Antimicrobial stewardship for long term care facility patients: in the ED

长期护理机构患者的抗菌药物管理：在急诊室

• 批准号: 8724318
• 负责人: Jeffrey M Caterino
• 金额: $ 15.38万
• 依托单位: OHIO STATE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-09-30 至 2016-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8724318
• 关键词: Accident and Emergency department; Acute; Address; Adverse effects; Aging; Agreement; Algorithms; Antibiotic Therapy; Antibiotics; Antimicrobial Resistance; Biology of Aging; Caring; Chronic; Clinical; Clinical Research; Cohort Studies; Data; Development Plans; Diagnosis; Diagnostic; Dose; Educational Curriculum; Elderly; Emergency Department Physician; Ensure; Failure; Formularies; Functional disorder; Goals; Guidelines; Hepatic; Infection; Infection Control; Information Systems; Inpatients; Intervention; Kidney; Lead; Literature; Long-Term Care; Morbidity - disease rate; Nursing Homes; Online Systems; Outcome; Patients; Pharmacists; Phase; Physicians; Population; Positioning Attribute; Public Health; Recommendation; Renal function; Research; Research Personnel; Resistance; Resources; Site; Techniques; Testing; Time; Work; antimicrobial; antimicrobial drug; base; career development; clinically significant; combat; design; diagnostic accuracy; experience; health information technology; high risk; improved; intervention program; meetings; microorganism; mortality; new technology; novel; prevent; programs; prospective; public health relevance; tool; treatment site

This proposal represents a five-year curriculum and research plan designed to transition the candidate to an independent investigator in clinical research. During the five years the candidate will complete coursework relevant to the project and will execute the research plan. Infection is one of the leading causes of morbidity and mortality in residents of long-term care facilities (LTCFs). As a result, LTCF residents are exposed to large numbers of antimicrobial agents but use of antimicrobials in LTCF residents is often suboptimal due to difficulty in distinguishing acute infection from colonization and due to the increased likelihood of inaccurate or inappropriate antibiotic prescribing in LTCF residents (for example due to increased presence of antimicrobial resistance). The emergency department (ED) is a common site for treatment of infection in LTCF residents, particularly those most severely ill. Comprehensive programs to address problems of antimicrobial use for LTCF residents in the ED are currently lacking. The conceptual framework for the study is borrowed from the literature on antimicrobial stewardship programs (ASPs), empiric antibiotic treatment, and LTCF infection control guidelines. ASPs have been successfully implemented in inpatient populations to improve antimicrobial prescribing practices and outcomes with resulting decreases in resistance and side effects. This study expands their use to a high-risk ED population with the goal of incorporating both improved diagnostic accuracy and empiric antimicrobial prescribing. Current LTCF infection control guidelines recommend that acute infection be diagnosed in LTCF patients only when they meet specific criteria in order to differentiate active infection from colonization and prevent overuse of antibiotics. These guidelines were developed for use in the LTCFs themselves and have not yet been studied in the ED or inpatient settings. As failure to differentiate acute infection from colonization in the ED may lead to inappropriate antibiotic use, validating diagnostic guidelines in the ED setting is an important step towards appropriate antimicrobial stewardship. Another key concept of these studies is efficiency, driven primarily by Health Information Technology (HIT). In an era of limited resources utilizing pre-existing HIT systems and information will allow extension of ASPs to novel clinical settings and populations. The majority of moderately- to severely-ill LTCF patients receive their initial diagnosis and initiation of antimicrobials in the ED. To improve care of this high-risk population, our overall objective is to develop and implement an antimicrobial stewardship program (ASP) based on use of health information technology (HIT) for ED LTCF patients that will result in improvements both in accuracy of diagnosis and in correct antimicrobial prescribing. To achieve this objective, we will conduct two projects with the following Specific Aims: Specific Aim 1 (ED-observational): To develop a validated definition for acute infection and to identify antimicrobial stewardship needs in ED LTCF patients. Specific Aim 2 (ED-interventional): To test the effect of implementing a health information technology (HIT)-based ASP for ED-LTCF patients on diagnosis and treatment of acute infection. For Specific Aim 1, the project (SA1: ED-observational) will consist of a prospective observational cohort study of ED LTCF patients. It will be used to validate definitions for the presence of acute infection in ED LTCF patients (as distinct from colonization), establish baseline rates of need for ASP interventions, and develop data required to construct specific antimicrobial recommendations and an ASP for ED LTCF patients. For Specific Aim 2, a prospective, interventional trial (SA 2: ED-interventional) will be conducted in which an ASP program tailored to ED LTCF patients will be devised and implemented. This phase will rely on the use of a real-time web-based health information technology (HIT) decision support tool to provide the intervention. It will include factors such as the suggested algorithms for diagnosing an acute infection in LTCF patients, a newly developed antibiotic by site grid, patient specific past culture results, patient specific data on hepatic and renal function with recommended dosing, and formulary restrictions. Outcomes will include accuracy of diagnosis, appropriateness of empiric antibiotics, and ongoing requirements for ASP intervention. The career development plan will include didactic work in advanced biostatistical techniques useful in conducting these studies. Coursework will also be undertaken in specific aspects of aging studying biology of aging and challenges in aging research. It will also include a significant component studying the application of health information technology including didactic coursework, online coursework, and practical experience to allow completion of the proposed research and position the candidate for further studies. Based on the results achieved, it will be possible to develop validated and reproducible interventions to improve antimicrobial stewardship in a variety of settings. The proposed projects and career development plan will provide an important initial step towards the ultimate goal of improving care for residents of LTCFs.

