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IIR 15-120 – HSR&D Study

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IIR 15-120
Improving Antimicrobial Stewardship in Veterans Affairs (VA) Community Living Centers
David Dosa MD
Providence VA Medical Center, Providence, RI
Providence, RI
Funding Period: December 2016 - November 2020

BACKGROUND/RATIONALE:
Antimicrobial resistance is a public health crisis. This crisis has been created through indiscriminate antimicrobial use, which promotes selection for multidrug resistant organisms, increases the risk of adverse drug reactions/interactions and renders us vulnerable to drug-resistant infections. In the long-term care setting, up to 75% of antimicrobial use is reported to be inappropriate or unnecessary. For Veterans Affairs (VA) long-term care facilities, (referred to as Community Living Centers or CLCs), antimicrobial utilization rates, antimicrobial resistance patterns and effective antimicrobial stewardship (AMS) interventions are largely unknown. Though VA Directives mandate increased AMS efforts in all VA medical facilities, implementation into CLCs has been lagging comparatively to VA Medical Centers (VAMCs). There is a critical need to evaluate the stewardship needs and develop tailored interventions to improve the care of the 50,000+ Veterans who reside in CLCs annually.

OBJECTIVE(S):
Aim 1: Measure antimicrobial use and resistance in VA-CLCs nationally through the development of a longitudinal database of antimicrobial use and resistance. This database would allow us to quantify regional and temporal trends, and identify areas of high antimicrobial use and resistance nationally.

Aim 2: Develop and implement various well researched antimicrobial stewardship practices and programs at three CLCs

Aim 3: Measure Antimicrobial Stewardship interventions on resistance, antimicrobial use and outcomes data from pilot CLCs.

METHODS:
Aim 1: We will assemble a longitudinal database of antimicrobial use and resistance in the VA. This database will be used to quantify regional and temporal trends, as well as to identify areas of high use and resistance nationally permitting identification of target areas for improvement and enabling the development of facility-specific interventions.

Aim 2: We will develop, implement and evaluate three different levels of AMS interventions in CLCs. These CLCs will pilot test a menu of options for future implementation work ranging from less to more resource intensive.

Aim 3: We will use a mixed-methods approach to evaluate the implementation and success of each intervention. We will conduct semi-structured qualitative interviews with key informants at each participating CLC at various time points. These interviews will provide insight regarding the barriers and facilitators to the intervention implementation, describe changes to the facilities' AMS practices, and identify changes in the AMS culture at each facility. Using secondary data, we will compare the effectiveness of the AMS interventions by assessing within-facility changes in antibiotic utilization rates and select clinical outcome measures during the study period, as well as between-facility changes with matched control CLCs.

FINDINGS/RESULTS:
Aim 1 analyses show that over the 8-year period of study, the number of cultures obtained per nursing home admission decreased significantly by 8.4% per year (95% CI, -10.1- -6.6%). Approximately half (53.7%, n=183,974) of cultures obtained were positive for microbial growth. The proportion of positive cultures obtained remained stable over the study period (AAPC = -0.4% per year [95% CI, -1.1-0.4%], p=0.3). The number of cultures obtained from all source types (urine, blood, skin and lung) decreased significantly over the study period. The proportion of cultures positive for S. aureus decreased significantly by 5% per year (95% CI, -7.6- -2.5%) and the proportion of cultures positive for E. coli increased significantly by 3.3% per year (95% CI, 2.4%- 4.3%). The proportions of all other Gram-negative organisms assessed increased significantly over the study period, except M. morganii.

IMPACT:
In recent decades, rates of multi-drug resistant infections have soared while antimicrobial development has slowed. Infections caused by drug-resistant pathogens are increasingly complicated to treat and are associated with increased morbidity and mortality, longer hospital stays, and increased healthcare costs. These pathogens are particularly concerning for our Veterans since medically complex, elderly patients are at an increased risk of developing such infections and suffering the worst consequences, due to the infection itself and treatment-related adverse events.

PUBLICATIONS:

Journal Articles

  1. Appaneal HJ, Jiang L, Dosa DM, LaPlante KL. Antibiotic Prescribing Pathway for Urinary Tract Infections: A "Low-Hanging Fruit" Antibiotic Stewardship Target in Nursing Homes. Journal of the American Geriatrics Society. 2017 Dec 1; 65(12):2744-2745.
  2. Morrill HJ, Morton JB, Caffrey AR, Jiang L, Dosa D, Mermel LA, LaPlante KL. Antimicrobial Resistance of Escherichia coli Urinary Isolates in the Veterans Affairs Health Care System. Antimicrobial agents and chemotherapy. 2017 May 1; 61(5):doi: 10.1128/AAC.02236-16.


DRA: Health Systems
DRE: TRL - Applied/Translational
Keywords: Guideline Development and Implementation, Medication Management, Practice Patterns/Trends
MeSH Terms: none