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/基本原理：抗菌素管理作为打击抗生素传播的一种手段- 无论是在VHA内部还是外部，耐药细菌都已成为国家优先事项。本IIR项目侧重于 通过减少对无症状菌尿(ASB)的不适当使用来提高退伍军人的安全性，a 在急性和长期护理中导致过度使用抗菌剂的非常常见的情况。我们进行了一次 成功的干预措施减少了ASB患者尿培养和抗生素使用指南不一致的情况。这 单点干预，题为“踢管相关性尿路感染：无膝-- 不必要的ASB筛查减少了71%，减少了不必要的治疗 在一个大型而复杂的退伍军人医疗中心，ASB减少了75%。近期进行的UTI用药评价 退伍军人管理局抗菌特别工作组(ASTF)的调查显示，迫切需要我们的干预，因为57%的 作为尿路感染(使用抗生素)治疗的1,219种尿液培养实际上是ASB。我们的工作是创新的，因为我们 解决导致过度使用抗生素的认知偏见，鼓励更慎重的选择。项目 目标：该项目的目标是促进可扩展版本的踢腿的实施 CAUTI在四个地理位置不同的退伍军人管理局开展活动，同时评估 抗菌管理干预对成功和可持续性至关重要。我们的项目团队和我们的 业务伙伴将提供专门知识和外部便利，同时在 设施级别将由负责抗菌管理的当地人员执行。两大主打 干预工具是(1)基于证据的算法，将指南提炼成简化的临床 (2)基于病例的审计和反馈，以培训临床医生使用该算法。干预措施是 针对急性和长期护理的提供者，目标是减少对和 ASB的治疗适用于所有患者和居民，而不仅仅是那些使用导尿管的患者。目标1是确定 指南的障碍.介入时导管相关性菌尿管理的推荐实施规程 并召集当地的实施团队。目标2是实现和评估可伸缩版本的 在四个VA设施中进行踢腿CAUTI干预，使用另外四个地点作为同期对照。 我们将测量尿液培养顺序、抗生素使用和梭状芽胞杆菌感染的临床结果。 使用公司数据仓库和审查每个站点的选定图表进行艰难菌感染。2B：我们会的 研究干预剂量与临床结局的关系。目标3：评估 通过预算影响分析干预措施的经济影响。方法：我们的干预将 包括每个设施入口时段，该时段由中央领导的与本地站点冠军的电话组成，且 基线调查。基于案例的审计和反馈将在入口期后在给定的地点开始，并 持续12个月。我们将按季度错开推出四项干预措施 网站。三年的项目时间表允许项目启动3个月，每个站点上线3个月，12 积极干预措施的实施需要几个月的时间，每个地点都有一个可持续性阶段。我们对AIM的分析 2A将使用来自公司数据仓库的临床结果数据来执行中断的时间序列 分段回归分析。对Aim 2B的分析将使用回归模型来评估是否有更多 完整的实施与更好的临床结果相关，使用关键的过程措施 实施组件。预算影响分析将从以下方面评估干预的节省和成本 VHA视角。在整个项目中，我们每年将与我们的运营合作伙伴进行两次通话。 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，在过去的一年里为这项提案的设计提供了建议和指导 并将从项目启动之时起继续参与，以帮助规划全国传播。