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Vicentini C, Libero G, Cugudda E, Gardois P, Zotti CM, Bert F. Barriers to the implementation of antimicrobial stewardship programmes in long-term care facilities: a scoping review. J Antimicrob Chemother 2024; 79:1748-1761. [PMID: 38870077 PMCID: PMC11290887 DOI: 10.1093/jac/dkae146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Long-term care facilities (LTCFs) present specific challenges for the implementation of antimicrobial stewardship (AMS) programmes. A growing body of literature is dedicated to AMS in LTCFs. OBJECTIVES We aimed to summarize barriers to the implementation of full AMS programmes, i.e. a set of clinical practices, accompanied by recommended change strategies. METHODS A scoping review was conducted through Ovid-MEDLINE, CINAHL, Embase and Cochrane Central. Studies addressing barriers to the implementation of full AMS programmes in LTCFs were included. Implementation barriers described in qualitative studies were identified and coded, and main themes were identified using a grounded theory approach. RESULTS The electronic search revealed 3904 citations overall. Of these, 57 met the inclusion criteria. All selected studies were published after 2012, and the number of references per year progressively increased, reaching a peak in 2020. Thematic analysis of 13 qualitative studies identified three main themes: (A) LTCF organizational culture, comprising (A1) interprofessional tensions, (A2) education provided in silos, (A3) lack of motivation and (A4) resistance to change; (B) resources, comprising (B1) workload and staffing levels, (B2) diagnostics, (B3) information technology resources and (B4) funding; and (C) availability of and access to knowledge and skills, including (C1) surveillance data, (C2) infectious disease/AMS expertise and (C3) data analysis skills. CONCLUSIONS Addressing inappropriate antibiotic prescribing in LTCFs through AMS programmes is an area of growing interest. Hopefully, this review could be helpful for intervention developers and implementers who want to build on the most recent evidence from the literature.
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Affiliation(s)
- Costanza Vicentini
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Giulia Libero
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Eleonora Cugudda
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Paolo Gardois
- Department of Public Health Sciences and Pediatrics, Medical Library ‘Ferdinando Rossi’, University of Turin, Torino, Italy
| | - Carla Maria Zotti
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Fabrizio Bert
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
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Coffey KC, Claeys K, Morgan DJ. Diagnostic Stewardship for Urine Cultures. Infect Dis Clin North Am 2024; 38:255-266. [PMID: 38575490 DOI: 10.1016/j.idc.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Urinary tract infections are among the most common infectious diagnoses in health care, but most urinary tract infections are diagnosed inappropriately in patients without signs or symptoms of infection. Asymptomatic bacteriuria leads to inappropriate antibiotic prescribing and negative downstream effects, including antimicrobial resistance, health care-associated infections, and adverse drug events. Diagnostic stewardship is the process of modifying the ordering, performing, or reporting of test results to improve clinical care. Diagnostic stewardship impacts the diagnostic pathway to decrease inappropriate detection and treatment of asymptomatic bacteriuria. This article reviews diagnostic stewardship methods and closes with a case study illustrating these principles in practice.
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Affiliation(s)
- K C Coffey
- Epidemiology and Public Health, University of Maryland School of Medicine, 10 S. Pine Street, Baltimore, MD 21201, USA.
| | - Kimberley Claeys
- Department of Practice and Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Daniel J Morgan
- Epidemiology and Public Health, University of Maryland School of Medicine, 10 S. Pine Street, Baltimore, MD 21201, USA
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Vaughn VM, Gupta A, Petty LA, Malani AN, Osterholzer D, Patel PK, Younas M, Bernstein SJ, Burdick S, Ratz D, Szymczak JE, McLaughlin E, Czilok T, Basu T, Horowitz JK, Flanders SA, Gandhi TN. A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria. JAMA Intern Med 2023; 183:933-941. [PMID: 37428491 PMCID: PMC10334295 DOI: 10.1001/jamainternmed.2023.2749] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/23/2023] [Indexed: 07/11/2023]
Abstract
Importance Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events. Objective To determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB. Design, Setting, and Participants This 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022. Exposure Participation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion. Main Outcomes and Measures Overall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration. Results Of the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00). Conclusions and Relevance This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.
