A Randomized Controlled Trial of a Diagnostic Stewardship Intervention to Reduce Inappropriate Antibiotic Use for Urinary Tract Infections in Primary Care

摘要 尿培养是美国门诊最常见的微生物检测方法。 不幸的是，收集过程中的污染很普遍，并破坏了测试的准确性，导致不正确 诊断、不必要的治疗、浪费的实验室资源和膨胀的成本。不必要的抗生素 治疗增加了产生抗菌素耐药性的风险，这是对患者最严重的威胁之一 和公共卫生。我们之前发现，从女性和女性身上收集的1265种尿液培养物中，有一半以上 两家初级保健诊所的男性受到了污染。先前的试验试图减少尿液污染 使用患者教育的结果好坏参半。然而，这些先前的研究没有包括利益相关者 在此之前，没有进行试点研究，这是制定干预措施过程中的一个关键步骤。 在我们进行有效的干预之前，受污染的样本将继续产生毫无意义的结果，引发 过度使用抗生素，并抬高成本。该项目的总体目标是提高 尿液诊断检测，从而进一步加强门诊护理环境中的抗生素管理。我们将创建一个 新颖的患者教育干预措施，纳入利益相关者的意见并解决先前确定的问题 对适当的中游清洁捕获尿样采集的障碍。关键障碍包括竞争护理 优先事项，病人的语言障碍，糟糕的健康素养，以及护士和医务助理对 讨论基本的解剖细节。为了解决这些障碍，我们的英文动画视频和图片传单 西班牙语将为女性和男性提供收集尿液的循序渐进的指导。内容和 我们将与对这一进程至关重要的利益攸关方合作，制定我们的干预方案： 病人、护士和医疗助理。拟议项目的总体目标是设计和测试 减少不同就诊人群尿液污染的双语教育干预 初级保健诊所网。在目标1(干预开发)中，我们将反复开发一种教育 使用患者咨询委员会、护士和医务人员的意见进行干预(教学视频和传单) 助理。视频和传单将为患者提供收集尿样的循序渐进的指导。在……里面 目标2(试点研究)，评估和改进干预措施的可接受性、适当性和可行性 使用混合方法，包括定量调查和定性访谈 利益相关者。在目标3(随机对照试验)中，我们将测试我们患者教育的有效性 减少与尿液培养相关的尿液污染和抗生素使用的干预措施。建议数 这项研究意义重大，因为它将开发一种干预措施，以减少尿液培养的污染。这个 拟议的研究具有创新性，因为它采用了以利益相关者为中心的方法。如果成功，这将是 干预可以传播到其他临床环境，在这些环境中，尿培养污染会导致抗生素 过度使用，包括急诊科和长期护理机构。

Abstract Urine culture is the most common microbiological test in the outpatient setting in the United States. Unfortunately, contamination during collection is prevalent and undermines test accuracy, leading to incorrect diagnosis, unnecessary treatment, wasted laboratory resources, and inflated costs. Unnecessary antibiotic treatment increases the risk of developing antimicrobial resistance, one of the most serious threats to patients and public health. We previously found that more than half of 1,265 urine cultures collected from women and men in two primary care clinics were contaminated. Prior trials that attempted to reduce urine contamination using patient education had mixed results. However, these prior studies did not include stakeholder engagement and were not preceded by pilot studies, a critical step in the process of intervention development. Until we have an effective intervention, contaminated samples will continue to give meaningless results, trigger undue antibiotic use, and inflate costs. The overarching goal of this project is to improve the accuracy of urinary diagnostic testing, thus furthering antibiotic stewardship in ambulatory care settings. We will create a novel patient education intervention that incorporates stakeholder input and addresses previously identified barriers to proper midstream clean-catch urine sample collection. Key barriers include competing nursing priorities, patient language barriers, poor health literacy, and reticence of nurses and medical assistants to discuss essential anatomic details. To address these barriers, our animated video and pictorial flyer in English and Spanish will provide step-by-step guidance for urine collection for women and men. The content and presentation of our intervention will be developed in collaboration with stakeholders central to this process: patients, nurses and medical assistants. The overall objective of the proposed project is to design and test a bilingual educational intervention to reduce urine contamination in a diverse patient population visiting safety net primary care clinics. In Aim 1 (intervention development), we will iteratively develop an educational intervention (instructional video and flyer) with input from a patient advisory board, nurses, and medical assistants. The video and flyer will provide step-by-step guidance to patients for collecting a urine sample. In Aim 2 (pilot study), we will assess and improve the intervention’s acceptability, appropriateness and feasibility using a mixed methods approach that includes a quantitative survey and qualitative interviews with stakeholders. In Aim 3 (randomized controlled trial), we will test the effectiveness of our patient education intervention at reducing urine contamination and antibiotic use associated with urine cultures. The proposed research is significant because it will develop an intervention to reduce contamination of urine cultures. The proposed research is innovative because it uses a stakeholder-centered approach. If successful, this intervention can be disseminated to other clinical settings in which urine culture contamination drives antibiotic overuse, including emergency departments and long-term care settings.