Antibiotic prescribing practice in the spinal cord injury system of care

相比之下，患有脊髓损伤或疾病(SCI/D)的人感染风险较高 对普通患者人群来说，由于频繁住院等因素， 抗生素的使用，经常和长期使用侵入性医疗设备，如导尿管， 和压疮的发展。其中许多感染是由抗菌剂引起的。 耐药生物，如耐多药的革兰氏阴性细菌或耐甲氧西林的细菌 金黄色葡萄球菌。因为感染通常需要抗菌治疗，所以 抗生素处方过多或抗生素处方不足的情况很常见。 抗菌药物管理计划的目标是通过限制抗生素的使用来优化抗生素的使用 过度使用和改善治疗不足，同时最大限度地减少意外后果，如 作为抗生素耐药生物体的选择。对抗生素的耐药性增加了发生 最初的治疗不充分。不充分的抗生素治疗指的是没有 对特定微生物的“体外”效力；换句话说，该微生物是 对开出的特定抗生素不敏感。有充分的证据证明有必要 预防感染的抗生素治疗不充分，因为这会影响患者的预后， 通过实施抗菌药物管理资源和方案。抗菌图谱 (报告来自某机构患者的所有测试微生物分离物的耐药性摘要-或 已被证明是改善经验性处方的有效干预措施。在……里面 对于患有SCI/D的人来说，这一点更加重要，因为他们感染的风险增加。 然而，很少有工作集中于识别可修改的患者、提供者和/或系统 在治疗这些常见疾病时与抗生素治疗不足相关的水平特征 SCI/D患者的感染；也没有实施有效的抗菌药 管理干预措施，如使用抗生素图谱。为患有SCI/D的退伍军人提供的退伍军人服务是 通过从25个地区SCI/D中心延伸的中心和辐条护理系统提供服务 由多学科团队(中心)为134个SCI/D提供初级护理和专科护理 当地退伍军人医疗中心的初级保健团队(发言人)。了解此枢纽的影响 为了确保有效的抗菌剂，需要在供应商决策中使用轮辐式系统 管理战略，以减少不充分处方的流行率以及 减少相关结果的负面影响，如更高的入院率和 死亡率。考虑到多达50%的脊髓损伤患者可能只有 在没有专业SCI/D中心的VHA设施中被看到。拟议的研究涉及 SCI QUERI战略计划改善#年感染治疗和管理的优先领域 将重点放在QUERI过程的步骤3-4上。作为整体的一部分 为了提高这一人群的抗菌药物管理水平，我们建议进行一项全国性的 用枢轴和辐条评估BSI不充分处方变异的混合方法研究 设施和实施抗菌图谱干预试点，以改善处方。

Individuals with spinal cord injury or disorder (SCI/D) are at high risk for infections compared to the general patient population due to factors such as frequent hospitalization, previous antibiotic use, frequent and chronic use of invasive medical devices such as urinary catheters, and development of pressure ulcers. Many of these infections are caused by antimicrobial resistant organisms such as multidrug-resistant gram-negative bacteria or Methicillin-resistant Staphylococcus aureus. Because infections often require antimicrobial treatment, the opportunities for over-prescribing of antibiotics or inadequate antibiotic prescribing are common. The goal of antimicrobial stewardship programs are to optimize antibiotic use by limiting overuse and improving inadequate treatment while minimizing unintended consequences such as the selection of antibiotic resistant organisms. Antibiotic resistance increases the likelihood of initial inadequate therapy. Inadequate antibiotic therapy refers to treatment that does not have `in vitro' effectiveness against a particular microorganism; in other words, the microorganism is not susceptible to the particular antibiotic prescribed. There is a well-documented need to prevent inadequate antibiotic treatment of infections, due to its impact on patient outcomes, through the implementation of antimicrobial stewardship resources and programs. Antibiograms (summaries reporting resistance of all tested microbiology isolates from patients at a facility- or unit-level) have been shown to be an effective intervention in improving empiric prescribing. In persons with SCI/D, this is even more important due to their increased risk of infection. However, very little work has focused on identifying modifiable patient, provider, and/or system level characteristics associated with inadequate antibiotic therapy in treating these common infections among individuals with SCI/D; nor in implementation of effective antimicrobial stewardship interventions such as using antibiograms. VA services for Veterans with SCI/D are delivered through a hub and spoke system of care, extending from 25 regional SCI/D Centers offering primary care and specialty care by multidisciplinary teams (hubs) to the 134 SCI/D Primary Care teams (spokes) at local VA medical centers. Understanding the impact of this hub and spoke system in provider decision-making is needed to ensure effective antimicrobial stewardship strategies that reduce the prevalence of inadequate prescribing as well as decrease the negative impact of related outcomes, such as higher hospital admission and mortality rates. This is important to assess considering that up to 50% of SCI patients may only be seen in a VHA facility without a specialty SCI/D Center. The proposed study addresses the SCI QUERI strategic plan priority area of improving treatment and management of infections in Veterans with SCI/D and will focus on Steps 3-4 of the QUERI process. As part of an overall goal of improving antimicrobial stewardship in this population, we propose to conduct a national mixed-methods study to assess variation in inadequate prescribing in BSI by hub and spoke facilities and implement a pilot antibiogram intervention to improve prescribing.¿