Developing a novel antibiogram tool to improve empiric antibiotic prescribing in nursing homes

项目摘要/摘要 抗生素使用不当是导致药物不良反应和抗生素使用的常见问题 养老院的阻力(NHS)。在NHS中，经验性的抗生素选择决策往往是次优的。 基于患者培养的累积敏感性报告，即所谓的抗生素图谱，是越来越多的工具 用于改进NHS的经验性抗生素决策。然而，大多数NHS收集的培养物数量不足 允许创建可靠的特定于设施的抗菌图，从而使许多设施转向集合设施 抗生素图谱。基于组合来自多个设施的培养数据的抗生素图谱提高了 报告的敏感性估计并准确地反映了区域抗生素耐药模式，但可能会呈现 扭曲了地方一级的易感模式。因此，有可能增加对 汇集的设施抗生素图谱可能会恶化而不是改善NHS的经验性抗生素决策。 加权发病综合征联合抗菌图谱(WISCA)是一种新的更好地应用于临床的方法 当培养结果稀缺时，可利用的微生物学数据。WISCA还以如下方式呈现数据 可能会减轻临床医生的认知负荷。我们相信WISCA将被证明比传统的更可靠 抗生素图谱，并对NHS的经验性抗生素决策产生更大的影响。这项研究的目的是 开发用户友好的WISCA工具，将其与传统的抗生素图谱进行比较，并为ITS开发工具包 在国民健康保险制度中的实施和评估。我们将通过以下具体目标实现这些目标： 在目标1中，我们将在四个州的82个NHS中进行一项前瞻性监测研究，以确定抗生素的特征 使用传统抗生素图谱和WISCA的NHS中的敏感性模式。现有的研究NH文化数据将是 从他们的参考实验室获得。将评估两种抗菌图谱格式的可靠性，并 将估计单个和合并设施敏感度估计之间的一致性。 在目标2中，我们将开发一种用户友好的WISCA格式，并听取NH临床医生的意见。生成的工具将是 使用模拟案例研究方法进行评估，300名NH临床医生将被要求完成以下几项 描述常见NH泌尿综合征的临床小插曲。参与者将被随机分配以完成 单独使用临床信息或在汇集的抗菌图谱或WISCA工具的帮助下使用小片段。 抗生素决定的适当性将在三个研究部门进行比较。 在目标3中，我们将在6-10年的国民健康保险制度中进行一项促进实施试点研究，以开发一个工具包 实施和评估WISCA干预措施。我们将使用混合方法，围绕 SEIPS模型和理论领域框架，以确定研究中的实施障碍和推动因素 并确定和设计战略，以促进采用WISCA干预措施。由此产生的结果 将利用这项工作开发一项大规模实用临床试验，以评估WISCA对 在真实的临床实践环境中做出抗生素决定。

PROJECT SUMMARY/ABSTRACT Inappropriate antibiotic use is a common problem that contributes to adverse drug events and antibiotic resistance in nursing homes (NHs). Empiric antibiotic selection decisions in NHs are frequently suboptimal. Cumulative susceptibility reports based on patient cultures, known as antibiograms, are tools increasingly being used to improve empiric antibiotic decisions in NHs. However, most NHs collect an insufficient number of cultures to permit creation of reliable facility-specific antibiograms causing many facilities to turn to pooled facility antibiograms. Antibiograms based on combining culture data from multiple facilities improve the reliability of reported susceptibility estimates and accurately reflect regional antibiotic resistance patterns but may present a distorted picture of susceptibility patterns at the local level. Consequently, it is possible that increasing use of pooled facility antibiograms may worsen rather than improve empiric antibiotic decisions in NHs. The weighted-incidence syndromic combination antibiogram (WISCA) is a novel method that makes better use of available microbiology data when culture results are scarce. A WISCA also presents data in a manner that may reduce cognitive load on clinicians. We believe WISCAs will prove to be more reliable than traditional antibiograms and exert a greater effect on empiric antibiotic decisions in NHs. The objectives of this study are to develop a user-friendly WISCA tool, compare it to a traditional antibiogram and develop a toolkit for its implementation and evaluation in NHs. We will achieve these objectives through the following specific aims: In Aim 1, we will conduct a prospective surveillance study in 82 NHs in four states to characterize antibiotic susceptibility patterns in NHs using traditional antibiograms and WISCAs. Existing study NH culture data will be obtained from their reference laboratories. The reliability of the two antibiogram formats will be evaluated and the congruence between single and pooled facility susceptibility estimates will be estimated. In Aim 2, we will develop a user-friendly WISCA format with input from NH clinicians. The resulting tool will be evaluated using a simulated case-study approach in which 300 NH clinicians will be asked to complete several clinical vignettes describing common NH urinary syndromes. Participants will be randomized to complete the vignettes using either clinical information alone or with the assistance of a pooled antibiogram or a WISCA tool. Appropriateness of antibiotic decisions will be compared across the three study arms. In Aim 3, we will perform a facilitated implementation pilot study in 6-10 NHs in order to develop a toolkit for implementing and evaluating the WISCA intervention. We will use a mixed-methods approach, structured around the SEIPS model and Theoretical Domains Framework, to identify implementation barriers and enablers in study NHs and to identify and design strategies to enhance adoption of the WISCA intervention. Outcomes from this work will be used to develop a large-scale pragmatic clinical trial to assess the effects the WISCA has on antibiotic decisions in a real clinical practice environment.