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Affiliation(s)
- Valerie M. Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Division of Health System Innovation & Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Ashwin Gupta
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lindsay A. Petty
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Anurag N. Malani
- Division of Infectious Diseases, Department of Internal Medicine, Trinity Health, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan
| | - Danielle Osterholzer
- Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan
- Department of Internal Medicine, College of Human Medicine, Michigan State University, East Lansing
| | - Payal K. Patel
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah
| | - Mariam Younas
- Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan
| | - Steven J. Bernstein
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Division of General Internal Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Stephanie Burdick
- Division of Hospital Medicine, Corewell Health, Grand Rapids, Michigan
| | - David Ratz
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Julia E. Szymczak
- Division of Health System Innovation & Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elizabeth McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Tawny Czilok
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Tanima Basu
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Jennifer K. Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Scott A. Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Tejal N. Gandhi
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
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Amenta E, Grigoryan L, Rajan SS, Ramsey D, Kramer JR, Walder A, Chou A, Van JN, Krein SL, Hysong S, Naik AD, Trautner BW. Quantifying the Implementation and Cost of a Multisite Antibiotic Stewardship Intervention for Asymptomatic Bacteriuria. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e115. [PMID: 37502251 PMCID: PMC10369447 DOI: 10.1017/ash.2023.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 07/29/2023]
Abstract
Objective The intensity of an antibiotic stewardship intervention to achieve clinical impact is not known. We conducted a multisite dissemination project of an intervention to reduce treatment of asymptomatic bacteriuria (ASB) and studied: (1) the association between implementation metrics and clinical outcomes and (2) the cost of implementation. Design/Setting/Participants A central site facilitated a multimodality intervention to decrease unnecessary urine cultures and antibiotic treatment in patients with ASB at 4 Veterans Affairs medical centers. Methods The intervention consisted of a decision support aid algorithm and interactive teaching cases that provided in the moment audit and feedback on how to manage ASB. Implementation outcomes included minutes spent in intervention delivery, number of healthcare professionals reached, and number of sessions delivered. Clinical outcomes included days of antibiotic therapy (DOT), length of antibiotic therapy (LOT), and number of urine cultures ordered per 1000 bed days. Personnel reported weekly time logs. Results Minutes spent in intervention delivery were inversely correlated with two clinical outcomes, DOT (R -0.3, P = .04) and LOT (R -0.3, P = .02). Number of healthcare professionals reached and number of sessions delivered were not correlated with clinical outcomes of DOT (R -0.003, P = .98, R = -0.059, P = .69) or LOT (R +0.073, P = .62, R -0.102, P = .49). Physician champions spent an average of 3.8% of effort on the intervention. The implementation cost was USD 22,299/year per site on average. Conclusions The amount of time local teams spent in delivery of an antibiotic stewardship intervention was correlated with the desired decrease in antibiotic use. Implementing this successful antibiotic stewardship intervention required minimal time.
