A Cluster Randomized Trial of Two Implementation Strategies to Disseminate a Successful Antibiotic Stewardship Intervention

不必要的抗生素使用对公众健康和每个患者都是一种威胁。减少不必要的开支 抗生素的使用或管理对于保持抗生素现在和未来的有效性至关重要。 几代人。最近的国家授权强调了建立抗生素管理的重要性 医院和疗养院的计划，但我们不知道实施抗生素的最佳方式 在大范围和现实世界条件下的管理。无症状性菌尿(ASB)，一种 患者有细菌定植在膀胱内而没有任何泌尿症状，是非常常见的情况 在住院病人和养老院居民中。ASB经常与尿路感染(UTI)混淆， 但ASB与UTI不同，在临床上微不足道，不应使用抗生素治疗。不必要的筛查 ASB的治疗和治疗是医院和疗养院不必要使用抗生素的主要驱动因素。我们 已经制定了有效的干预措施，以实施循证抗生素管理指南 ASB通过连续的研究项目。我们现在建议使用此工具来评估以下各项的相对优点 两种大规模实施战略，一种虚拟协作学习(有小组学习机会) 与技术援助(可根据要求提供个性化支持)相比。这两个实现 这些策略被广泛使用，但对它们的有效性进行的随机对照试验 1~2成熟。在这项试验中，我们将测试这两种实施策略，并观察临床结果。我们会 将同时提供医院和疗养院护理的退伍军人医院随机分配到两种实施方案之一 战略。将与退伍军人管理局反微生物管理工作队合作招聘退伍军人医院 (ASTF)，一个致力于在所有退伍军人事务部扩大抗生素管理活动的组织。我们驻扎在 我们关于学习健康周期的计划，在这个周期中，我们与一个 带领每个医院的人员产生知识，从而减少尿液培养订单和天数 抗生素的使用，以及行为的改变会带来性能的提高。我们的五年计划将需要 大约20-25家医院通过一个周期的变化，同时建设能力，使周期在之后继续 项目结束了。这项工作将通过三个目标进行：(目标1)评估环境和资源 实施。(目标2)将虚拟学习协作与技术援助进行比较 整群随机试验中的实施策略。主要结果是交付所需的分钟数 但我们也将通过减少尿培养和抗生素使用来评估有效性。我们 将通过定性的方式探讨利益相关者对实施战略的满意度和可持续性 方法：研究方法。(目标3)通过预算影响评估执行战略所涉费用 分析。通过这次试验，我们将增加有关使用大规模实施策略和 使抗生素管理计划在现实世界中取得成功。

Unnecessary antibiotic use is a threat to public health and to each individual patient. Reducing unnecessary use, or antibiotic stewardship, is essential to preserving the effectiveness of antibiotics now and for future generations. Recent national mandates underscore the importance of establishing antibiotic stewardship programs in hospitals and nursing homes, but we do not know the best way to implement antibiotic stewardship on a wide scale and under real-world conditions. Asymptomatic bacteriuria (ASB), a condition in which the patient has bacteria colonizing the bladder without any urinary symptoms, is very common condition in hospitalized patients and nursing home residents. ASB is often confused with urinary tract infection (UTI), but ASB, unlike UTI, is clinically insignificant and should not be treated with antibiotics. Unnecessary screening for and treatment of ASB is a major driver of unnecessary antibiotic use in hospitals and nursing homes. We have developed an effective intervention to implement evidence-based antibiotic stewardship guidelines for ASB through successive research projects. We now propose to use this tool to assess the relative merits of two large-scale implementation strategies, a virtual learning collaborative (with group learning opportunities) compared to technical assistance (individualized support available on request). These two implementation strategies are widely used, but randomized, controlled trials of their effectiveness compared to each other are rare. In this trial we will test the two implementation strategies and observe clinical outcomes. We will randomize VA hospitals that provide both hospital and nursing home care to one of the two implementation strategies. VA hospitals will be recruited in partnership with the VA Antimicrobial Stewardship Task Force (ASTF), an organization dedicated to expanding antibiotic stewardship activities across all VA sites. We base our plans on a learning health cycle, in which we share data about urine culture orders and antibiotic use with a lead person at each hospital to generate knowledge, which leads to fewer urine culture orders and fewer days of antibiotics, and behavior change leads to improved performance. Our five-year project will take approximately 20-25 hospitals through one cycle of change, while building capacity for cycles to continue after the project ends. The work will occur through three aims: (Aim 1) Assess context and resources for implementation. (Aim 2) Compare a virtual learning collaborative versus technical assistance as implementation strategies in a cluster randomized trial. The primary outcome is minutes spent in delivery of the intervention, but we will also assess effectiveness through decreased urine cultures and antibiotic use. We will explore stakeholder satisfaction with and sustainability of implementation strategies through qualitative methods. (Aim 3) is to assess the cost implications of the implementation strategies through budget impact analysis. Through this trial, we will add to knowledge about using wide scale implementation strategies and making antibiotic stewardship programs successful in real-world settings.