Less is More: Improving Antimicrobial Stewardship for Asymptomatic Bacteriuria

少即是多：改善无症状菌尿症的抗菌药物管理

• 批准号: 9653885
• 负责人: BARBARA Wells TRAUTNER
• 金额: --
• 依托单位: MICHAEL E DEBAKEY VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-02-01 至 2021-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9653885
• 关键词: Acute; Address; Adoption; Adverse drug effect; Adverse drug event; Advisory Committees; Algorithms; Antibiotic Resistance; Antibiotics; Bacteremia; Bacteria; Bacterial Antibiotic Resistance; Bacteriuria; Baseline Surveys; Catheter Management; Catheters; Clinical; Clinical Pathways; Clostridium difficile; Cognitive; Combating Antibiotic Resistant Bacteria; Communicable Diseases; Complex; Data; Diagnosis; Dose; Effectiveness of Interventions; Evaluation; Exhibits; Feedback; Geography; Goals; Guidelines; Health care facility; Healthcare; Hospital Nursing; Hospitals; Human Resources; Infection; Institution; Interruption; Intervention; Knee; Long-Term Care; Measurement; Measures; Medical center; Medicare; Medicare/Medicaid; Methods; Modeling; Nursing Homes; Organism; Outcome; Patients; Pharmaceutical Preparations; Phase; Practice Guidelines; Practice Management; Process Measure; Program Effectiveness; Provider; Publishing; Ramp; Regression Analysis; Reporting; Resistance; Resources; Risk; Safety; Savings; Series; Services; Site; Source; Symptoms; Telephone; Time; Training; United States; Urinary tract; Urine; Veterans; Work; antimicrobial; bacterial resistance; budget impact; case-based; catheter associated UTI; clinical practice; combat; cost; data warehouse; design; economic implication; effectiveness evaluation; effectiveness measure; evidence base; health administration; improved; innovation; inpatient service; interest; intervention cost; patient oriented; patient safety; pharmacy benefit; prevent; primary outcome; programs; screening; success; successful intervention; tool; unnecessary treatment; urinary

Project Background/Rationale: Antimicrobial stewardship as a means to combat the spread of antibiotic- resistant bacteria has become a national priority, both within and outside the VHA. This IIR project focuses on improving Veteran safety by reducing inappropriate use of antimicrobials for asymptomatic bacteriuria (ASB), a very common condition that leads to antimicrobial overuse in acute and long-term care. We conducted a successful intervention to decrease guideline-discordant ordering of urine cultures and antibiotics for ASB. This single site intervention, entitled “Kicking Catheter Associated Urinary Tract Infection (CAUTI): the No Knee- Jerk Antibiotics Campaign,” reduced unnecessary screening for ASB by 71% and unnecessary treatment of ASB by 75% in a large and complex VA medical center. The UTI medication use evaluation recently conducted by the VA Antimicrobial Stewardship Task Force (ASTF) shows an acute need for our intervention, as 57% of 1,219 urine cultures treated as UTI (with antibiotics) were actually ASB. Our work is innovative in that we address the cognitive biases that drive overuse of antibiotics and encourage more deliberate choice. Project Objectives: The objective of this project is to facilitate implementation of a scalable version of the Kicking CAUTI campaign across four geographically diverse VA facilities while assessing what aspects of an antimicrobial stewardship intervention are essential to success and sustainability. Our project team and our operational partners will provide expertise and external facilitation, while intervention implementation at the facility level will be performed by the local personnel tasked with antimicrobial stewardship. The two main intervention tools are (1) an evidence-based algorithm that distills the guidelines into a streamlined clinical pathway, and (2) case-based audit and feedback to train clinicians to use the algorithm. The intervention is directed at providers in acute and long-term care, and the goal is to reduce inappropriate screening for and treatment of ASB in all patients and residents, not just those with urinary catheters. Aim 1 is to determine barriers to guideline-recommended practices for management of catheter-associated bacteriuria at intervention sites and assemble the local implementation teams. Aim 2 is to implement and evaluate a scalable version of the Kicking CAUTI intervention in four VA facilities, using four additional sites as contemporaneous controls. 2a: We will measure the clinical outcomes of urine cultures ordered, antibiotic use, and episodes of Clostridium difficile infection using Corporate Data Warehouse and review of selected charts at each site. 2b: We will study the relationship between the dose of the intervention delivered and clinical outcomes. Aim 3: Assess the economic implications of the intervention through a budget impact analysis. Methods: Our intervention will include an on-ramp period for each facility consisting of centrally-led phone calls with local site champions and baseline surveys. Case-based audit and feedback will begin at a given site after the on-ramp period and continue for twelve months. We will stagger intervention roll-out by quarter for each of the four intervention sites. The three-year project timeframe allows 3 months for project start-up, 3 months on-ramp at each site, 12 months for the active intervention implementation, and a sustainability phase at each site. Our analysis for Aim 2A will use clinical outcome data from Corporate Data Warehouse to conduct interrupted time series with segmented regression analysis. The analysis for Aim 2B will use regression models to assess whether more complete implementation is associated with better clinical outcomes, using process measures of key implementation components. The budget impact analysis will assess savings and costs of the intervention from the VHA perspective. Throughout the project we will have two calls each year with our operational partners. These partners, the National Center for Patient Safety, the National Infectious Diseases Service, the ASTF, and Pharmacy Benefits Management, have advised and directed the design of this proposal over the past year and will continue their involvement from the time of project launch to help plan for national dissemination.