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Affiliation(s)
- Eva Amenta
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Larissa Grigoryan
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Suja S. Rajan
- UTHealth Science Center, Institute for Stroke and Cerebral Vascular Disease, Houston, TX, USA
| | - David Ramsey
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer R. Kramer
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Annette Walder
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Andrew Chou
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - John N. Van
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
| | - Sarah L. Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sylvia Hysong
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aanand D. Naik
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston, TX, USA
- UTHealth Consortium on Aging, University of Texas Health Science Center, Houston, TX, USA
| | - Barbara W. Trautner
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Grigoryan L, Naik AD, Lichtenberger P, Graber CJ, Patel PK, Drekonja DM, Gauthier TP, Shukla B, Sales AE, Krein SL, Van JN, Dillon LM, Hysong SJ, Kramer JR, Walder A, Ramsey D, Trautner BW. Analysis of an Antibiotic Stewardship Program for Asymptomatic Bacteriuria in the Veterans Affairs Health Care System. JAMA Netw Open 2022; 5:e2222530. [PMID: 35877123 PMCID: PMC9315417 DOI: 10.1001/jamanetworkopen.2022.22530] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Antibiotic stewardship for asymptomatic bacteriuria (ASB) is an important quality improvement target. Understanding how to implement successful antibiotic stewardship interventions is limited. OBJECTIVE To evaluate the effectiveness of a quality improvement stewardship intervention on reducing unnecessary urine cultures and antibiotic use in patients with ASB. DESIGN, SETTING, AND PARTICIPANTS This interrupted time series quality improvement study was performed at the acute inpatient medical and long-term care units of 4 intervention sites and 4 comparison sites in the Veterans Affairs (VA) health care system from October 1, 2017, through April 30, 2020. Participants included the clinicians who order or collect urine cultures and who order, dispense, or administer antibiotics. Clinical outcomes were measured in all patients in a study unit during the study period. Data were analyzed from July 6, 2020, to May 24, 2021. INTERVENTION Case-based teaching on how to apply an evidence-based algorithm to distinguish urinary tract infection and ASB. The intervention was implemented through external facilitation by a centralized coordinating center, with a site champion at each intervention site serving as an internal facilitator. MAIN OUTCOMES AND MEASURES Urine culture orders and days of antibiotic therapy (DOT) and length of antibiotic therapy in days (LOT) associated with urine cultures, standardized by 1000 bed-days, were obtained from the VA's Corporate Data Warehouse. RESULTS Of 11 299 patients included, 10 703 (94.7%) were men, with a mean (SD) age of 72.6 (11.8) years. The decrease in urine cultures before and after the intervention was not significant in intervention sites per segmented regression analysis (-0.04 [95% CI, -0.17 to 0.09]; P = .56). However, difference-in-differences analysis comparing intervention with comparison sites found a significant reduction in the number of urine cultures ordered by 3.24 urine cultures per 1000 bed-days (P = .003). In the segmented regression analyses, the relative percentage decrease of DOT in the postintervention period at the intervention sites was 21.7% (P = .007), from 46.1 (95% CI, 28.8-63.4) to 37.0 (95% CI, 22.6-51.4) per 1000 bed-days. The relative percentage decrease of LOT in the postintervention period at the intervention sites was 21.0% (P = .001), from 36.7 (95% CI, 23.2-50.2) to 29.6 (95% CI, 18.2-41.0) per 1000 bed-days. CONCLUSIONS AND RELEVANCE The findings of this quality improvement study suggest that an individualized intervention for antibiotic stewardship for ASB was associated with a decrease in urine cultures and antibiotic use when implemented at multiple sites via external and internal facilitation. The electronic health record database-derived outcome measures and centralized facilitation approach are both suitable for dissemination.
