) based on use of health information technology (HIT) for ED LTCF patients that will result in improvements both in accuracy of diagnosis and in correct antimicrobial prescribing. To achieve this objective, we will conduct two projects with the following Specific Aims: Specific Aim 1 (ED-observational): To develop a validated definition for acute infection and to identify antimicrobial stewardship needs in ED LTCF patients. Specific Aim 2 (ED-interventional): To test the effect of implementing a health information technology (HIT)-based ASP for ED-LTCF patients on diagnosis and treatment of acute infection. For Specific Aim 1, the project (SA1: ED-observational) will consist of a prospective observational cohort study of ED LTCF patients. It will be used to validate definitions for the presence of acute infection in ED LTCF patients (as distinct from colonization), establish baseline rates of need for ASP interventions, and develop data required to construct specific antimicrobial recommendations and an ASP for ED LTCF patients. For Specific Aim 2, a prospective, interventional trial (SA 2: ED-interventional) will be conducted in which an ASP program tailored to ED LTCF patients will be devised and implemented. This phase will rely on the use of a real-time web-based health information technology (HIT) decision support tool to provide the intervention. It will include factors such as the suggested algorithms for diagnosing an acute infection in LTCF patients, a newly developed antibiotic by site grid, patient specific past culture results, patient specific data on hepatic and renal function with recommended dosing, and formulary restrictions. Outcomes will include accuracy of diagnosis, appropriateness of empiric antibiotics, and ongoing requirements for ASP intervention. The career development plan will include didactic work in advanced biostatistical techniques useful in conducting these studies. Coursework will also be undertaken in specific aspects of aging studying biology of aging and challenges in aging research. It will also include a significant component studying the application of health information technology including didactic coursework, online coursework, and practical experience to allow completion of the proposed research and position the candidate for further studies. Based on the results achieved, it will be possible to develop validated and reproducible interventions to improve antimicrobial stewardship in a variety of settings. The proposed projects and career development plan will provide an important initial step towards the ultimate goal of improving care for residents of LTCFs. PUBLIC HEALTH RELEVANCE: This research addresses antimicrobial stewardship in nursing home patients, an important means of combating antimicrobial resistance which is a significant and increasing threat to public health. By developing novel technology-based techniques to improve information available and provide decision support to physicians in emergency department the project will ultimately improve accuracy of antibiotic treatment in elders.

描述（由申请人提供）：该提案代表了一项为期五年的课程和研究计划，旨在将候选人转换为临床研究的独立研究者。 在五年中，候选人将完成与项目相关的课程，并将执行研究计划。 感染是长期护理设施（LTCF）居民发病和死亡率的主要原因之一。 结果，LTCF居民暴露于大量抗菌剂中，但在LTCF居民中使用抗菌剂通常是由于难以区分急性感染与定殖的困难，并且由于LTC居民的不合适或不当抗生素处方的可能性增加（例如，在LTC居民中增加了可能增加的抗菌性感染。 急诊科（ED）是LTCF居民（尤其是最严重患病的人）感染治疗感染的常见地点。 目前缺乏解决急诊室LTCF居民抗菌使用问题的全面计划。 该研究的概念框架是从有关抗菌管理计划（ASP），经验性抗生素治疗和LTCF感染控制指南的文献中借用的。 ASP已在住院群体中成功实施，以改善抗菌处方实践和结果，从而降低阻力和副作用。 这项研究将其使用扩展到高风险的人群，目的是纳入提高的诊断准确性和经验性抗菌处方。当前的LTCF感染控制指南建议，仅当LTCF患者符合特定标准以区分主动感染与定殖并防止过度使用抗生素时，才能在LTCF患者中诊断急性感染。 这些准则是在LTCF本身中使用的，尚未在ED或住院设置中进行研究。 由于无法区分急性感染与ED中的定殖可能导致不适当的抗生素使用，因此在ED环境中验证诊断指南是迈向适当的抗菌剂管理的重要一步。这些研究的另一个关键概念是效率，主要由健康信息技术（HIT）驱动。 在利用预先存在的HIT系统和信息的资源有限的时代，将使ASP扩展到新颖的临床环境和人群。 大多数中度至严重的LTCF患者接受了ED中抗菌剂的初步诊断和启动。 为了改善对这一高风险人群的护理，我们的总体目标是基于对ED LTCF患者的健康信息技术（HIT）的使用（HIT）制定和实施抗菌管理计划（ASP），这将在诊断准确性和正确的抗菌处方方面提高。 为了实现这一目标，我们将进行两个具有以下特定目的的项目： 特定目标1（ED型观察）：为急性感染制定验证的定义，并确定ED LTCF患者的抗菌管理需求。 具体目的2（授课）：测试对ED-LTCF患者实施基于健康​​信息技术（HIT）ASP对急性感染的诊断和治疗的影响。 对于特定的目标1，该项目（SA1：ED-observational）将由ED LTCF患者的前瞻性观察队列研究组成。 它将用于验证ED LTCF患者中急性感染的定义（与定殖不同），建立了对ASP干预措施的基线速率，并开发了构建特定抗菌剂建议和ASP的所需数据和ED LTCF患者的ASP。 对于特定的目标2，将进行一项前瞻性，介入的试验（SA 2：授课），在该试验中，将设计和实施针对ED LTCF患者量身定制的ASP计划。此阶段将依靠基于实时的基于Web的健康信息技术（HIT）决策支持工具来提供干预措施。 它将包括用于诊断LTCF患者急性感染的建议算法，通过现场网格新开发的抗生素，特定于患者的过去培养结果，具有建议的肝功能和肾功能的特定数据，具有建议的给药，并进行了限制。 结果将包括诊断的准确性，经验性抗生素的适当性以及对ASP干预的持续要求。 职业发展计划将包括对进行这些研究有用的先进生物统计技术的教学工作。 课程工作还将在衰老研究衰老研究生物学和衰老研究挑战的特定方面进行。 它还将包括研究健康信息技术的应用，包括教学课程，在线课程和实践经验，以允许完成拟议的研究并定位进一步研究的候选人。 根据所取得的结果，可以开发经过验证且可重复的干预措施，以改善各种环境中的抗菌管理。 拟议的项目和职业发展计划将为改善LTCF居民护理的最终目标提供重要的第一步。 公共卫生相关性：这项研究涉及疗养院患者的抗菌管理，这是打击抗菌抗药性的重要手段，这是对公共卫生的巨大威胁。通过开发新颖的基于技术的技术来改善可用信息并向急诊科医师提供决策支持，该项目将最终提高长者中抗生素治疗的准确性。