Antibiotic Spectrum Scoring to Measure Hospital-Level Antibiotic De-escalation

描述（由申请人提供）：在住院患者中使用早期，积极的广谱抗生素治疗是常见的。抗生素降级广义上是指停止使用活性谱超过必要范围的抗生素，或在患者病情稳定后改用窄谱治疗。尽管实践指南认可抗生素减少剂量，但有限的数据表征了抗生素减少剂量在实践中的应用。此外，研究人员主观地测量了抗生素的降级，这阻碍了医院之间降级率的比较，并阻碍了对可能解释医院间降级率差异的因素的评估。建议的目标包括：1)开发和验证表征抗生素相对细菌谱的度量，该度量可用于测量抗生素降级；2)将抗生素降级指标应用于患有医疗保健相关性肺炎（HCAP）的退伍军人队列，以便比较医院之间抗生素降级率；3)确定解释医院间抗生素降级率差异的因素。在目标1中，利用全国药房和实践抗生素降级的医师专家的德尔菲过程将：a)制定一个频谱评分指标来测量抗生素活性的频谱；b)根据基于评分指标的标准定义抗生素降级。德尔菲过程输出将应用于开发一个规则，对基于电子医疗记录的抗生素给药数据中的抗生素降级状态进行分类。将评估内部效度，并通过比较临床医生的降级判断和基于规则的降级判断来校准降级规则以优化专家意见的预测。在目标2中，抗生素降级规则将应用于全国124家VAMC住院机构中因医疗保健相关肺炎（HCAP）入院的患者的回顾性队列。抗生素降级率将在医院一级表示，根据设施特征（如规模和复杂程度）分层。在目标3中，将开发抗生素降级概率的混合效应多变量logistic模型，以更好地了解医院之间降级率的可变性。调整在验证模型中选择的协变量将允许评估抗生素降级和细菌培养率之间的关联。这项拟议的研究为理解细菌谱、培养实践和治疗决策（如抗生素降级）之间的关系提供了基础，具有显著的改善健康的潜力。

DESCRIPTION (provided by applicant): The use of early, aggressive broad-spectrum antibiotic therapy is common in hospitalized patients. Antibiotic de-escalation broadly refers to the discontinuation of antibiotics that are providing a spectrum of activity greater than necessary, or switching to narrower spectrum therapy once a patient is stable. Despite endorsement of antibiotic de-escalation by practice guidelines, limited data characterize the application of antibiotic de-escalation in practice. Furthermore, researchers have subjectively measured antibiotic de-escalation, which has prevented comparison of de-escalation rates between hospitals, and hindered evaluation of factors that may explain inter-hospital variability in de-escalation rates. Proposal aims include: 1) development and validation of a metric that characterizes the relative bacterial spectrum of antibiotics which can be used to measure antibiotic de-escalation; 2) application of the de- escalation metric to a cohort of veterans with health care associated pneumonia (HCAP) allowing comparison of antibiotic de-escalation rates between hospitals; and 3) identification of factors that explain inter-hospital variability in antibiotic de-escalation rates. In aim 1 a Delphi process utilizing a national pool of pharmacy and physician experts who practice antibiotic de- escalation will: a) develop a spectrum scoring metric to measure spectrum of antibiotic activity; and b) define antibiotic de-escalation according to criteria based on the scoring metric. The Delphi process output will be applied to develop a rule to classify antibiotic de-escalation status in electronic medical records-based antibiotic administration data. Internal validity will be assessed and calibration of the de-escalation rule to optimize the prediction of expert opinion will be accomplished by comparing de-escalation judgments of clinicians to rule based de- escalation. In aim 2, the antibiotic de-escalation rule will be applied to a retrospective cohort of patients admitted with health care associated pneumonia (HCAP) in 124 VAMC inpatient facilities nationwide. Antibiotic de-escalation rates will be expressed at the hospital level, stratified based on facility characteristics such as size and complexity level. In aim 3, a mixed- effects multivariable logistic model of antibiotic de-escalation probability will be developed to better understand the variability in de-escalation rates between hospitals. Adjusting for covariates selected in the validated model will allow associations between antibiotic de- escalation and bacterial culturing rates to be evaluated. The proposed research has significant potential to improve health by providing a basis for understanding relationships between bacterial spectrum, culturing practices, and treatment decisions such as antibiotic de-escalation. PUBLIC HEALTH RELEVANCE: Antibiotic de-escalation refers to the discontinuation of antibiotics that are providing a spectrum of bacterial activity greater than necessary to prevent the development of antibiotic resistance. This study seeks to develop a method for determining if antibiotic de-escalation has been practiced, measuring antibiotic de-escalation rates between hospitals, and determining factors that positively influence antibiotic de-escalation. The proposed research has significant potential to improve health by providing a basis for understanding relationships influencing antibiotic de- escalation practices.