该提案代表了一项为期五年的课程和研究计划，旨在将候选人转变为临床研究的独立研究者。在五年的时间里，候选人将完成与项目相关的课程，并执行研究计划。 感染是长期护理机构（LTCF）居民发病和死亡的主要原因之一。因此，LTCF居民暴露于大量的抗菌剂，但由于难以区分急性感染与定植以及LTCF居民中不准确或不适当的抗生素处方的可能性增加（例如，由于抗菌药物耐药性的增加），LTCF居民中抗菌剂的使用通常不是最佳的。 急诊科（艾德）是LTCF居民感染治疗的常见场所，特别是那些病情最严重的患者。目前缺乏解决艾德地区LTCF居民抗菌药物使用问题的综合方案。该研究的概念框架是从抗菌药物管理计划（ASP），经验性抗生素治疗和LTCF感染控制指南的文献中借来的。ASP已在住院人群中成功实施，以改善抗菌药物处方实践和结果，从而降低耐药性和副作用。本研究将其应用扩展到高危艾德人群，目的是提高诊断准确性和经验性抗菌药物处方。目前的LTCF感染控制指南建议，只有当LTCF患者符合特定标准时，才能诊断急性感染，以区分活动性感染和定植，并防止过度使用抗生素。这些指南是为LTCF本身而制定的，尚未在艾德或住院患者中进行研究。由于未能区分艾德中的急性感染与定植可能导致抗生素使用不当，因此验证艾德环境中的诊断指南是实现适当抗菌药物管理的重要一步。这些研究的另一个关键概念是效率，主要由卫生信息技术（HIT）驱动。在资源有限的时代，利用现有的HIT系统和信息将允许将ASP扩展到新的临床环境和人群。 大多数中度至重度LTCF患者在ED接受初步诊断并开始使用抗菌药物。为了改善这一高危人群的护理，我们的总体目标是开发和实施基于艾德LTCF患者健康信息技术（HIT）的抗菌药物管理计划（ASP），这将导致诊断准确性和正确的抗菌药物处方的改善。为了实现这一目标，我们将开展两个项目，具体目标如下： 具体目标1（ED-观察性）：制定急性感染的有效定义，并确定艾德LTCF患者的抗菌管理需求。 具体目标2（ED-介入）：测试对ED-LTCF患者实施基于健康信息技术（HIT）的ASP对诊断和治疗急性感染的影响。 对于特定目的1，该项目（SA 1：ED-观察性）将包括一项艾德LTCF患者的前瞻性观察性队列研究。它将用于验证艾德LTCF患者中急性感染的定义（与定植不同），确定ASP干预的基线需求率，并开发构建特定抗菌建议和艾德LTCF患者ASP所需的数据。 对于特定目标2，将进行一项前瞻性干预性试验（SA 2：ED-干预性），其中将设计并实施针对艾德LTCF患者的ASP计划。这一阶段将依赖于使用基于网络的实时健康信息技术（HIT）决策支持工具来提供干预。它将包括以下因素，如诊断LTCF患者急性感染的建议算法、按研究中心网格新开发的抗生素、患者特定既往培养结果、推荐剂量的患者特定肝肾功能数据以及处方集限制。结局将包括诊断的准确性、经验性抗生素的适当性和ASP干预的持续要求。 职业发展计划将包括在进行这些研究中有用的先进生物统计技术的教学工作。课程还将在衰老的具体方面进行，研究衰老生物学和衰老研究的挑战。它还将包括一个重要的组成部分，研究健康信息技术的应用，包括教学课程，在线课程和实践经验，以完成拟议的研究和定位候选人进一步研究。 根据所取得的结果，将有可能开发出经过验证的和可重复的干预措施，以改善各种环境中的抗菌药物管理。拟议的项目和职业发展计划将为实现改善对LTCF居民的护理的最终目标迈出重要的第一步。