项目背景/理由：抗菌管理作为对抗抗生素传播的一种手段 - 抗性细菌已成为VHA内外的国家优先事项。这个IIR项目的重点 通过减少对不对称细菌（ASB）的不适当使用来提高退伍军人的安全性，A 非常常见的疾病，导致抗菌性过度使用急性和长期护理。我们进行了一个 成功的干预措施减少了对ASB的尿培养和抗生素的指南订单。这 单个现场干预，标题为“踢导管相关的尿路感染（CAUTI）：无膝盖 - 混蛋抗生素运动，”将ASB的不必要筛查减少了71％，不必要的治疗 在一个大而复杂的VA医疗中心中，ASB占75％。最近进行的UTI用药使用评估 VA抗菌管理工作组（ASTF）表明了我们干预的急需 1,219种被视为UTI（抗生素）的尿培养物实际上是ASB。我们的工作是创新的 解决驱动抗生素过度使用并鼓励更多故意选择的认知偏见。项目 目标：该项目的目的是促进实施踢的可扩展版本 在四个地理上多样化的VA设施中的CAUTI运动，同时评估一个方面 抗菌管理干预对于成功和可持续性至关重要。我们的项目团队和我们的 运营合作伙伴将提供专业知识和外部设施，而干预实施 设施级别将由负责抗菌管理的当地人员进行。两个主 干预工具是（1）一种基于证据的算法，该算法将准则提取为精简的临床 途径，以及（2）基于病例的审计和反馈，以培训临床医生使用该算法。干预是 针对急性和长期护理的提供者，目标是减少不适当的筛查和 所有患者和居民的ASB治疗，不仅是患有尿导管的患者。目标1是确定 干预时导管相关细菌的管理指南的障碍 站点并组装本地实施团队。 AIM 2是实施和评估可扩展版本的 在四个VA设施中踢cauti干预，使用其他四个站点作为当代控制。 2a：我们将测量有序尿培养物，抗生素使用和梭状芽胞杆菌发作的临床结果 使用公司数据仓库的艰难梭菌感染并在每个站点上查看选定图表。 2B：我们会的 研究提供的干预剂量与临床结果之间的关系。目标3：评估 通过预算影响分析对干预的经济影响。方法：我们的干预将 在每个设施中包括一个由当地网站冠军的中央电话的坡道期间，并 基线调查。基于案件的审计和反馈将在坡道后期的给定站点开始， 继续十二个月。四个干预措施中的每一个 站点。为期三年的项目时间表允许3个月进行项目启动，每个站点3个月跨度3个月，12个 积极干预实施的月份和每个站点的可持续性阶段。我们的目标分析 2A将使用公司数据仓库中的临床结果数据与中断时间序列进行 分段回归分析。 AIM 2B的分析将使用回归模型来评估是否更多 完整的实施与更好的临床结果有关，使用关键的过程度量 实施组件。预算影响分析将评估从 VHA的观点。通过该项目，我们每年将与我们的运营合作伙伴进行两个电话。 这些合作伙伴，国家患者安全中心，国家传染病服务，ASTF， 和药房福利管理，在过去的一年中建议并指示该提案的设计 并将从项目启动时开始继续参与，以帮助计划国家传播。