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Affiliation(s)
- Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Paola Lichtenberger
- Department of Medicine, University of Miami Miller School of Medicine and the Miami VA Healthcare System, University of Miami, Miami, Florida
| | - Christopher J. Graber
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA (University of California, Los Angeles)
| | - Payal K. Patel
- Division of Infectious Diseases, Department of Medicine, University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor
| | - Dimitri M. Drekonja
- Division of Infectious Diseases and International Medicine, University of Minnesota Medical School and Minneapolis VA Health Care System, Minneapolis
| | | | - Bhavarth Shukla
- Department of Medicine, University of Miami Miller School of Medicine and the Miami VA Healthcare System, University of Miami, Miami, Florida
| | - Anne E. Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | - Sarah L. Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - John N. Van
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Laura M. Dillon
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Sylvia J. Hysong
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer R. Kramer
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Annette Walder
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David Ramsey
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Hemenway AN, DuBois DL. A Scoping Review of the Use of Social and Behavioral Change in Acute Care Antimicrobial Stewardship Initiatives. Hosp Pharm 2022; 57:138-145. [PMID: 35521015 PMCID: PMC9065515 DOI: 10.1177/0018578721990887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Purpose: Antimicrobial stewardship (AS) initiatives are implemented with a goal of reducing antimicrobial resistance. It is unknown exactly how many acute care AS initiatives have since been based on social and behavioral theory. The purpose of this scoping review is to provide an updated review of theory-informed acute care AS initiatives in the published literature, including how social and behavioral theories have been used in the described interventions. Methods: PubMed, EMBASE, CINAHL, PsycINFO, and ProQuest Dissertations were searched using a combination of AS, acute care, and social and behavioral theory search terms from April 2011 to November 2019. Using both an initial review of titles and abstracts and a second review of full text, a total of 4 articles were identified after a review of 2014 records. Each article was coded using a guide that abstracted details of study methods, the AS intervention, and use of theory based on a validated theory coding scheme. Results: The interventions included combinations of decision-making tools, provider education, and prospective audit and feedback. Two studies included an evaluation of the described initiative, with findings indicating improvement in antimicrobial use. All interventions utilized theory in developing AS interventions. However, gaps were evident in the use of theory in the evaluations, including inconsistent measurement of theory constructs and lack of testing of the theory. Conclusion: AS interventions are frequently published; however, theory-based acute care AS interventions are not commonly described. More consistent and comprehensive utilization of social and behavioral theories may enhance effectiveness of AS programs.
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Affiliation(s)
- Alice N. Hemenway
- College of Pharmacy, University of Illinois Chicago—Rockford Health Sciences Campus, Rockford, IL, USA,Alice N. Hemenway, Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago—Rockford Health Sciences Campus, 1601 Parkview Avenue S223, Rockford, IL 61107, USA.
| | - David L. DuBois
- School of Public Health, University of Illinois Chicago, Chicago, IL, USA
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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. Am J Infect Control 2020; 48:1322-1328. [PMID: 32437753 DOI: 10.1016/j.ajic.2020.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Prior to implementing an antibiotic stewardship intervention for asymptomatic bacteriuria (ASB), we assessed institutional barriers to change using the Organizational Readiness to Change Assessment. METHODS Surveys were self-administered on paper in inpatient medicine and long-term care units at 4 Veterans Affairs facilities. Participants included providers, nurses, and pharmacists. The survey included 7 subscales: evidence (perceived strength of evidence) and six context subscales (favorability of organizational context). Responses were scored on a 5-point Likert-type scale. RESULTS One hundred four surveys were completed (response rate = 69.3%). Overall, the evidence subscale had the highest score; the resources subscale (mean 2.8) was significantly lower than other subscales (P < .001). Scores for budget and staffing resources were lower than scores for training and facility resources (P < .001 for both). Pharmacists had lower scores than providers for the staff culture subscale (P = .04). The site with the lowest scores for resources (mean 2.4) also had lower scores for leadership and lower pharmacist effort devoted to stewardship. CONCLUSIONS Although healthcare professionals endorsed the evidence about nontreatment of ASB, perceived barriers to antibiotic stewardship included inadequate resources and leadership support. These findings provide targets for tailoring the stewardship intervention to maximize success.