项目成果

Discordance between patient report and chart review of risk factors for antimicrobial resistance in ED patients.

患者报告与 ED 患者抗菌药物耐药性危险因素图表审查之间存在不一致。

• DOI: 10.1016/j.ajem.2013.06.014
• 发表时间: 2013
• 期刊: The American journal of emergency medicine
• 作者: Caterino,JeffreyM;Graham,Lauren;King,Andrew;Hoppes,Tyler
• 通讯作者: Hoppes,Tyler

Accuracy of Current Diagnostic Criteria for Acute Bacterial Infection in Older Adults in the Emergency Department.

• DOI: 10.1111/jgs.14912
• 发表时间: 2017-08
• 期刊: Journal of the American Geriatrics Society
• 影响因子: 6.3
• 作者: Caterino JM;Leininger R;Kline DM;Southerland LT;Khaliqdina S;Baugh CW;Pallin DJ;Stevenson KB
• 通讯作者: Stevenson KB

Head Trauma from Falling Increases Subsequent Emergency Department Visits More Than Other Fall-Related Injuries in Older Adults.

• DOI: 10.1111/jgs.14041
• 发表时间: 2016-04
• 期刊: Journal of the American Geriatrics Society
• 影响因子: 6.3
• 作者: Southerland LT;Stephens JA;Robinson S;Falk J;Phieffer L;Rosenthal JA;Caterino JM
• 通讯作者: Caterino JM

Emergency department recidivism in adults older than 65 years treated for fractures.

因骨折接受治疗的 65 岁以上成人急诊室累犯。

• DOI: 10.1016/j.ajem.2014.05.005
• 发表时间: 2014
• 期刊: The American journal of emergency medicine
• 作者: Southerland,LaurenT;Richardson,DanielS;Caterino,JeffreyM;Essenmacher,AlexC;Swor,RobertA
• 通讯作者: Swor,RobertA

Emergency department and outpatient treatment of acute injuries in older adults in the United States: 2009-2010.

• DOI: 10.1111/jgs.12877
• 发表时间: 2014-07
• 期刊: Journal of the American Geriatrics Society
• 影响因子: 6.3
• 作者: Betz ME;Ginde AA;Southerland LT;Caterino JM
• 通讯作者: Caterino JM