Antimicrobial stewardship for long term care facility patients: in the ED

这项提案代表了一项为期五年的课程和研究计划，旨在将候选人转变为临床研究的独立研究员。在五年的时间里，候选人将完成与项目相关的课程，并执行研究计划。 感染是长期护理机构(LTCFs)居民发病和死亡的主要原因之一。因此，长期合作伙伴关系居民接触到大量抗菌剂，但长期合作伙伴关系居民使用抗菌剂往往不是最理想的，因为难以区分急性感染和定居，以及长期合作伙伴关系居民抗生素处方不准确或不适当的可能性增加(例如，由于抗菌素耐药性的增加)。 急诊科(ED)是长期持续发展基金居民，特别是那些病情最严重的患者感染的常见治疗场所。目前缺乏全面的方案来解决急诊室长期住院患者使用抗菌剂的问题。这项研究的概念框架借鉴了关于抗菌药物管理计划(ASP)、经验性抗生素治疗和LTCF感染控制指南的文献。ASP已成功地在住院人群中实施，以改善抗菌药物的处方实践和结果，从而减少耐药性和副作用。这项研究将它们的使用扩展到高危ED人群，目的是将提高的诊断准确性和经验性的抗菌药物处方结合起来。目前的LTCF感染控制指南建议，只有当LTCF患者符合特定标准时才能诊断出他们的急性感染，以区分活动性感染和定植，并防止过度使用抗生素。这些指南是为长期护理中心本身使用而制定的，尚未在急诊室或住院环境中进行研究。由于未能区分急性感染和在急诊室的定植，可能会导致抗生素的不适当使用，因此，在急诊室环境中验证诊断指南是朝着适当的抗菌素管理迈出的重要一步。这些研究的另一个关键概念是效率，主要由卫生信息技术(HIT)驱动。在资源有限的时代，利用现有的HIT系统和信息将允许将ASP扩展到新的临床环境和人群。 大多数病情中等至严重的LTCF患者在急诊室接受初步诊断并开始使用抗菌药。为了改善对这一高危人群的护理，我们的总体目标是为ED LTCF患者开发和实施基于健康信息技术(HIT)的抗菌管理计划(ASP)，从而提高诊断的准确性和正确的抗菌药物处方。为达致这个目标，我们会进行两项计划，具体目标如下： 具体目标1(ED-观察性)：为急性感染制定一个有效的定义，并确定ED LTCF患者的抗微生物管理需求。 具体目标2(ED-干预)：测试为ED-LTCF患者实施基于卫生信息技术(HIT)的ASP对急性感染的诊断和治疗的效果。 对于特定目标1，该项目(SA1：ED-观察性)将包括对ED LTCF患者的前瞻性观察性队列研究。它将用于验证ED LTCF患者存在急性感染的定义(不同于定植)，建立ASP干预的基线需要率，并为ED LTCF患者制定具体的抗菌建议和ASP所需的数据。 对于特定目标2，将进行一项前瞻性介入试验(SA 2：ED-介入)，在该试验中将设计并实施专为ED LTCF患者量身定做的ASP计划。这一阶段将依赖于使用基于网络的实时卫生信息技术(HIT)决策支持工具来提供干预。它将包括一些因素，如诊断LTCF患者急性感染的建议算法、按部位网格新开发的抗生素、患者特定的过去培养结果、具有推荐剂量的患者特定的肝和肾功能数据，以及处方限制。结果将包括诊断的准确性、经验性抗生素的适当性以及对ASP干预的持续要求。 职业发展计划将包括对进行这些研究有用的先进生物统计技术方面的教学工作。课程内容还包括老龄研究的具体方面、老龄生物学和老龄研究中的挑战。它还将包括一个重要的组成部分，研究卫生信息技术的应用，包括教学课程、在线课程和实践经验，以便完成拟议的研究并为进一步学习奠定基础。 根据所取得的成果，将有可能开发有效和可重复的干预措施，以改善各种环境中的抗菌药物管理。拟议的项目和职业发展计划将为实现改善长期护理中心居民的护理这一最终目标迈出重要的第一步。

This proposal represents a five-year curriculum and research plan designed to transition the candidate to an independent investigator in clinical research. During the five years the candidate will complete coursework relevant to the project and will execute the research plan. Infection is one of the leading causes of morbidity and mortality in residents of long-term care facilities (LTCFs). As a result, LTCF residents are exposed to large numbers of antimicrobial agents but use of antimicrobials in LTCF residents is often suboptimal due to difficulty in distinguishing acute infection from colonization and due to the increased likelihood of inaccurate or inappropriate antibiotic prescribing in LTCF residents (for example due to increased presence of antimicrobial resistance). The emergency department (ED) is a common site for treatment of infection in LTCF residents, particularly those most severely ill. Comprehensive programs to address problems of antimicrobial use for LTCF residents in the ED are currently lacking. The conceptual framework for the study is borrowed from the literature on antimicrobial stewardship programs (ASPs), empiric antibiotic treatment, and LTCF infection control guidelines. ASPs have been successfully implemented in inpatient populations to improve antimicrobial prescribing practices and outcomes with resulting decreases in resistance and side effects. This study expands their use to a high-risk ED population with the goal of incorporating both improved diagnostic accuracy and empiric antimicrobial prescribing. Current LTCF infection control guidelines recommend that acute infection be diagnosed in LTCF patients only when they meet specific criteria in order to differentiate active infection from colonization and prevent overuse of antibiotics. These guidelines were developed for use in the LTCFs themselves and have not yet