OPTIMIZING ANTIBIOTIC USE IN LONG-TERM CARE

这项拟议研究的主要目标是确定在长期护理机构(LTCFs)中管理老年人尿路感染(UTI)的临床算法是否可以减少LTCFs中抗生素的总体使用。三个次要目标是：1)论证循证诊断和治疗算法在LTCFs中实施的可行性，2)评估在目标人群中减少UTIs诊断测试和抗生素使用的安全性，3)评估在LTCFs中采用所提出的算法的过程。减少长期临床试验中抗生素的使用将降低L)抗生素耐药性发展的潜力，2)药物不良反应和有害药物相互作用的可能性，3)与不适当使用抗生素相关的巨额成本。为了达到研究目标，将进行一项随机对照试验，将参与试验的LTCFs随机分为干预组(临床算法)和对照组。开发了一种循证诊断和治疗算法，并补充了在住宅LTCFs工作的初级保健医生和护士的反馈。这项研究将使用定量和定性相结合的方法来评估实施临床算法的过程和结果。将使用随机配对设计，在12对LTCFs中的每一对中，将有一对被随机分配到干预(临床算法)。另一半将为推定的尿路感染提供“常规”治疗。量化结果将包括L)用于泌尿系统适应症的抗生素疗程比例，2)抗生素使用疗程总数，3)订购尿培养的比率，4)尿路感染住院率，5)死亡率。在研究的前两个月，该算法将在干预家庭中进行试点测试。这项干预措施将通过电话会议和内部服务两种方式进行。这项研究的定性部分将是对卫生服务干预的前瞻性个案研究评估(关于长期癌症中心居民使用抗生素的尿路感染的诊断和治疗算法)。该研究的这一部分将检查实施的简便性和医疗保健提供者对诊断和治疗算法的满意度。使用标准抽样，将采访两组受访者，参与长期合作伙伴关系的主要临床管理人员(医疗主任、护理主任、感染控制官员)和将实施算法的护理人员。

The primary objective of the proposed study is to determine if a clinical algorithm for managing urinary tract infections (UTIs) in older adults in residential long-term care facilities (LTCFs) can reduce the overall use of antibiotics in LTCFs. Three secondary aims are 1) to demonstrate the feasibility of implementing evidence-based diagnostic and therapeutic clinical algorithms in LTCFs, 2) to assess the safety of reducing the number of diagnostic tests and antibiotic use for UTIs in the target population, 3) to evaluate the process of adopting the proposed algorithms in LTCFs. Reducing the use of antibiotics in LTCFs will reduce l) the potential for the development of antibiotic resistance, 2) the potential for adverse drug effects and harmful drug interactions, 3) significant costs associated with inappropriate use of antibiotics. To achieve the research goals, a randomized controlled trial with participating LTCFs randomized to either intervention (clinical algorithm) or control group will be conducted. An evidence-based diagnostic and a treatment algorithm was developed, augmented with feedback from primary care physicians and nurses working in residential LTCFs. The study will use a combined quantitative and qualitative approach to evaluate the process and outcomes of implementing the clinical algorithm. A randomized matched pair design will be used where, within each of the 12 pairs of LTCFs, one will be randomized to the intervention (clinical algorithm). The other half will provide "usual" management of presumptive urinary tract infections. Quantitative outcomes will include l) the proportion of antibiotic courses prescribed for urinary indications, 2) the total number of courses of antibiotics used, 3) rates of urine cultures ordered, 4) hospitalization rates for urinary tract infections, and 5) mortality rates. During the first two months of the study, the algorithm will be pilot tested in the intervention homes. Adoption of the intervention will be through both teleconferences and in-services. The qualitative component of this study will be a prospective case study evaluation of a health service intervention (diagnostic and treatment algorithms concerning antibiotic use for UTIs in residents of LTCFs). This component of the study will examine the ease of implementation and healthcare provider satisfaction with diagnostic and treatment algorithms. Using criterion sampling, two groups of respondents will be interviewed, key clinical administrators in the participating LTCFs (medical directors, directors of nursing, infection control officers), and nursing staff who will implement the algorithms.