Reducing Antimicrobial Use Associated with Ventilator Associated Pneumonia and Ca

描述(由研究人员提供)：促进合理使用抗生素的干预措施可以减少抗菌药物的总体使用，提高患者的安全性，因为患者在最合适的时间内以正确的剂量接受最好的药物，并减少抗菌素耐药性。该项目的目标是开发、实施和评估用于诊断和治疗呼吸机相关肺炎(VAP)和导管相关尿路感染(CAUTI)的算法，以减少不适当的抗菌药物使用，提高患者预后。为了做到这一点，我们建议开发一种系统的方法，在三个关键时间点优化VAP和CAUTI的抗菌药使用决策：1)最初怀疑感染的时间，2)微生物学数据的可用性能够缩小抗生素谱或停止使用抗生素的时间，以及3)决定治疗时间的时间。为了确定VAP和CAUTI目前的抗菌药物使用模式，我们将收集基线数据，以确定与这些感染相关的不适当抗菌治疗的程度。为了优化VAP的抗菌药使用，我们将开发和实施诊断和治疗算法，为临床决策提供循证方法。我们将在五个ICU中实施不同的方法来促进遵守这些算法，并比较它们在减少不适当的抗菌药物使用方面的有效性。正在研究的方法包括通过使用微型细支气管肺泡灌洗技术获取下呼吸道样本进行定量培养来提高诊断能力，抗菌药物管理干预措施，以及使用抗生素自动停用令来影响治疗持续时间。对于CAUTI，我们将实施一项介入性计划，旨在强调拆除不必要的导管和适当使用抗生素的重要性。干预措施的组成部分将包括制定管理菌尿和真菌尿的算法，以及通过袖珍卡片和海报删除和传播这些材料的指南，以及向个别医生反馈有关适当使用导管和抗菌剂的信息，以及向护士反馈有关其病房中可能有不必要导管的患者的信息。VAP和CAUTI研究将采用准实验研究设计，以评估这些干预措施的影响。我们将比较抗菌药物和导管使用的基线比率与干预后的比率。我们还将分析VAP和CAUTI研究中的患者结果；我们将在基线和干预期间评估研究单位的住院时间、死亡率、住院费用、耐药发生率、艰难梭菌疾病发生率以及MRSA和VRE的获得率。我们假设，这种方法将加强VAP和CAUTI的抗菌药的适当使用，并通过减少已知的抗菌药物过度使用的后遗症来改善患者的预后。

DESCRIPTION (provided by investigator): Interventions to promote rational antibiotic use can lead to decreased overall antimicrobial use, enhanced patient safety in that patients receive the best agent at the right dose for the most suitable time period, and decreased antimicrobial resistance. The goals of this project are to develop, implement and evaluate algorithms for both the diagnosis and treatment of ventilator-associated pneumonia (VAP) and catheter- associated urinary tract infections (CAUTI) that reduce inappropriate antimicrobial use and enhanced patient outcomes. We propose to do this by developing a systematic approach to optimize decision making regarding antimicrobial usage for VAP and CAUTI at three critical time points: 1) the time of initial suspicion of infection, 2) the time when the availability of microbiological data enable narrowing the antibiotic spectrum or stopping antibiotics, and 3) the time at which duration of therapy is decided. To determine the current patterns of antimicrobial use for VAP and CAUTI we will collect baseline data to establish the extent of inappropriate antimicrobial therapy associated with these infections. To optimize antimicrobial usage for VAP, we will develop and implement diagnostic and treatment algorithms that provide evidence-based approaches for clinical decision making. We will implement different approaches to facilitate adherence to these algorithms in five ICUs and compare their efficacy in reducing inappropriate antimicrobial use. Approached to be studied include enhancing diagnosis by using the mini-brochoalveolar lavage technique to obtain lower respiratory samples for quantitative culture, antimicrobial stewardship interventions, and use of automatic stop orders for antibiotic to impact duration of therapy. For CAUTI, we will implement an interventional program designed both to emphasize the importance of removing unnecessary catheters and to use antibiotics appropriately. Components of the intervention will include development of algorithms for management of bacteriuria and funguria and guidelines for catheter removal and dissemination of these materials via pocket cards and posters as well as feedback both to individual physicians about appropriate use of catheters and antimicrobials and to nurses regarding patients on their units with potentially unnecessary catheters. A quasi-experimental study design will be used in both the VAP and CAUTI studies to evaluate the impact of these interventions. We will compare the baseline rates of antimicrobial use and catheter use to those after the intervention. We will also analyze patient outcomes in both the VAP and CAUTI studies; we will assess length of stay, mortality, hospital costs, rates of emergence of resistance, rates of Clostridium difficile disease and rates of acquisition of MRSA and VRE in the study units during the baseline and intervention periods. We hypothesize that this approach will enhance appropriate use of antimicrobials for both VAP and CAUTI and improve patient outcomes by reducing the known sequelae of antimicrobial overuse.