Reducing Antimicrobial Use Associated with Ventilator Associated Pneumonia and Ca

描述（由研究者提供）：促进合理抗生素使用的干预措施可减少总体抗菌药物使用，增强患者安全性，即患者在最合适的时间内以合适的剂量接受最佳药物，并减少抗菌药物耐药性。该项目的目标是开发、实施和评估用于诊断和治疗呼吸机相关性肺炎（VAP）和导管相关性尿路感染（CAUTI）的算法，以减少不适当的抗菌药物使用并提高患者的预后。我们建议通过开发一种系统的方法来优化VAP和CAUTI在三个关键时间点的抗菌药物使用决策：1)最初怀疑感染的时间，2)微生物学数据可用性可以缩小抗生素谱或停用抗生素的时间，以及3)决定治疗持续时间的时间。为了确定目前VAP和CAUTI的抗菌药物使用模式，我们将收集基线数据，以确定与这些感染相关的不适当抗菌治疗的程度。为了优化VAP的抗菌药物使用，我们将开发和实施诊断和治疗算法，为临床决策提供循证方法。我们将在五个icu中实施不同的方法来促进对这些算法的遵守，并比较它们在减少不适当使用抗菌药物方面的功效。研究的方法包括通过使用微型支气管肺泡灌洗技术获得下呼吸道样本进行定量培养，抗菌药物管理干预，以及使用抗生素自动停药令来影响治疗时间，从而增强诊断。对于CAUTI，我们将实施一项介入计划，旨在强调去除不必要的导管和适当使用抗生素的重要性。干预措施的组成部分将包括制定细菌和真菌病的管理算法和导管取出指南，并通过口袋卡和海报传播这些材料，以及向个别医生反馈导管和抗菌素的适当使用，并向护士反馈其单位中可能存在不必要导管的患者。VAP和CAUTI研究将采用准实验研究设计来评估这些干预措施的影响。我们将比较干预后抗菌素使用和导管使用的基线率。我们还将分析VAP和CAUTI研究的患者结果；我们将评估基线期和干预期各研究单位的住院时间、死亡率、住院费用、耐药性出现率、艰难梭菌病的发生率以及MRSA和VRE的获得率。我们假设，这种方法将加强对VAP和CAUTI抗生素的适当使用，并通过减少抗生素过度使用的已知后遗症来改善患者的预后。

DESCRIPTION (provided by investigator): Interventions to promote rational antibiotic use can lead to decreased overall antimicrobial use, enhanced patient safety in that patients receive the best agent at the right dose for the most suitable time period, and decreased antimicrobial resistance. The goals of this project are to develop, implement and evaluate algorithms for both the diagnosis and treatment of ventilator-associated pneumonia (VAP) and catheter- associated urinary tract infections (CAUTI) that reduce inappropriate antimicrobial use and enhanced patient outcomes. We propose to do this by developing a systematic approach to optimize decision making regarding antimicrobial usage for VAP and CAUTI at three critical time points: 1) the time of initial suspicion of infection, 2) the time when the availability of microbiological data enable narrowing the antibiotic spectrum or stopping antibiotics, and 3) the time at which duration of therapy is decided. To determine the current patterns of antimicrobial use for VAP and CAUTI we will collect baseline data to establish the extent of inappropriate antimicrobial therapy associated with these infections. To optimize antimicrobial usage for VAP, we will develop and implement diagnostic and treatment algorithms that provide evidence-based approaches for clinical decision making. We will implement different approaches to facilitate adherence to these algorithms in five ICUs and compare their efficacy in reducing inappropriate antimicrobial use. Approached to be studied include enhancing diagnosis by using the mini-brochoalveolar lavage technique to obtain lower respiratory samples for quantitative culture, antimicrobial stewardship interventions, and use of automatic stop orders for antibiotic to impact duration of therapy. For CAUTI, we will implement an interventional program designed both to emphasize the importance of removing unnecessary catheters and to use antibiotics appropriately. Components of the intervention will include development of algorithms for management of bacteriuria and funguria and guidelines for catheter removal and dissemination of these materials via pocket cards and posters as well as feedback both to individual physicians about appropriate use of catheters and antimicrobials and to nurses regarding patients on their units with potentially unnecessary catheters. A quasi-experimental study design will be used in both the VAP and CAUTI studies to evaluate the impact of these interventions. We will compare the baseline rates of antimicrobial use and catheter use to those after the intervention. We will also analyze patient outcomes in both the VAP and CAUTI studies; we will assess length of stay, mortality, hospital costs, rates of emergence of resistance, rates of Clostridium difficile disease and rates of acquisition of MRSA and VRE in the study units during the baseline and intervention periods. We hypothesize that this approach will enhance appropriate use of antimicrobials for both VAP and CAUTI and improve patient outcomes by reducing the known sequelae of antimicrobial overuse.