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IIR 09-104 – HSR&D Study

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IIR 09-104
Guideline Implementation to Decrease Inappropriate Bacteriuria Treatment
Barbara Trautner MD
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: April 2010 - March 2013

BACKGROUND/RATIONALE:
Evidence-based guidelines recommend that providers neither screen for nor treat asymptomatic bacteriuria in most catheterized patients. However, a significant gap exists between these guidelines and clinical practice, including at our VA hospital.

OBJECTIVE(S):
We hypothesized that implementing the existing evidence-based guidelines about non-treatment of ABU would dramatically reduce the unnecessary use of antibiotics to treat ABU and the incidence of incorrectly diagnosed CAUTI. Our first objective was to improve quality of care concerning ABU in terms of specific clinical outcomes (inappropriate screening for and treatment of ABU) through implementation of an audit-feedback strategy. We also hypothesized that successful implementation of an audit-feedback strategy would result in measurable changes in clinicians' knowledge and attitudes concerning ABU practice guidelines. Our second objective was to assess through surveys the effect of the implementation on clinicians' guideline awareness, familiarity, acceptance, and outcome expectancy.

METHODS:
Our guidelines implementation strategy employed audit-feedback, applied as a post-prescription antimicrobial review based on established guidelines. We also created a streamlined diagnostic algorithm for CAUTI versus ABU, based upon the IDSA guidelines. The study population for the clinical outcomes was all inpatients on certain wards at the intervention site (Houston VA) and the control site (San Antonio VA). Our study population for the audit-feedback intervention and surveys was the health care providers on these wards. During the first year we observed the baseline incidence of inappropriate screening for and treatment of ABU at both sites. During the second year, we distributed the guidelines at both sites. We performed a pre-intervention survey of guidelines awareness, familiarity, acceptance, knowledge, and outcome expectancy at the intervention site in July-Sept 2011. From July 2011-June 2012, we provided individualized, case-based feedback to clinicians at the intervention site about whether their management of bacteriuria was guideline-compliant. We repeated the survey at the intervention site in May-September 2012 and also performed the survey at the control site during this time period. During the third year of the intervention, the individualized audit and feedback was replaced by case presentation in the residents' morning report.

FINDINGS/RESULTS:
We first validated and published our urinary catheter surveillance protocol. Our daily surveillance for urinary catheters and associated urine cultures created a large database. From this, we were able to measure how often various urinary catheter types were associated with positive urine cultures. Interestingly, external (condom) catheters accounted for a large portion of catheter-associated bacteriuria-- 37.3% of the 1,009 catheter-associated positive urine cultures over a 12 month period at the two sites. We compared our catheter numbers to those reported to infection control by the wards and found some inaccuracies. Urinary-catheter-days reported to infection control missed 20.1% of the actual days of indwelling catheter use, whereas 12.0% of the reported catheter-days were false (patient no longer on the ward or no longer had a catheter). The challenges of manual reporting methods are not a VA specific problem.
We followed two main clinical outcomes: screening for ABU (urine cultures) and treatment of ABU (antibiotic use). At the intervention site, urine culture ordering decreased by 42% in Houston, from 49.87 cultures/bed-days prior to the intervention to 23.98 cultures/bed-days after the intervention. In comparison, the change at the control site in urine culture ordering was 0%. The differences of the change at each site was significant (p=0.04, Wilcoxon).
Inappropriate treatment of ABU also decreased at our intervention site. Prior to the intervention, providers' specificity at diagnosing ABU (and withholding antibiotics) was 0.63; this improved to 0.79 post-intervention (non-overlapping confidence intervals). Specificity at the control site did not change. Most importantly, the following outcomes decreased significantly at the intervention site but did not change significantly at the control site: inappropriate treatment of bacteriuria in general, inappropriate use of antimicrobials for ABU, and failure to use antimicrobials to treat CAUTI (P<0.0.01, negative binomial). In other words, we did not simply decrease antibiotic use all around but instead improved the providers' diagnostic and management skills, as the number of cases that met CAUTI criteria and yet were not treated with antimicrobial agents fell over time.
This concrete improvement in clinical parameters was backed by measurable changes in knowledge and attitudes about the ABU guidelines. At the start of our intervention year, only 42% of 169 respondents reported greater than minimal recall of ABU guidelines content. The mean provider score on a set of case scenarios designed to test knowledge of guidelines content was 57.5% prior to the intervention at the intervention site. In multivariate analysis, behavior, cognitive biases, and year of training were correlated with the knowledge score (P<0.05). At the start of year 3 of the project, we administered the post-intervention survey in both the intervention and the control site. On this follow-up survey 77% of providers at the intervention site reported greater than minimal recall (P<0.0001, Chi-Square, in comparison to pre-intervention). The mean provider knowledge score at the intervention site also improved from 57.5% to 70.9% (p<0.001, T-test). At the control site, the appropriate treatment score from surveys given at the start of year 3 was 62.5% correct, which was not significantly different from the pre-intervention score at the intervention site but was significantly lower than the post-intervention score in at the intervention site (p=0.007,T-test).

