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CDA 16-204 – HSR&D Study

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CDA 16-204
Improving antimicrobial use at hospitals that lack infectious disease specialists
Daniel J Livorsi MD MS
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: October 2017 - September 2022

Antimicrobial resistance (AMR) is one of today's most urgent public health problems. Antimicrobial stewardship programs (ASPs) can optimize antimicrobial-prescribing, thereby reducing the emergence of AMR while improving patient safety. VHA Directive 1031 mandated that every VHA facility establish and maintain an ASP, and similar regulations have been implemented in non-VHA settings. However, widespread ASP implementation will be challenging. Many ASPs lack access to Infectious Disease (ID) specialists, including 23% of VHA-ASPs. It is unclear how ASPs can be effective in such resource-limited settings. This application will begin to address this problem through an ambitious but achievable Research Plan.

The objective of the proposal is to evaluate and improve antimicrobial stewardship processes at VHA hospitals lacking local ID support. The specific aims are to: 1) identify structural factors and processes associated with facility-level ASP performance; 2) determine provider attitudes and organizational factors that impede or foster antimicrobial stewardship at VHA hospitals lacking ID support, and 3) conduct a pilot intervention to bolster antimicrobial stewardship at VHA hospitals that have low-performing ASPs and lack local ID support. The design of this pilot intervention will be informed by the findings of Aims 1 and 2.

This study will use multilevel regression techniques to evaluate antimicrobial-prescribing across a large cohort of VHA inpatients. Qualitative assessments will also be conducted to understand local barriers and facilitators to antimicrobial stewardship. Finally, a pilot intervention will be implemented at 2 sites to augment local stewardship efforts. The model of Physician Mentored Implementation will guide this intervention, and a pretest-posttest design will be used to assess the effect of the intervention at the 2 intervention hospitals compared to 2 control hospitals.

Not yet available.

Due to the crisis of AMR, there will be an ongoing need to improve antimicrobial use. For this reason, all VHA medical facilities are now mandated to have an active ASP. However, it's unclear how VHA-ASPs without ID support have implemented stewardship processes and whether these processes are effective. The findings from Aim 1 and Aim 2 should address this critical gap in the literature. Our work in Aim 3 will trial novel strategies for improving antimicrobial use in these settings.


