OPTIMIZING ANTIBIOTIC USE IN LONG-TERM CARE

拟议研究的主要目的是确定在长期护理机构（LTCF）中管理老年人尿路感染（UTI）的临床算法是否可以减少LTCF中抗生素的总体使用。三个次要目的是：1）证明在LTCF中实施循证诊断和治疗临床算法的可行性，2）评估减少目标人群中UTI诊断测试和抗生素使用数量的安全性，3）评价在LTCF中采用拟议算法的过程。在LTCF中减少抗生素的使用将减少1）抗生素耐药性发展的可能性，2）药物不良反应和有害药物相互作用的可能性，3）与抗生素不当使用相关的重大成本。为了实现研究目标，将进行一项随机对照试验，将参与的LTCF随机分配到干预（临床算法）或对照组。开发了一种循证诊断和治疗算法，并根据在住宅LTCF工作的初级保健医生和护士的反馈进行了增强。本研究将采用定量和定性相结合的方法来评价实施临床算法的过程和结果。将使用随机匹配配对设计，其中在12对LTCF中的每一对中，将一对随机分配至干预（临床算法）。另一半将提供“常规”管理推定尿路感染。定量结果将包括1）针对泌尿系适应症开具的抗生素疗程比例，2）使用的抗生素疗程总数，3）订购的尿培养率，4）尿路感染的住院率，以及5）死亡率。在研究的前两个月，该算法将在干预家庭中进行试点测试。干预措施将通过电话会议和在职培训的方式予以采纳。 本研究的定性部分将是一项前瞻性病例研究，评价卫生服务干预措施（关于LTCF居民UTI抗生素使用的诊断和治疗算法）。该研究的这一部分将检查实施的难易程度和医疗保健提供者对诊断和治疗算法的满意度。使用标准抽样，两组受访者将接受采访，在参与LTCF（医疗主任，护理主任，感染控制人员）的主要临床管理人员，和护理人员谁将实施的算法。

The primary objective of the proposed study is to determine if a clinical algorithm for managing urinary tract infections (UTIs) in older adults in residential long-term care facilities (LTCFs) can reduce the overall use of antibiotics in LTCFs. Three secondary aims are 1) to demonstrate the feasibility of implementing evidence-based diagnostic and therapeutic clinical algorithms in LTCFs, 2) to assess the safety of reducing the number of diagnostic tests and antibiotic use for UTIs in the target population, 3) to evaluate the process of adopting the proposed algorithms in LTCFs. Reducing the use of antibiotics in LTCFs will reduce l) the potential for the development of antibiotic resistance, 2) the potential for adverse drug effects and harmful drug interactions, 3) significant costs associated with inappropriate use of antibiotics. To achieve the research goals, a randomized controlled trial with participating LTCFs randomized to either intervention (clinical algorithm) or control group will be conducted. An evidence-based diagnostic and a treatment algorithm was developed, augmented with feedback from primary care physicians and nurses working in residential LTCFs. The study will use a combined quantitative and qualitative approach to evaluate the process and outcomes of implementing the clinical algorithm. A randomized matched pair design will be used where, within each of the 12 pairs of LTCFs, one will be randomized to the intervention (clinical algorithm). The other half will provide "usual" management of presumptive urinary tract infections. Quantitative outcomes will include l) the proportion of antibiotic courses prescribed for urinary indications, 2) the total number of courses of antibiotics used, 3) rates of urine cultures ordered, 4) hospitalization rates for urinary tract infections, and 5) mortality rates. During the first two months of the study, the algorithm will be pilot tested in the intervention homes. Adoption of the intervention will be through both teleconferences and in-services. The qualitative component of this study will be a prospective case study evaluation of a health service intervention (diagnostic and treatment algorithms concerning antibiotic use for UTIs in residents of LTCFs). This component of the study will examine the ease of implementation and healthcare provider satisfaction with diagnostic and treatment algorithms. Using criterion sampling, two groups of respondents will be interviewed, key clinical administrators in the participating LTCFs (medical directors, directors of nursing, infection control officers), and nursing staff who will implement the algorithms.