Less is More: Improving Antimicrobial Stewardship for Asymptomatic Bacteriuria

项目背景/原理：抗菌药物管理是对抗抗生素传播的一种手段- 耐药细菌已成为国家的优先事项，无论是在VHA内外。这个IIR项目的重点是 通过减少无症状菌尿（ASB）的抗菌药物不当使用，提高退伍军人的安全性， 在急性和长期护理中导致抗生素过度使用的非常常见的情况。我们进行了一项 成功干预，以减少ASB的尿培养和抗生素指南不一致的顺序。这 单部位干预，标题为“踢导管相关尿路感染：无膝关节- Jerk抗生素运动，”减少了71%的不必要的ASB筛查和不必要的 在一个大型复杂的退伍军人医疗中心，ASB提高了75%。最近进行的UTI药物使用评估 VA抗菌药物管理工作组（ASTF）的研究表明，迫切需要我们的干预，因为57%的 1，219例被视为UTI（使用抗生素）的尿培养物实际上是ASB。我们的工作是创新的， 解决导致过度使用抗生素的认知偏见，并鼓励更慎重的选择。项目 目标：该项目的目标是促进Kicking的可扩展版本的实施 在四个地理位置不同的VA设施中开展了一项活动， 抗生素管理干预对于成功和可持续性至关重要。我们的项目团队和 业务伙伴将提供专门知识和外部便利， 设施级将由负责抗菌管理的当地人员执行。两个主要 干预工具是（1）一种基于证据的算法，将指南提炼成一个精简的临床 路径，以及（2）基于病例的审核和反馈，以培训临床医生使用该算法。述干预 针对急性和长期护理的提供者，目标是减少不适当的筛查， 所有患者和居民的ASB治疗，而不仅仅是那些导尿管。目标1：确定 介入治疗时导管相关菌尿管理指南推荐实践的障碍 并组建当地实施团队。目标2是实现和评估一个可扩展版本的 在四个VA设施中进行Kicking CITTI干预，使用另外四个站点作为同期对照。 2a：我们将测量尿培养、抗生素使用和梭菌病发作的临床结局 使用公司数据仓库和审查每个研究中心的选定图表。2B：我们会的 研究干预剂量与临床结果之间的关系。目标3：评估 通过预算影响分析干预的经济影响。方法：我们的干预将 包括由中央领导的与当地现场负责人的电话联系组成的每个设施的进入阶段， 基线调查。基于案例的审计和反馈将在爬坡期后开始， 持续十二个月。我们将按季度错开四项干预措施的推出 网站.三年的项目时间表允许3个月的项目启动，3个月的坡道在每个网站，12 每个地点都有一个可持续发展阶段。我们对Aim的分析 2A将使用公司数据仓库中的临床结局数据进行中断时间序列分析， 分段回归分析对目标2B的分析将使用回归模型来评估是否有更多的 完整的实施与更好的临床结果相关，使用关键的过程测量 执行部分。预算影响分析将评估干预措施的节余和费用， VHA的观点。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电话联系。 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，在过去的一年里建议并指导了这一提案的设计 并将从项目启动之时起继续参与，以帮助规划国家传播工作。

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.