De-Implementation of Unnecessary Surgical Antibiotic Prophylaxis in Children

项目摘要 背景：抗生素已经彻底改变了医疗保健，使临床医生能够治疗危及生命的疾病。 感染，并防止在挽救生命的手术后感染。不幸的是，抗生素的过度使用会导致 抗生素耐药性细菌和不必要的不良事件，包括艰难梭菌感染（CDI）。 目前的数据表明，抗生素耐药性细菌和CDI每年杀死多达150，000和29，000人 美国人分别。外科抗生素预防是不必要的抗生素使用的常见领域 在儿童中。最近CDC手术部位感染（SSI）指南和AAP明智选择运动 建议对于认为SSI风险较低的手术，不进行术后抗生素预防。显著 抗菌药物管理计划（ASP）和外科医生的最佳干预措施存在差距， 在儿童中实施（消除）不必要的术后抗生素预防。 目标：确定并测试两项循证实施战略， 儿童术后抗生素使用，同时评估重要的临床结局，包括SSI和CDI。 方法：首先，我们将在i-PARIHS的指导下制定基于证据的去执行策略 （一）促进卫生服务研究实施行动的综合框架。 基于外科医生焦点小组和当前文献的初步数据，标准顺序集综述和 修改（控制干预）将在9家儿童医院实施，这些医院是 儿科管理（SHARPS）和国家外科质量共享抗菌报告 改进计划-儿科（NSQIP-P）。利用iPARIHS框架了解关键因素 在参与实施的情况下，将实施加强的ASP促进干预措施。我们将 研究这些干预措施的影响，利用阶梯楔形设计，将依次提供 随着时间的推移，所有医院都进行了促进干预。这些干预措施将得到实施和执行 将利用SHARPS协作组织的既定ASP评估结果（如渗透率）， 致力于改善儿童抗生素的大型国家合作。临床结局（例如术后 抗生素使用、SSI、CDI）将使用NSQIP-P在每家医院收集的数据进行评估。 创新和影响：本研究具有创新性和影响力，因为它将：1）联合收割机的专业知识 外科医生、抗菌管理员和实施科学家制定基于理论的策略， 抗生素的使用; 2）评估这些策略对儿童手术的影响，这是一个代表性不足的群体; 3） 使用阶梯楔形设计严格测试两种干预措施; 4）收集临床结果（例如抗生素 使用，SSI，CDI）对ASP和外科医生很重要; 5）收集实施结果， 传播的战略，以其他医院和6）之间的协同作用，2大协作（SHARPS和 NSQIP），这将提高儿科ASP和改善需要外科手术的儿童的护理。

PROJECT SUMMARY Background: Antibiotics have revolutionized healthcare allowing clinicians the ability to treat life-threatening infections and to prevent infections following life-saving surgery. Unfortunately, antibiotic overuse results in antibiotic resistant bacteria and unnecessary adverse events including Clostridioides difficile infections (CDI). Current data demonstrates that antibiotic resistant bacteria and CDI annually kill up to 150,000 and 29,000 Americans, respectively. Surgical antibiotic prophylaxis is a common area for unnecessary antibiotic use among children. Recent CDC surgical site infection (SSI) guidelines and the AAP Choosing Wisely Campaign recommend no postoperative antibiotic prophylaxis for procedures considered low risk for an SSI. A significant gap exists on the best interventions for antimicrobial stewardship programs (ASPs) and surgeons to de- implement (eliminate) unnecessary postoperative antibiotic prophylaxis in children. Goal: To determine and test two evidence-based implementation strategies to de-implement unnecessary postoperative antibiotic use in children while assessing important clinical outcomes including SSI and CDI. Methods: First, we will develop evidence-based de-implementation strategies guided by the i-PARIHS framework (Integrated Framework for Promoting Action on Research Implementation in Health Services). Based on preliminary data from surgeon focus groups and current literature, standard order set review and modification (control intervention) will be implemented in 9 Children's hospitals that are members of both the SHaring Antimicrobial Reports for Pediatric Stewardship (SHARPS) and the National Surgical Quality Improvement Program-Pediatric (NSQIP-P). Utilizing the iPARIHS framework to understand the key factors involved with implementation, an enhanced ASP facilitation intervention will then be implemented. We will study the impact of these interventions utilizing a stepped-wedge design that will sequentially deliver the facilitation intervention over time to all hospitals. These interventions will be implemented and implementation outcomes (e.g. penetration) will be assessed utilizing established ASPs from the SHARPS collaborative, a large national collaborative dedicated to improving antibiotics in children. Clinical outcomes (e.g. postoperative antibiotic use, SSI, CDI) will be assessed using data collected at each hospital by NSQIP-P. Innovation and Impact: This study is innovative and impactful because it will: 1) combine expertise from surgeons, antimicrobial stewards and implementation scientist to develop theory based strategies to improve antibiotic use; 2) assess the impact of these strategies on surgeries in children, an underrepresented group; 3) rigorously test two interventions utilizing a stepped-wedge design; 4) collect clinical outcomes (e.g. antibiotic use, SSI, CDI) important to ASPs and surgeons; 5) collect implementation outcomes that will inform the dissemination of the strategies to other hospitals; and 6) synergy between 2 large collaboratives (SHARPS & NSQIP) that will enhance pediatric ASPs and improve the care of children requiring surgical procedures.