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Sustainability of innovations in healthcare: A systematic review and conceptual framework for professional pharmacy services. Res Social Adm Pharm 2020; 16:1331-1343. [DOI: 10.1016/j.sapharm.2020.01.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 12/13/2019] [Accepted: 01/26/2020] [Indexed: 01/11/2023]
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Targeting Asymptomatic Bacteriuria in Antimicrobial Stewardship: the Role of the Microbiology Laboratory. J Clin Microbiol 2020; 58:JCM.00518-18. [PMID: 32051261 DOI: 10.1128/jcm.00518-18] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
This minireview focuses on the microbiologic evaluation of patients with asymptomatic bacteriuria, as well as indications for antibiotic treatment. Asymptomatic bacteriuria is defined as two consecutive voided specimens (preferably within 2 weeks) with the same bacterial species, isolated in quantitative counts of ≥105 CFU/ml in women, including pregnant women; a single voided urine specimen with one bacterial species isolated in a quantitative count ≥105 CFU/ml in men; and a single catheterized urine specimen with one or more bacterial species isolated in a quantitative count of ≥105 CFU/ml in either women or men (or ≥102 CFU/ml of a single bacterial species from a single catheterized urine specimen). Any urine specimen with ≥104 CFU/ml group B Streptococcus is significant for asymptomatic bacteriuria in a pregnant woman. Asymptomatic bacteriuria occurs, irrespective of pyuria, in the absence of signs or symptoms of a urinary tract infection. The two groups with the best evidence of adverse outcomes in the setting of untreated asymptomatic bacteriuria include pregnant women and patients who undergo urologic procedures with risk of mucosal injury. Screening and treatment of asymptomatic bacteriuria is not recommended in the following patient populations: pediatric patients, healthy nonpregnant women, older patients in the inpatient or outpatient setting, diabetic patients, patients with an indwelling urethral catheter, patients with impaired voiding following spinal cord injury, patients undergoing nonurologic surgeries, and nonrenal solid-organ transplant recipients. Renal transplant recipients beyond 1 month posttransplant should not undergo screening and treatment for asymptomatic bacteriuria. There is insufficient evidence to recommend for or against screening of renal transplant recipients within 1 month, patients with high-risk neutropenia, or patients with indwelling catheters at the time of catheter removal. Unwarranted antibiotics place patients at increased risk of adverse effects (including Clostridioides difficile diarrhea) and contribute to antibiotic resistance. Methods to reduce unnecessary screening for and treatment of asymptomatic bacteriuria aid in antibiotic stewardship.
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Saukko PM, Oppenheim BA, Cooper M, Rousham EK. Gaps in communication between different staff groups and older adult patients foster unnecessary antibiotic prescribing for urinary tract infections in hospitals: a qualitative translation approach. Antimicrob Resist Infect Control 2019; 8:130. [PMID: 31404364 PMCID: PMC6683464 DOI: 10.1186/s13756-019-0587-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022] Open
Abstract
Background Studies have reported large scale overprescribing of antibiotics for urinary tract infection (UTI) in hospitalised older adults. Older adults often have asymptomatic bacteriuria, and clinicians have been found to diagnose UTIs inappropriately based on vague symptoms and positive urinalysis and microbiology. However, the joined perspectives of different staff groups and older adult patients on UTI diagnosis have not been investigated. Methods Thematic analysis of qualitative interviews with healthcare staff (n = 27) and older adult patients (n = 14) in two UK hospitals. Results Interviews featured a recurrent theme of discrepant understandings and gaps in communication or translation between different social groups in three key forms: First, between clinicians and older adult patients about symptom recognition. Second, between nurses and doctors about the use and reliability of point-of-care urinary dipsticks. Third, between nurses, patients, microbiologists and doctors about collection of urine specimens, contamination of the specimens and interpretation of mixed growth laboratory results. The three gaps in communication could all foster inappropriate diagnosis and antibiotic prescribing. Conclusion Interventions to improve diagnosis and prescribing for UTIs in older adults typically focus on educating clinicians. Drawing on the sociological concept of translation and interviews with staff and patients our findings suggest that inappropriate diagnosis and antibiotic prescribing in hospitals can be fuelled by gaps in communication or translation between different staff groups and older adult patients, using different languages and technologies or interpreting them differently. We suggest that interventions in this area may be improved by also addressing discrepant understandings and communication about symptoms, urinary dipsticks and the process of urinalysis.
