Developing a novel antibiogram tool to improve empiric antibiotic prescribing in nursing homes

项目总结/摘要 不适当的抗生素使用是一个常见的问题，有助于不良药物事件和抗生素 养老院（NHs）。经验性抗生素选择决策在NHS中经常是次优的。 基于患者培养物的累积敏感性报告，称为细菌谱，是越来越多的工具， 用于改善NHS的经验性抗生素决策。然而，大多数国家卫生机构收集的培养物数量不足 允许创建可靠的设施特定的流程图，从而导致许多设施转向池化设施 电子邮件基于来自多个设施的组合培养数据的抗生素谱提高了 报告的敏感性估计，并准确地反映了区域抗生素耐药模式，但可能会出现 地方一级的敏感性模式的扭曲情况。因此，增加使用 合并的机构处方可能会恶化而不是改善NHS的经验性抗生素决策。 加权发病率综合征图（WISCA）是一种新的方法，更好地利用了 当培养结果缺乏时，可用的微生物数据。WISCA还以一种 可以减少临床医生的认知负荷。我们相信WISCA将被证明比传统的更可靠 结果表明，抗生素对NHS的经验性抗生素决定有更大的影响。本研究的目的是 开发一个用户友好的WISCA工具，将其与传统的图表进行比较，并为其开发一个工具包。 在国家卫生机构实施和评价。我们将通过以下具体目标实现这些目标： 在目标1中，我们将在四个州的82个NHS中进行前瞻性监测研究， 使用传统的遗传图和WISCA的易感性模式。现有研究NH培养数据将 从他们的参考实验室。将对两种电子表格格式的可靠性进行评估， 将估计单一和合并设施敏感性估计值之间的一致性。 在目标2中，我们将开发一个用户友好的WISCA格式，并从NH临床医生那里获得输入。由此产生的工具将是 使用模拟病例研究方法进行评估，其中300名NH临床医生将被要求完成几个 描述常见NH泌尿系统综合征的临床插图。受试者将被随机分配，以完成 使用单独的临床信息或在合并的脑电图或WISCA工具的帮助下的小插图。 将在三个研究组中比较抗生素决定的适当性。 在目标3中，我们将在6 - 10个国家卫生机构开展一项促进实施试点研究，以开发一个工具包， 实施和评估WISCA干预措施。我们将使用混合方法， SEIPS模型和理论领域框架，以确定研究中的实施障碍和推动因素 国家卫生机构，并确定和设计战略，以加强采用WISCA干预。由此产生的结果 这项工作将用于开发一项大规模的实用临床试验，以评估WISCA对 真实的临床实践环境中的抗生素决策。

PROJECT SUMMARY/ABSTRACT Inappropriate antibiotic use is a common problem that contributes to adverse drug events and antibiotic resistance in nursing homes (NHs). Empiric antibiotic selection decisions in NHs are frequently suboptimal. Cumulative susceptibility reports based on patient cultures, known as antibiograms, are tools increasingly being used to improve empiric antibiotic decisions in NHs. However, most NHs collect an insufficient number of cultures to permit creation of reliable facility-specific antibiograms causing many facilities to turn to pooled facility antibiograms. Antibiograms based on combining culture data from multiple facilities improve the reliability of reported susceptibility estimates and accurately reflect regional antibiotic resistance patterns but may present a distorted picture of susceptibility patterns at the local level. Consequently, it is possible that increasing use of pooled facility antibiograms may worsen rather than improve empiric antibiotic decisions in NHs. The weighted-incidence syndromic combination antibiogram (WISCA) is a novel method that makes better use of available microbiology data when culture results are scarce. A WISCA also presents data in a manner that may reduce cognitive load on clinicians. We believe WISCAs will prove to be more reliable than traditional antibiograms and exert a greater effect on empiric antibiotic decisions in NHs. The objectives of this study are to develop a user-friendly WISCA tool, compare it to a traditional antibiogram and develop a toolkit for its implementation and evaluation in NHs. We will achieve these objectives through the following specific aims: In Aim 1, we will conduct a prospective surveillance study in 82 NHs in four states to characterize antibiotic susceptibility patterns in NHs using traditional antibiograms and WISCAs. Existing study NH culture data will be obtained from their reference laboratories. The reliability of the two antibiogram formats will be evaluated and the congruence between single and pooled facility susceptibility estimates will be estimated. In Aim 2, we will develop a user-friendly WISCA format with input from NH clinicians. The resulting tool will be evaluated using a simulated case-study approach in which 300 NH clinicians will be asked to complete several clinical vignettes describing common NH urinary syndromes. Participants will be randomized to complete the vignettes using either clinical information alone or with the assistance of a pooled antibiogram or a WISCA tool. Appropriateness of antibiotic decisions will be compared across the three study arms. In Aim 3, we will perform a facilitated implementation pilot study in 6-10 NHs in order to develop a toolkit for implementing and evaluating the WISCA intervention. We will use a mixed-methods approach, structured around the SEIPS model and Theoretical Domains Framework, to identify implementation barriers and enablers in study NHs and to identify and design strategies to enhance adoption of the WISCA intervention. Outcomes from this work will be used to develop a large-scale pragmatic clinical trial to assess the effects the WISCA has on antibiotic decisions in a real clinical practice environment.