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: 8527661
• 负责人: Jeffrey M Caterino
• 金额: $ 15.05万
• 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 2015-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8527661
• 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; 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。在五年内，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 居民会接触大量抗菌药物，但由于难以区分急性感染和定植，并且 LTCF 居民中抗生素处方不准确或不适当的可能性增加（例如，由于抗菌药物耐药性增加），因此 LTCF 居民中抗菌药物的使用往往不是最理想的。 急诊科 (ED) 是治疗 LTCF 居民感染感染的常见场所，尤其是病情最严重的居民。目前缺乏解决急诊科 LTCF 居民抗菌药物使用问题的综合计划。该研究的概念框架借鉴了有关抗菌药物管理计划 (ASP)、经验性抗生素治疗和 LTCF 感染控制指南的文献。 ASP 已在住院患者中成功实施，以改善抗菌药物处方实践和结果，从而减少耐药性和副作用。这项研究将其用途扩大到高危 ED 人群，目标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，才能诊断出急性感染，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 本身使用而制定的，尚未在急诊室或住院病人环境中进行研究。由于未能区分急诊室中的急性感染和定植可能会导致抗生素使用不当，因此在急诊室中验证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，主要由健康信息技术 (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 ASP 扩展到新的临床环境和人群。 大多数中度至重度 LTCF 患者在急诊室接受初步诊断并开始使用抗菌药物。为了改善对这一高危人群的护理，我们的总体目标是针对 ED LTCF 患者制定和实施基于健康​​信息技术 (HIT) 的抗菌药物管理计划 (ASP)，这将提高诊断的准确性和正确的抗菌药物处方。为了实现这一目标，我们将开展两个具有以下具体目标的项目： 具体目标 1（ED 观察）：制定急性感染的有效定义并确定 ED LTCF 患者的抗菌药物管理需求。 具体目标 2（ED 干预）：测试针对 ED-LTCF 患者实施基于健康​​信息技术 (HIT) 的 ASP 对急性感染诊断和治疗的效果。 对于具体目标 1，该项目（SA1：ED 观察性）将包括 ED LTCF 患者的前瞻性观察性队列研究。它将用于验证 ED LTCF 患者存在急性感染的定义（与定植不同），建立 ASP 干预需求的基线率，并开发为 ED LTCF 患者构建特定抗菌建议和 ASP 所需的数据。 对于具体目标 2，将进行一项前瞻性干预试验（SA 2：ED 干预），其中将设计并实施针对 ED LTCF 患者量身定制的 ASP 计划。此阶段将依靠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。它将包括诸如诊断 LTCF 患者急性感染的建议算法、按位点网格新开发的抗生素、患者特定的过去培养结果、患者肝肾功能的特定数据以及推荐剂量和处方限制等因素。结果将包括诊断的准确性、经验性抗生素的适当性以及 ASP 干预的持续需求。 职业发展计划将包括对进行这些研究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。它还将包括研究健康信息技术应用的重要组成部分，包括教学课程、在线课程和实践经验，以完成拟议的研究并为候选人提供进一步的学习定位。 根据所取得的结果，将有可能开发出经过验证且可重复的干预措施，以改善各种环境下的抗菌药物管理。拟议的项目和职业发展计划将为实现改善长期护理基金居民护理的最终目标迈出重要的第一步。