Optimizing Bacteriuria Management in Veterans with Spinal Cord Injury

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Candidate: Dr. Felicia Skelton completed medical school at Baylor College of Medicine (BCM), residency in rehabilitation medicine at the University of Washington, serving as chief resident, and clinical fellowship in spinal cord injury (SCI) medicine at BCM. She is a current health services R&D (HSR&D) post-doctoral fellow at the Center for Innovations in Quality, Effectiveness and Safety (IQuESt) at the Michael E. DeBakey VA Medical Center (MEDVAMC) in Houston, TX. She has four first-authored publications, one submitted manuscript and two pending manuscripts. She is dedicated to a career as a clinician scientist, and as a Black female, an ideal candidate for the Historically Black College or University (HBCU) Research Scientist Training Program. Career Development and Goals: During this award period Dr. Skelton will obtain the necessary epidemiologic, qualitative methods, database analysis and implementation science skills to become an independently-funded clinician scientist exploring optimal health care delivery and outcomes for Veterans with SCI. This will be achieved through completion of coursework leading to a masters in clinical investigation from BCM, as well as other targeted educational opportunities developed by her diverse group of mentors and advisors. Environment: IQuESt and MEDVAMC are the ideal settings to complete this research, as the premiere HSR center in the Southwest and the one of the largest SCI centers in the nation, serving over 450 Veterans in the outpatient setting annually, respectively. Dr. Skelton has the support of clinical, research, administrative and patient advocacy leadership both locally and nationally for this project. Research: Bacteriuria, ether asymptomatic (ASB) or symptomatic urinary tract infection (UTI) is common in persons SCI. Current Veterans Health Administration (VHA) guidelines recommend a screening urine culture for every Veteran with SCI during their annual evaluation, even when symptomatic, which is contrary to other national guidelines. Our preliminary data suggest that a positive urine culture (even without signs or symptoms of infection) drives antibiotic use. As the clinical outcomes of the annual exam testing have not been explored, we theorize some Veterans are receiving antibiotics unnecessarily. The negative consequences of antibiotic overuse and antibiotic resistance are well documented, and have a national and even global focus. This study will develop an intervention aimed to educate stakeholders on evidence-based management of ASB and UTI, and guide antibiotic stewardship in this high-risk population. Aim 1 will identify patient, provider, and facility factors driving bacteriuria testing and subsequent antibiotic use after the SCI annual evaluation using qualitative interviews and quantitative surveys. Aim 2 will use national VHA databases to identify the predictors of urine testing and subsequent antibiotic use during the annual examination, and compare the clinical outcomes of those who received antibiotics to those who did not. Aim 3 will use the information gathered from the previous aims to develop the “Test Smart, Treat Smart” intervention, a combination of patient and provider education and resources that will help all stakeholders have informed conversations about urine testing and antibiotic use; feasibility will be tested at a single site. The next step wil be to refine the intervention and test its feasibility and effectiveness at multiple sites, with VA merit review funding, as well as guiding policy reform surrounding this common, but burdensome condition.