Building a Novel Antibiotic Stewardship intervention for nursing homes

描述（由申请人提供）：高达75%的抗生素使用在疗养院是不合适的。不适当的抗生素使用增加了疗养院居民的不良药物事件、艰难梭菌感染和抗生素耐药菌感染的风险，这些风险随后可能传播给他人。在疗养院进行抗生素管理干预的结果喜忧参半。虽然针对提供者知识和影响处方决策的工作系统方面的多组分干预似乎可以减少养老院中不适当的抗生素使用，但这些干预措施的作用机制尚不清楚。在缺乏这方面的知识，成功地传播这些干预措施，以其他养老院设置将是不可能的。因此，迫切需要进行养老院抗生素管理研究，不仅评估干预措施对处方模式的影响，还评估它们介导变化的机制。我们的长期目标是减少养老院中不适当的抗生素使用。因此，我们的小组开发了一种新的抗生素管理干预措施，其目标是提供者的知识以及影响养老院抗生素决策的重要工作系统因素。该特定应用的目的是证明我们在两个州的养老院中抗生素管理干预的有效性，并开发资源以促进向其他养老院环境的传播。我们将通过三个具体目标实现本项目的目标：1）为最佳实施量身定制抗生素管理干预; 2）评估其对研究疗养院抗生素使用的影响; 3）利用获得的知识开发传播工具包。在第一个目标中，我们将使用人为因素分析来确定实施抗生素管理干预的障碍和促进因素。干预措施的组成部分将针对克服这些障碍而量身定制，并将根据研究疗养院中关键知情人的结构化输入制定实施方案。在第二个目标中，将使用威斯康星州大学开创的质量改进协作方法在研究疗养院实施量身定制的抗生素管理干预，并将抗生素利用措施与对照设施进行比较。在第三个目标中，将利用对干预措施的可靠性、可持续性和机制进行混合方法评估所产生的知识以及干预措施介导的研究成果，开发一个传播工具包。我们将用来调整我们的干预措施和支持其实施的方法（质量改进合作）以及我们将用来开发传播工具包的严格的计划评估都是本提案的创新方面。拟议的研究意义重大，因为预计它将导致 一种多方面的干预措施，可以广泛推广，以有效减少和改善设施中抗生素的使用，从而减少C。艰难梭菌感染和抗生素耐药性的出现和传播，在疗养院和他们所服务的社区。

DESCRIPTION (provided by applicant): Up to 75% of antibiotic use in nursing homes is inappropriate. Inappropriate antibiotic use increases the nursing home resident's risk of adverse drug events, Clostridium difficile infection and infection with antibiotic- resistant bacteria, whih may then be spread to others. Results of antibiotic stewardship interventions in nursing homes have been mixed. While multi-component interventions targeting provider knowledge and aspects of the work system influencing prescribing decisions appear to reduce inappropriate antibiotic use in nursing homes, the mechanisms by which these interventions work is unclear. In the absence of this knowledge, successful dissemination of these interventions to other nursing home settings will not be possible. Consequently, there is a critical need for nursing home antibiotic stewardship studies that not only evaluate the impact of interventions on prescribing patterns but also evaluate the mechanisms by which they mediate change. Our long-term goal is to reduce inappropriate antibiotic use in nursing homes. Accordingly, our group has developed a novel antibiotic stewardship intervention that targets provider knowledge as well as important work system factors influencing antibiotic decision-making in nursing homes. The objectives of this particular application are to demonstrate the effectiveness of our antibioti stewardship intervention in nursing homes in two states and develop a resource to facilitate dissemination to other nursing home settings. We will achieve the objectives of this project through three specific aims: 1) tailor the antibiotic stewardship intervention for optimal implementation; 2) assess its impact on antibiotic use in study nursing homes; and 3) use knowledge gained to develop a dissemination toolkit. In the first aim, we will use human factors analyses to identify barriers and facilitators to implementation of the antibiotic stewardship intervention. Components of the intervention will be tailored to overcome these barriers and an implementation package will be developed with structured input from key informants in study nursing homes. In the second aim, the tailored antibiotic stewardship intervention will be implemented in study nursing homes using a quality improvement collaborative approach pioneered at the University of Wisconsin and antibiotic utilization measures will be compared with control facilities. In the third aim, knowledge generated from a mixed-methods assessment of intervention fidelity, sustainability and mechanisms by with the intervention mediates study outcomes will be used to develop a dissemination toolkit. The methods we will used to tailor our intervention and support its implementation (quality improvement collaborative) as well as the rigorous program evaluation we will employ to develop a dissemination toolkit are all innovative aspects of this proposal. The proposed research is significant; because it is expected to result in a multi-faceted intervention that can be exported broadly to effectively reduce improve antibiotic use in facilities, which will, in turn, will reduce C. difficile infections and the emergence and spread of antibiotic resistance in nursing homes and the communities they serve.