Journal Articles

  1. Nair R, Perencevich EN, Goto M, Livorsi DJ, Balkenende E, Kiscaden E, Schweizer ML. Patient care experience with utilization of isolation precautions: A systematic literature review and meta-analysis. Clinical Microbiology and Infection : The Official Publication of The European Society of Clinical Microbiology and Infectious Diseases. 2020 Jan 29.
  2. Morris AM, Calderwood MS, Fridkin SK, Livorsi DJ, McGregor JC, Mody L, Moehring RW, Pakyz AL, Stenehjem E, Szymczak JE, Tamma PD. Research needs in antibiotic stewardship. Infection control and hospital epidemiology. 2019 Dec 1; 40(12):1334-1343.
  3. Musuuza JS, McKinley L, Keating JA, Obasi C, Knobloch MJ, Crnich C, Evans CT, Evans ME, Livorsi D, Morgan DJ, Perencevich EN, Reisinger HS, Schweizer ML, Suda KJ, Simbartl LA, Safdar N. Correlation of prevention practices with rates of health care-associated infection. Infection control and hospital epidemiology. 2020 Jan 1; 41(1):52-58.
  4. Feller J, Lund BC, Perencevich EN, Alexander B, Heintz B, Beck B, Nair R, Goto M, Livorsi DJ. Post-discharge oral antimicrobial use among hospitalized patients across an integrated national healthcare network. Clinical Microbiology and Infection : The Official Publication of The European Society of Clinical Microbiology and Infectious Diseases. 2019 Oct 7.
  5. Suzuki H, Perencevich EN, Alexander B, Beck BE, Goto M, Lund BC, Nair R, Livorsi DJ. Inpatient Fluoroquinolone Stewardship Improves the Quantity and Quality of Fluoroquinolone-prescribing at Hospital Discharge: A Retrospective Analysis among 122 Veterans Health Administration Hospitals. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2019 Sep 28.
  6. Puig-Asensio M, Perencevich EN, Livorsi DJ. Prolonged postprocedural antimicrobial use: A survey of the Society for Healthcare Epidemiology of America Research Network. Infection control and hospital epidemiology. 2019 Nov 1; 40(11):1281-1283.
  7. Dykes LA, Heintz SJ, Heintz BH, Livorsi DJ, Egge JA, Lund BC. Contrasting qSOFA and SIRS Criteria for Early Sepsis Identification in a Veteran Population. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2019 Mar 1; 36(Suppl 2):S21-S24.
  8. Khaw C, Oberle AD, Lund BC, Egge J, Heintz BH, Erickson BA, Livorsi DJ. Assessment of Guideline Discordance With Antimicrobial Prophylaxis Best Practices for Common Urologic Procedures. JAMA Network Open. 2018 Dec 7; 1(8):e186248.
  9. Griebel ME, Heintz B, Alexander B, Egge J, Goto M, Livorsi DJ. Understanding changes in the standardized antimicrobial administration ratio for total antimicrobial use after implementation of prospective audit and feedback. Infection control and hospital epidemiology. 2018 Dec 1; 39(12):1476-1479.
  10. Chandra S, Klair JS, Soota K, Livorsi DJ, Johlin FC. Endoscopic Retrograde Cholangio-Pancreatography-Obtained Bile Culture Can Guide Antibiotic Therapy in Acute Cholangitis. Digestive diseases (Basel, Switzerland). 2018 Oct 3; 1-6.
  11. Masadeh M, Chandra S, Livorsi D, Johlin F, Silverman W. Evaluation of Biliary Bacterial Resistance in Patients with Frequent Biliary Instrumentation, One Size Does Not Fit All. Digestive diseases and sciences. 2018 Dec 1; 63(12):3474-3479.
  12. Livorsi DJ, Chorazy ML, Schweizer ML, Balkenende EC, Blevins AE, Nair R, Samore MH, Nelson RE, Khader K, Perencevich EN. A systematic review of the epidemiology of carbapenem-resistant Enterobacteriaceae in the United States. Antimicrobial resistance and infection control. 2018 Apr 24; 7:55.
  13. Keating JA, Obasi C, McKinley L, Musuuza J, Knobloch MJ, Crnich C, Evans CT, Evans M, Livorsi D, Morgan DJ, Perencevich E, Reisinger HS, Schweizer ML, Suda KJ, Safdar N. Building Implementation Science for Veterans Affairs Healthcare Associated Infection Prevention: VA Healthcare-Associated Infection Prevention Network (VHIN). Infection control and hospital epidemiology. 2018 Jun 1; 39(6):753-757.
  14. Suda KJ, Livorsi DJ, Goto M, Forrest GN, Jones MM, Neuhauser MM, Hoff BM, Ince D, Carrel M, Nair R, Knobloch MJ, Goetz MB. Research Agenda for Antimicrobial Stewardship in the Veterans Health Administration. Infection control and hospital epidemiology. 2018 Feb 1; 39(2):196-201.
  15. Livorsi DJ, Linn CM, Alexander B, Heintz BH, Tubbs TA, Perencevich EN. The Value of Electronically Extracted Data for Auditing Outpatient Antimicrobial Prescribing. Infection control and hospital epidemiology. 2018 Jan 1; 39(1):64-70.
Journal Other

  1. Livorsi DJ, Reisinger HS, Stenehjem E. Adapting Antibiotic Stewardship to the Community Hospital. JAMA Network Open. 2019 Aug 2; 2(8):e199356.
  2. Hoff BM, Ford DC, Ince D, Ernst EJ, Livorsi DJ, Heintz BH, Masse V, Brownlee MJ, Ford BA. Implementation of a Mobile Clinical Decision Support Application to Augment Local Antimicrobial Stewardship. Journal of pathology informatics. 2018 Apr 2; 9:10.
  3. Livorsi DJ, Evans CT, Morgan DJ, Reisinger HS, Safdar N, Suda KJ, Perencevich EN. Setting the Research Agenda for Preventing Infections From Multidrug-Resistant Organisms in the Veterans Health Administration. Infection control and hospital epidemiology. 2018 Feb 1; 39(2):186-188.

DRA: Health Systems, Infectious Diseases
DRE: none
Keywords: none
MeSH Terms: none

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