IMPACT:
We have decreased unnecessary ordering of urine cultures and unnecessary use of antimicrobial agents to treat bacteriuria. We have made an impact in a highly relevant and clinically important quality gap in care delivery. Our next step will be to streamline the intervention for dissemination through existing antimicrobial stewardship programs, both within the VA and in non-VA settings.

PUBLICATIONS:

Journal Articles

  1. Naik AD, Skelton F, Amspoker AB, Glasgow RA, Trautner BW. A fast and frugal algorithm to strengthen diagnosis and treatment decisions for catheter-associated bacteriuria. PLoS ONE. 2017 Mar 28; 12(3):e0174415.
  2. Grigoryan L, Naik AD, Horwitz D, Cadena J, Patterson JE, Zoorob R, Trautner BW. Survey finds improvement in cognitive biases that drive overtreatment of asymptomatic bacteriuria after a successful antimicrobial stewardship intervention. American journal of infection control. 2016 Dec 1; 44(12):1544-1548.
  3. Trautner BW, Grigoryan L, Petersen NJ, Hysong S, Cadena J, Patterson JE, Naik AD. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter-Associated Asymptomatic Bacteriuria. JAMA internal medicine. 2015 Jul 1; 175(7):1120-7.
  4. Grigoryan L, Abers MS, Kizilbash QF, Petersen NJ, Trautner BW. A comparison of the microbiologic profile of indwelling versus external urinary catheters. American journal of infection control. 2014 Jun 1; 42(6):682-4.
  5. Trautner BW, Grigoryan L. Approach to a positive urine culture in a patient without urinary symptoms. Infectious Disease Clinics of North America. 2014 Mar 1; 28(1):15-31.
  6. Kizilbash QF, Petersen NJ, Chen GJ, Naik AD, Trautner BW. Bacteremia and mortality with urinary catheter-associated bacteriuria. Infection control and hospital epidemiology. 2013 Nov 1; 34(11):1153-9.
  7. Trautner BW, Patterson JE, Petersen NJ, Hysong S, Horwitz D, Chen GJ, Grota P, Naik AD. Quality gaps in documenting urinary catheter use and infectious outcomes. Infection control and hospital epidemiology. 2013 Aug 1; 34(8):793-9.
  8. Gupta K, Trautner BW. Diagnosis and management of recurrent urinary tract infections in non-pregnant women. BMJ (Clinical research ed.). 2013 May 29; 346:f3140.
  9. Trautner BW, Bhimani RD, Amspoker AB, Hysong SJ, Garza A, Kelly PA, Payne VL, Naik AD. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC medical informatics and decision making. 2013 Apr 15; 13:48.
  10. Burns AC, Petersen NJ, Garza A, Arya M, Patterson JE, Naik AD, Trautner BW. Accuracy of a urinary catheter surveillance protocol. American journal of infection control. 2012 Feb 1; 40(1):55-8.
  11. Lin E, Bhusal Y, Horwitz D, Shelburne SA, Trautner BW. Overtreatment of enterococcal bacteriuria. Archives of internal medicine. 2012 Jan 9; 172(1):33-8.
  12. Trautner BW. Asymptomatic bacteriuria: when the treatment is worse than the disease. Nature reviews. Urology. 2011 Dec 6; 9(2):85-93.
  13. Trautner BW, Kelly PA, Petersen N, Hysong S, Kell H, Liao KS, Patterson JE, Naik AD. A hospital-site controlled intervention using audit and feedback to implement guidelines concerning inappropriate treatment of catheter-associated asymptomatic bacteriuria. Implementation science : IS. 2011 Apr 22; 6(1):41.
  14. Trautner BW. Management of catheter-associated urinary tract infection. Current opinion in infectious diseases. 2010 Feb 1; 23(1):76-82.
Center Products

  1. Trautner B. Asymptomatic bacterium: when the treatment is worse than the disease. Webinar for the Institute of Health Metrics Nursing Quality Education, a non-profit organization that reports to 60 hospitals on quality metrics. 2012 Jul 1.
  2. Trautner B. Asymptomatic bacteriuria: When the treatment is worse than the disease. Webinar for the STOP-CAUTI workgroup, composed of 20 hospitals participating in NICHE (Nurse Improving the Care of Health System Elders). 2011 Sep 26.
  3. Trautner B. Asymptomatic Bacteriuria: When the treatment is worse than the disease. 2011 Sep 1.
Conference Presentations