been studied in the ED or inpatient settings. As failure to differentiate acute infection from colonization in the ED may lead to inappropriate antibiotic use, validating diagnostic guidelines in the ED setting is an important step towards appropriate antimicrobial stewardship. Another key concept of these studies is efficiency, driven primarily by Health Information Technology (HIT). In an era of limited resources utilizing pre-existing HIT systems and information will allow extension of ASPs to novel clinical settings and populations. The majority of moderately- to severely-ill LTCF patients receive their initial diagnosis and initiation of antimicrobials in the ED. To improve care of this high-risk population, our overall objective is to develop and implement an antimicrobial stewardship program (ASP) based on use of health information technology (HIT) for ED LTCF patients that will result in improvements both in accuracy of diagnosis and in correct antimicrobial prescribing. To achieve this objective, we will conduct two projects with the following Specific Aims: Specific Aim 1 (ED-observational): To develop a validated definition for acute infection and to identify antimicrobial stewardship needs in ED LTCF patients. Specific Aim 2 (ED-interventional): To test the effect of implementing a health information technology (HIT)-based ASP for ED-LTCF patients on diagnosis and treatment of acute infection. For Specific Aim 1, the project (SA1: ED-observational) will consist of a prospective observational cohort study of ED LTCF patients. It will be used to validate definitions for the presence of acute infection in ED LTCF patients (as distinct from colonization), establish baseline rates of need for ASP interventions, and develop data required to construct specific antimicrobial recommendations and an ASP for ED LTCF patients. For Specific Aim 2, a prospective, interventional trial (SA 2: ED-interventional) will be conducted in which an ASP program tailored to ED LTCF patients will be devised and implemented. This phase will rely on the use of a real-time web-based health information technology (HIT) decision support tool to provide the intervention. It will include factors such as the suggested algorithms for diagnosing an acute infection in LTCF patients, a newly developed antibiotic by site grid, patient specific past culture results, patient specific data on hepatic and renal function with recommended dosing, and formulary restrictions. Outcomes will include accuracy of diagnosis, appropriateness of empiric antibiotics, and ongoing requirements for ASP intervention. The career development plan will include didactic work in advanced biostatistical techniques useful in conducting these studies. Coursework will also be undertaken in specific aspects of aging studying biology of aging and challenges in aging research. It will also include a significant component studying the application of health information technology including didactic coursework, online coursework, and practical experience to allow completion of the proposed research and position the candidate for further studies. Based on the results achieved, it will be possible to develop validated and reproducible interventions to improve antimicrobial stewardship in a variety of settings. The proposed projects and career development plan will provide an important initial step towards the ultimate goal of improving care for residents of LTCFs.