Optimizing Antimicrobial Use in Maintenance Dialysis Units (OPTIMUS)

多重耐药菌(MDRO)的比率在需要维持的人中是最高的 血液透析(MHD)。抗菌药物暴露是MDRO出现和传播的主要危险因素。向上 在门诊透析设施使用的抗菌药中，有30%没有注明。减少不适当的， 因此，在透析设施中使用不必要或不理想的抗菌剂是至关重要的。我们最近发表了一篇 实施抗菌药物管理的临床和经济后果决策分析模型 在全国范围内的门诊透析设施的计划(ASP)。该模型预测感染人数将减少4.8% 由MDRO和艰难梭菌引起；与感染相关的死亡减少4.6%， 成本。2017年，PI完成了一项由AHRQ资助的关于门诊透析设施中的ASP的研究。该计划， 重点是教育和行为策略，导致抗菌药的使用减少(P=0.02)。 尽管取得了成功，但仍发现了三个障碍，以实现更有效的处方。首先，我们最初的ASP 方法不能完全识别不适当的剂量，在经验量之后及时给药。 因此，错过了改善处方的机会。第二，约55%的处方剂量 是出院时从转院医院接到的命令。与数据相关的数据 抗菌治疗的适应症和选择很少，因此限制了机会的数量 改进抗菌药物处方。第三，单位医务主任的参与度很低。缺乏 领导层的支持可能会阻止ASP变得更有效。在此基础上，利用一项研究 在我们上一次AHRQ拨款期间建立的基础设施，这项题为Optimus(优化)的建议 抗菌剂在维护透析单元中的使用)，将开发和实施一种改进的ASP。除了……之外 克服三大障碍的教育和行为构成要素、具体工具和战略 上述内容将在这个改进的ASP中开发和实现。这些工具包括一种抗菌剂 医院转院报告和透析设施中抗菌药物处方的循证检查表。我们 将加入达维塔透析单元，并已获得领导支持。我们的跨学科团队包括 具有ASP和实施科学专业知识的研究人员，具有质量经验的资深肾病学家 改善计划和我们的疾控中心顾问，在MHD医疗质量方面拥有专业知识。中断的时间 8个干预单元和8个控制单元将采用系列化设计。具体目标是：1]制定和实施 一种改进的门诊血液透析室的ASP，2]论证这种ASP在减少 抗菌药物使用，以及3]开发透析环境专用抗菌药物处方审计工具和 展示由于ASP的结果，抗菌药物处方模式的质量有所改善。 演示此ASP的有效性，并生成工具以帮助优化抗菌药物处方 在MHD人群中提供未得到满足和早该满足的需求，并最终改善他们的健康状况。

Rates of multidrug-resistant organisms (MDRO) are among the highest in persons requiring maintenance hemodialysis (MHD). Antimicrobial exposure is the main risk factor for the emergence and spread of MDRO. Up to 30% of antimicrobials administered in out-patient dialysis facilities are not indicated. Decreasing inappropriate, unnecessary or suboptimal antimicrobial use in dialysis facilities is therefore crucial. We recently published a decision analytic model on the clinical and economic consequences of implementing antimicrobial stewardship programs (ASP) in out-patient dialysis facilities nation-wide. The model predicted a 4.8% reduction in infections caused by MDRO and Clostridium difficile; a 4.6% reduction in infection-related deaths and a 5.0% reduction in costs. In 2017, the PI completed an AHRQ-funded study of an ASP in out-patient dialysis facilities. The program, which focused on educational and behavioral strategies, resulted in a reduction in antimicrobial use (P=0.02). Although successful, three barriers to even greater effective prescribing were identified. First, our initial ASP method could not fully identify inappropriate doses, administered after the empiric doses, in a timely manner. Thus, opportunities for improving prescribing were missed. Second, approximately 55% of doses prescribed were from orders received from the transferring hospital upon hospital discharge. Data pertaining to the indications for and choice of antimicrobial therapy were minimal and thereby limited the number of opportunities to improve antimicrobial prescribing. Third, engagement from unit medical directors was minimal. Lack of leadership support likely prevented the ASP to be more effective. With this foundation and leveraging a research infrastructure established during our previous AHRQ grant, this proposal, entitled OPTIMUS (Optimizing Antimicrobial Use In Maintenance Dialysis UnitS), will develop and implement an improved ASP. In addition to the previous educational and behavioral components, specific tools and strategies to overcome the three barriers mentioned above will be developed and implemented in this improved ASP. These tools include an antimicrobial hospital transfer report and an evidence-based checklist for antimicrobial prescribing in the dialysis facilities. We will enroll DaVita dialysis units and have already obtained leadership support. Our interdisciplinary team includes investigators with expertise in ASP and implementation science, senior nephrologists with experience in quality improvement initiatives and our CDC consultant, with expertise in MHD healthcare quality. An interrupted time series design will be used in 8 intervention and 8 control units. Specific aims are:1] To develop and implement an improved ASP in out-patient hemodialysis units, 2] To demonstrate the effectiveness of this ASP in reducing antimicrobial use, and 3] To develop a dialysis setting specific-antimicrobial prescribing audit tool and demonstrate improvement in the quality of antimicrobial prescribing patterns as a result of the ASP. Demonstrating the efficacy of this ASP and generating tools to assist in optimizing antimicrobial prescribing will provide an unmet and overdue need in the MHD population and will ultimately improve their health outcomes.