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Affiliation(s)
- Paula M. Saukko
- School of Social Sciences, Loughborough University, Loughborough, LE11 3TU UK
| | - Beryl A. Oppenheim
- Infection Prevention Team, New Cross Hospital, Royal Wolverhampton NHS Foundation Trust, Wolverhampton, WV10 0QP UK
| | - Mike Cooper
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, B15 2GW UK
| | - Emily K. Rousham
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU UK
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11
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Flores-Mireles A, Hreha TN, Hunstad DA. Pathophysiology, Treatment, and Prevention of Catheter-Associated Urinary Tract Infection. Top Spinal Cord Inj Rehabil 2019; 25:228-240. [PMID: 31548790 PMCID: PMC6743745 DOI: 10.1310/sci2503-228] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Urinary tract infections (UTIs) are among the most common microbial infections in humans and represent a substantial burden on the health care system. UTIs can be uncomplicated, as when affecting healthy individuals, or complicated, when affecting individuals with compromised urodynamics and/or host defenses, such as those with a urinary catheter. There are clear differences between uncomplicated UTI and catheter-associated UTI (CAUTI) in clinical manifestations, causative organisms, and pathophysiology. Therefore, uncomplicated UTI and CAUTI cannot be approached similarly, or the risk of complications and treatment failure may increase. It is imperative to understand the key aspects of each condition to develop successful treatment options and improve patient outcomes. Here, we will review the epidemiology, pathogen prevalence, differential mechanisms used by uropathogens, and treatment and prevention of uncomplicated UTI and CAUTI.
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Affiliation(s)
| | - Teri N. Hreha
- Washington University School of Medicine, Saint Louis, Missouri
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12
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Abstract
Antibiotic stewardship programs are needed in all health care facilities, regardless of size and location. Community hospitals that have fewer resources may have different priorities and require different strategies when defining antibiotic stewardship program components and implementing interventions. By following the Centers for Disease Control and Prevention Core Elements and using the strategies suggested in this article, readers should be able to design, develop, participate in, or improve antibiotic stewardship programs within community hospitals.
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Affiliation(s)
- Whitney R Buckel
- Intermountain Healthcare Pharmacy Services, 4292 South Riverboat Road, Suite 100, Taylorsville, UT 84123, USA.
| | - John J Veillette
- Division of Infectious Diseases and Epidemiology, Intermountain Infectious Diseases TeleHealth Service, 5121 South Cottonwood Drive, Murray, UT 84107, USA
| | - Todd J Vento
- Intermountain Infectious Diseases TeleHealth Service, 5121 South Cottonwood Drive, Murray, UT 84107, USA
| | - Edward Stenehjem
- Intermountain Healthcare and TeleHealth Service, 5121 South Cottonwood Drive, Murray, UT 84107, USA
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13
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Grabe MJ, Resman F. Antimicrobial Stewardship: What We All Just Need to Know. Eur Urol Focus 2018; 5:46-49. [PMID: 29970303 DOI: 10.1016/j.euf.2018.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 05/31/2018] [Accepted: 06/21/2018] [Indexed: 10/28/2022]
Abstract
CONTEXT Microbial resistance to antibiotics is increasing while antimicrobials are limited. Responsible use is necessary. OBJECTIVE Describe the present acquisitions of antimicrobial stewardship programmes (ASPs) in general and in urology. EVIDENCE SYNTHESIS Well-designed ASPs have an impact on reducing treatment duration, shortening intravenous treatment in favour of oral targeted therapy, and reducing the total antibiotic prescription. Moreover, the hospital length of stay can potentially be reduced without hazard for the patient. CONCLUSIONS It is recommended to set up an ASP for education and feedback as standard in urological practice. The exact design of the ASP should be tailored to regional prerequisites.
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Affiliation(s)
- Magnus J Grabe
- Department of Translational Medicine, Division of Urological Cancer, Lund University, Malmö, Sweden.
| | - Fredrik Resman
- Department of Translational Medicine, Clinical Infection Medicine, Lund University, Malmö, Sweden
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