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IIR 16-025 – HSR&D Study

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IIR 16-025
Less is More: Improving Antimicrobial Stewardship for Asymptomatic Bacteriuria
Barbara Trautner MD
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: February 2018 - September 2021

Antimicrobial stewardship as a means to combat the spread of antibiotic-resistant bacteria has become a national priority, both within and outside the VHA. This IIR project focuses on improving Veteran safety by reducing inappropriate use of antimicrobials for asymptomatic bacteriuria (ASB), a very common condition that leads to antimicrobial overuse in acute and long-term care. We conducted a successful intervention to decrease guideline-discordant ordering of urine cultures and antibiotics for ASB. This single site intervention, entitled "Kicking Catheter Associated Urinary Tract Infection (CAUTI): the No Knee-Jerk Antibiotics Campaign," reduced unnecessary screening for ASB by 71% and unnecessary treatment of ASB by 75% in a large and complex VA medical center. The UTI medication use evaluation recently conducted by the VA Antimicrobial Stewardship Task Force (ASTF) shows an acute need for our intervention, as 57% of 1,219 urine cultures treated as UTI (with antibiotics) were actually ASB. Our work is innovative in that we address the cognitive biases that drive overuse of antibiotics and encourage more deliberate choice.

The objective of this project is to facilitate implementation of a scalable version of the Kicking CAUTI campaign across four geographically diverse VA facilities while assessing what aspects of an antimicrobial stewardship intervention are essential to success and sustainability. Our project team and our operational partners will provide expertise and external facilitation, while intervention implementation at the facility level will be performed by the local personnel tasked with antimicrobial stewardship. The two main intervention tools are (1) an evidence-based algorithm that distills the guidelines into a streamlined clinical pathway, and (2) case-based audit and feedback to train clinicians to use the algorithm. The intervention is directed at providers in acute and long-term care, and the goal is to reduce inappropriate screening for and treatment of ASB in all patients and residents, not just those with urinary catheters. Aim 1 is to determine barriers to guideline-recommended practices for management of catheter-associated bacteriuria at intervention sites and assemble the local implementation teams. Aim 2 is to implement and evaluate a scalable version of the Kicking CAUTI intervention in four VA facilities, using four additional sites as contemporaneous controls. 2a: We will measure the clinical outcomes of urine cultures ordered, antibiotic use, and episodes of Clostridium difficile infection using Corporate Data Warehouse and review of selected charts at each site. 2b: We will study the relationship between the dose of the intervention delivered and clinical outcomes. Aim 3: Assess the economic implications of the intervention through a budget impact analysis.

Our intervention will include an on-ramp period for each facility consisting of centrally-led phone calls with local site champions and baseline surveys. Case-based audit and feedback will begin at a given site after the on-ramp period and continue for twelve months. We will stagger intervention roll-out by quarter for each of the four intervention sites. The three-year project timeframe allows 3 months for project start-up, 3 months on-ramp at each site, 12 months for the active intervention implementation, and a sustainability phase at each site. Our analysis for Aim 2A will use clinical outcome data from Corporate Data Warehouse to conduct interrupted time series with segmented regression analysis. The analysis for Aim 2B will use regression models to assess whether more complete implementation is associated with better clinical outcomes, using process measures of key implementation components. The budget impact analysis will assess savings and costs of the intervention from the VHA perspective.

As the project funding is just starting this month, we do not yet have findings to report.

Throughout the project we will have two calls each year with our operational partners. These partners, the National Center for Patient Safety, the National Infectious Diseases Service, the ASTF, and Pharmacy Benefits Management, have advised and directed the design of this proposal over the past year and will continue their involvement from the time of project launch to help plan for national dissemination.


Journal Articles

  1. Goebel MC, Trautner BW, Wang Y, Van JN, Dillon LM, Patel PK, Drekonja DM, Graber CJ, Shukla BS, Lichtenberger P, Helfrich CD, Sales A, Grigoryan L. Organizational readiness assessment in acute and long-term care has important implications for antibiotic stewardship for asymptomatic bacteriuria. American journal of infection control. 2020 Nov 1; 48(11):1322-1328.
  2. Drekonja DM, Grigoryan L, Lichtenberger P, Graber CJ, Patel PK, Van JN, Dillon LM, Wang Y, Gauthier TP, Wiseman SW, Shukla BS, Naik AD, Hysong SJ, Kramer JR, Trautner BW. Teamwork and safety climate affect antimicrobial stewardship for asymptomatic bacteriuria. Infection control and hospital epidemiology. 2019 Sep 1; 40(9):963-967.
  3. Grigoryan L, Germanos G, Zoorob R, Juneja S, Raphael JL, Paasche-Orlow MK, Trautner BW. Use of Antibiotics Without a Prescription in the U.S. Population: A Scoping Review. Annals of internal medicine. 2019 Jul 23.
  4. Grigoryan L, Nash S, Zoorob R, Germanos GJ, Horsfield MS, Khan FM, Martin L, Trautner BW. Qualitative Analysis of Primary Care Provider Prescribing Decisions for Urinary Tract Infections. Antibiotics (Basel, Switzerland). 2019 Jun 19; 8(2).
  5. Skelton F, Martin LA, Evans CT, Kramer J, Grigoryan L, Richardson P, Kunik ME, Poon IO, Holmes SA, Trautner BW. Determining Best Practices for Management of Bacteriuria in Spinal Cord Injury: Protocol for a Mixed-Methods Study. JMIR research protocols. 2019 Feb 14; 8(2):e12272.
  6. Trautner BW, Prasad P, Grigoryan L, Hysong SJ, Kramer JR, Rajan S, Petersen NJ, Rosen T, Drekonja DM, Graber C, Patel P, Lichtenberger P, Gauthier TP, Wiseman S, Jones M, Sales A, Krein S, Naik AD, Less is More Study Group. Protocol to disseminate a hospital-site controlled intervention using audit and feedback to implement guidelines concerning inappropriate treatment of asymptomatic bacteriuria. Implementation science : IS. 2018 Jan 19; 13(1):16.

DRA: Health Systems, Infectious Diseases
DRE: Treatment - Comparative Effectiveness, Treatment - Implementation, TRL - Applied/Translational
Keywords: Best Practices, Effectiveness, Implementation, Quality Improvement, Safety Measurement Development
MeSH Terms: none

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