  1. Grodzinsky A, Naik AD, Horwitz DJ, Cadena-Zuluaga JA, Patterson J, Zoorob R, Trautner B. An antimicrobial stewardship intervention for asymptomatic bacteriuria addressed cognitive biases. Poster session presented at: Society for Healthcare Epidemiology of America Annual Scientific Meeting; 2016 May 19; Atlanta, GA.
  2. Grodzinsky A, Naik AD, Horwitz DJ, Cadena-Zuluaga JA, Patterson J, Zoorob R, Trautner B. An antimicrobial stewardship intervention for asymptomatic bacteriuria addressed cognitive biases. Presented at: Society for Healthcare Epidemiology of America Annual Scientific Meeting; 2016 May 19; Atlanta, GA.
  3. Naik AD, Karel MJ, Mulligan E, Martin L, Moye J. The Taxonomy of Salient and Consistent Values among Older, Multimorbid Cancer Survivors. Poster session presented at: American Geriatrics Society Annual Meeting; 2014 May 16; Orlando, FL.
  4. Trautner B, Petersen NJ, Gendrett AJ, Hysong SJ, Patterson JE, Naik AD. An audit/feedback intervention reduces inappropriate screening and treatment in patients with urinary catheters. Poster session presented at: American Geriatrics Society Annual Meeting; 2014 May 15; Orlando, FL.
  5. Naik AD, Hysong SJ, Horwitz DJ, Petersen NJ, Trautner B. Knowledge of how to manage asymptomatic bacteriuria improves with level of training. Poster session presented at: ATLAS.ti Users Annual Conference; 2013 Oct 4; Berlin, Germany.
  6. Abers MS, Grigoryan L, Kizilbash Q, Petersen NJ, Trautner B. Comparing the microbiologic profile of indwelling vs. external urinary catheters. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2013 Oct 3; San Francisco, CA.
  7. Naik AD, Petersen NJ, Gendrett AJ, Hysong SJ, Patterson JE, Trautner B. Implementation of asymptomatic bacteriuria guidelines reduces inappropriate screening and treatment. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2013 Oct 3; San Francisco, CA.
  8. Naik AD, Petersen NJ, Hysong SJ, Horwitz DJ, Trautner B. Knowledge of How to Manage Asymptomatic Bacteriuria Improves with Level of Training. Poster session presented at: ID Week: A Joint Meeting of IDSA, SHEA, HIVMA, and PIDS; 2013 Oct 1; San Francisco, CA.
  9. Trautner B. Optimizing Management of Asymptomatic Bacteriuria. Paper presented at: Clinical and Scientific Advances in Urinary Tract Infections International Symposium; 2013 Jun 1; Columbus, OH.
  10. Marschall J, Carpenter C, Fowler S, Trautner B. Antibiotic prophylaxis for urinary tract infections after urinary catheter removal: A meta-analysis. Poster session presented at: European Society of Clinical Microbiology and Infectious Diseases Annual Congress; 2013 Apr 29; Berlin, Germany.
  11. Kizilbash Q, Naik AD, Chen GJ, Petersen NJ, Trautner B. Bacteremia and mortality after catheter-associated bacteriuria. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2012 Oct 18; San Diego, CA.
  12. Trautner B. Effective strategies to prevent catheter-associated UTIs. Poster session presented at: Interscience Conference on Antimicrobial Agents and Chemotherapy; 2012 Sep 9; San Francisco, CA.
  13. Burns AC, Garza A, Patterson JE, Grota P, Naik A, Trautner B. External (condom) catheters are associated with high rates of bacteriuria. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2011 Oct 20; Boston, MA.
  14. Grota P, Cadena J, Kelly C, Burns AC, Trautner B, Patterson JE. Comparison of two definitions for detection of catheter-associated urinary tract infection. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2011 Oct 20; Boston, MA.
  15. Liao K, Lehman S, Tweardy DJ, Donlan R, Trautner B. Bacteriophage as an adjunct to bacterial inference. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2011 Oct 20; Boston, MA.
  16. Lin E, Bhusal Y, Horwitz D, Shelburne S, Trautner B. Enterococcal bacteriuria is often overtreated and rarely leads to infections complications. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2011 Oct 20; Boston, MA.
  17. Burns A, Petersen NJ, Naik AD, Arya M, Kelly PA, Hysong SJ, Garza A, Kell H, Patterson JE, Trautner BW. Accurate urinary catheter surveillance requires individual chart review. Poster session presented at: Society for Healthcare Epidemiology of America Scientific Annual Meeting; 2011 Apr 3; Dallas, TX.
  18. Burns AC, Garza A, Arya M, Petersen N, Naik AD, Kelly PA, Hysong SJ, Trautner B. Reliability of electronic medical records for predicting catheter type at the VA medical center. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2010 Oct 21; Vancouver, Canada.
  19. Lin E, Horwitz D, Bhusal Y, Roig I, Shelburne S, Trautner B. Entercoccal bacteriuria is often managed inappropriately. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2010 Oct 21; Vancouver, Canada.


DRA: Health Systems
DRE: Treatment - Comparative Effectiveness
Keywords: Clinical practice guidelines, Education (provider)
MeSH Terms: none

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