Protocol to disseminate a hospital-site controlled intervention using audit and feedback to implement guidelines concerning inappropriate treatment of asymptomatic bacteriuria

Barbara W Trautner,Larissa Grigoryan,Jennifer R Kramer,Sylvia J Hysong,Payal Patel,Sarah Krein,Dimitri M Drekonja,Steve Wiseman,Timothy P Gauthier,Christopher Graber,Anne Sales,Tracey Rosen,Nancy J Petersen,Aanand Dinkar Naik,Makoto Jones,Pooja Prasad,Suja Rajan,Paola Lichtenberger

doi:10.1186/s13012-018-0709-x

Abstract

BackgroundAntimicrobial stewardship to combat the spread of antibiotic-resistant bacteria has become a national priority. This project focuses on 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 previously conducted a successful intervention, entitled “Kicking Catheter Associated Urinary Tract Infection (CAUTI): the No Knee-Jerk Antibiotics Campaign,” to decrease guideline-discordant ordering of urine cultures and antibiotics for ASB. The current objective is to facilitate implementation of a scalable version of the Kicking CAUTI campaign across four geographically diverse Veterans Health Administration facilities while assessing what aspects of an antimicrobial stewardship intervention are essential to success and sustainability.MethodsThis project uses an interrupted time series design with four control sites. 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. Our conceptual framework for the development and implementation of this intervention draws on May’s General Theory of Implementation. 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. The start-up for each facility consists 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 start-up period and continue for 12 months, followed by a sustainability assessment. In addition to the clinical outcomes, we will explore the relationship between the dose of the intervention and clinical outcomes.DiscussionThis project moves from a proof-of-concept effectiveness study to implementation involving significantly more sites, and uses the General Theory of Implementation to embed the intervention into normal processes of care with usual care providers. Aspects of implementation that will be explored include dissemination, internal and external facilitation, and organizational partnerships. “Less is More” is the natural next step from our prior successful Kicking CAUTI intervention, and has the potential to improve patient care while advancing the science of implementation.

Highlights

Antimicrobial stewardship to combat the spread of antibiotic-resistant bacteria has become a national priority
The need in the Veterans Health Administration (VHA) to improve this practice is acute, as the VA Antimicrobial Stewardship Task Force reported in April 2016 that 72% of cases of asymptomatic bacteriuria (ASB) were treated unnecessarily with antibiotics [5]
Unlike the original Kicking Catheter Associated Urinary Tract Infection (CAUTI) intervention, we will include all cases of bacteriuria, occurring with or without a urinary catheter, to be more broadly applicable, as UTI is a much more common reason for antibiotic use than CAUTI

Summary

Introduction

Antimicrobial stewardship to combat the spread of antibiotic-resistant bacteria has become a national priority This project focuses on reducing inappropriate use of antimicrobials for asymptomatic bacteriuria (ASB), a very common condition that leads to antimicrobial overuse in acute and long-term care. One of the most common reasons for overuse of antibiotics in both acute and long-term care is inappropriate treatment of asymptomatic bacteriuria (ASB), or bacteria in the urinary tract without related urinary symptoms [1,2,3]. We designed and validated a successful antimicrobial stewardship intervention to decrease guidelinediscordant management of ASB in Veterans in hospitals and long-term care [6] This “Kicking CAUTI Campaign” led to a 71% reduction in screening for ASB and a 75% reduction in treatment of ASB at one major VA medical center [7]. Unlike the original Kicking CAUTI intervention, we will include all cases of bacteriuria, occurring with or without a urinary catheter, to be more broadly applicable, as UTI is a much more common reason for antibiotic use than CAUTI

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