Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter-Associated Asymptomatic Bacteriuria
Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter-Associated Asymptomatic Bacteriuria
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DOI：
10.1001/jamainternmed.2015.1878
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发表时间：
2015-07-01
影响因子：
39
通讯作者：
Naik, Aanand D.
中科院分区：
文献类型：
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作者：
Trautner, Barbara W.;Grigoryan, Larissa;Naik, Aanand D.
无症状性细菌尿(ASB)在留置导尿管患者中过度治疗的重要性仍然很高。目的评估与标准质量改进方法相比，减少尿路细菌培养顺序和抗菌药物处方的干预措施的有效性和可持续性。设计、设置和参与者2010年7月至2013年6月在两个退伍军人事务部医疗保健系统与同期对照组进行干预前后的比较。研究人群为急性内科病房和长期护理病房的导尿管患者，以及订购尿液培养和处方抗菌药物的卫生保健专业人员。干预：多方面指南实施干预。主要结果和措施是每1000床日排序的尿液培养，以及ASB在干预和维持期接受抗生素治疗(过度治疗)的病例与两个地点的基线相比。患者水平的不适当使用抗菌药物的分析调整了个体协变量。结果研究监测包括289 754个总卧床天数。总的尿培养订单率在干预期间显著下降(从41.2/1000床日降至23.3/1000床日；发病率比[IRR]，0.57；95%CI，0.53~0.61)，并在维持期进一步下降(至12.0/1000床日；IRR，0.29；95%CI，0.26~0.32)(P<；.001)。在比较现场，订购的尿液培养在所有三个时期都没有显著变化。当使用纵向线性回归比较两个地点时，随着时间的推移，每月订购的尿液培养数量有显著差异(P<；.001)。在干预期间，干预地点ASB的过度治疗显著下降(从每1000床日1.6降至0.6；IRR，0.35；95%CI，0.22-0.55)，并在维持期持续(降至每1000床日0.4；IRR，0.24；95%CI，0.13-0.42)(P<；两者均为.001)。对比部位ASB的过度治疗在所有时期都是相似的(优势比为1.32；95%可信区间为0.69-2.52)。根据病房类型分析，ASB过度治疗在长期护理中显著减少。结论与标准质量改进方法相比，针对诊断和治疗导尿管患者的卫生保健专业人员的多方面干预减少了ASB过度治疗。这些改进在低强度维护期间持续存在。这种影响在长期护理中更为明显，这是抗菌药物管理的一个新兴领域。
IMPORTANCE Overtreatment of asymptomatic bacteriuria (ASB) in patients with urinary catheters remains high. Health care professionals have difficulty differentiating cases of ASB from catheter-associated urinary tract infections.OBJECTIVES To evaluate the effectiveness and sustainability of an intervention to reduce urine culture ordering and antimicrobial prescribing for catheter-associated ASB compared with standard quality improvement methods.DESIGN, SETTING, AND PARTICIPANTS A preintervention and postintervention comparison with a contemporaneous control group from July 2010 to June 2013 at 2 Veterans Affairs health care systems. Study populations were patients with urinary catheters on acute medicine wards and long-term care units and health care professionals who order urine cultures and prescribe antimicrobials.INTERVENTION A multifaceted guidelines implementation intervention.MAIN OUTCOMES AND MEASURES The primary outcomes were urine cultures ordered per 1000 bed-days and cases of ASB receiving antibiotics (overtreatment) during intervention and maintenance periods compared with baseline at both sites. Patient-level analysis of inappropriate antimicrobial use adjusted for individual covariates.RESULTS Study surveillance included 289 754 total bed-days. The overall rate of urine culture ordering decreased significantly during the intervention period (from 41.2 to 23.3 per 1000 bed-days; incidence rate ration [IRR], 0.57; 95% CI, 0.53-0.61) and further during the maintenance period (to 12.0 per 1000 bed-days; IRR, 0.29; 95% CI, 0.26-0.32) (P < .001 for both). At the comparison site, urine cultures ordered did not change significantly across all 3 periods. There was a significant difference in the number of urine cultures ordered per month over time when comparing the 2 sites using longitudinal linear regression (P < .001). Overtreatment of ASB at the intervention site fell significantly during the intervention period (from 1.6 to 0.6 per 1000 bed-days; IRR, 0.35; 95% CI, 0.22-0.55), and these reductions persisted during the maintenance period (to 0.4 per 1000 bed-days; IRR, 0.24; 95% CI, 0.13-0.42) (P < .001 for both). Overtreatment of ASB at the comparison site was similar across all periods (odds ratio, 1.32; 95% CI, 0.69-2.52). When analyzed by type of ward, the decrease in ASB overtreatment was significant in long-term care.CONCLUSIONS AND RELEVANCE A multifaceted intervention targeting health care professionals who diagnose and treat patients with urinary catheters reduced overtreatment of ASB compared with standard quality improvement methods. These improvements persisted during a low-intensity maintenance period. The impact was more pronounced in long-term care, an emerging domain for antimicrobial stewardship.