A Cluster-Randomized Trial of Two Strategies to Improve Antibiotic Use for Patients with a Complicated Urinary Tract Infection

Spoorenberg, V.; Hulscher, Marlies; Geskus, Ronald B.; Reijke, Theo M. de; Opmeer, Brent C.; Prins, Jan M.; Geerlings, Suzanne E.

doi:10.1371/journal.pone.0142672

Cited by 15 publications

(24 citation statements)

References 29 publications

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“…The mean reason is probably due to the low adherence to the distribution of the leaflets. Further, this could be due to the already high implementation of the recommendations, since it has been shown before that improvement is larger when the baseline performance is poor, 17 or due to shift changes with many different physicians in the ED. Earlier studies demonstrated that patient information leaflets can be very useful, especially for acute conditions where leaflets also improve adherence to treatment.…”

Section: Discussionmentioning

confidence: 99%

Patient education materials to implement choosing wisely recommendations for internal medicine at the emergency department

et al. 2021

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BackgroundChoosing Wisely aims to reduce low-value care to improve quality and lower costs. In the Netherlands, this campaign offers three recommendations for internal medicine applicable in emergency departments (EDs): (1) do not place an indwelling urinary catheter in non-critically ill patients who can void; (2) do not order plain abdominal radiographs in patients with acute abdominal pain; and (3) discuss whether treatment limitations are needed. This quality improvement project aims to increase the implementation of the recommendations by patient information leaflets.MethodsIn a prospective before–after study, we collected data every other week during baseline and intervention periods (both 7 months) in two university medical centres. The primary outcomes were the adherence rates to the recommendations.Results805 patients visited the EDs for internal medicine, of whom 391 (48.6%) were hospitalised. Only 153 (19%) patients received the information leaflet. We found no change in implementation rates of the recommendations after the introduction of the patient information leaflet. In the baseline period, 28 patients received a urinary catheter, of whom 5 (17.9%) had no appropriate indication, compared with 4 (25.0%) of 16 patients in the intervention period (p=0.572). Unnecessary abdominal X-ray occurred once in the baseline period and not in the intervention period. Treatment limitations were not reported in 13 (6.5%) of 200 hospitalised patients in the baseline period, and in 17 (8.9%) of 191 patients in the intervention period (p=0.373).ConclusionsPatient information leaflets did not increase the implementation of Choosing Wisely recommendations, which can be due to a high baseline rate and a poor dissemination of leaflets. Our ED seems not to be a practicable setting for dissemination of leaflets, since staff engagement was not possible due to high workload and shortage of qualified nursing staff in the Netherlands.

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Section: Discussionmentioning

confidence: 99%

Patient education materials to implement choosing wisely recommendations for internal medicine at the emergency department

et al. 2021

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“…This competitive feedback report will be used to raise awareness among healthcare workers. 23 During this meeting, we will distribute posters and pocket cards with an algorithm ( figure 3A, B ) for appropriate indications for urine cultures and urinalysis, and overtreatment of ASB, based on current guidelines. 5 24 The kick-off meeting will be led by the project coordinator and the local champion.…”

Section: Methods and Analysismentioning

confidence: 99%

“…This competitive feedback report will be used to raise awareness among healthcare workers. 23 During this meeting, Table 1 Definitions of positive urinalysis, UTI and ASB…”

Section: Deimplementation Strategymentioning

confidence: 99%

Deimplementation strategy to reduce overtreatment of asymptomatic bacteriuria: a study protocol for a stepped-wedge cluster randomised trial

et al. 2021

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IntroductionAntimicrobial treatment of asymptomatic bacteriuria (ASB) is one of the most common unnecessary uses of antimicrobials. Earlier studies have shown that the prevalence of this inappropriate treatment ranges from 45% to 83%. Multifaceted interventions based on international guidelines and antimicrobial stewardship can decrease overtreatment of ASB. We have designed a study protocol with the main objective of reducing overtreatment of ASB by 50% through use of a deimplementation strategy.Methods and analysisWe will use a stepped-wedge cluster randomised design, comparing outcomes before and after introduction of our intervention in the emergency department (ED) of five hospitals (clusters) in the Netherlands. All patients (≥18 years old) who have a urine test performed in the ED will be screened for eligibility. The deimplementation strategy consists of a combination of interventions, including education, audit and feedback. The primary endpoint is overtreatment of ASB in patients without risk factors (eg, pregnancy, planned invasive urological procedures and neutropenia). Secondary endpoints are the duration of antimicrobial treatment for ASB, the number of urine cultures and urinalysis per 1000 patients, and overtreatment of positive urinalysis in asymptomatic patients.Ethics and disseminationEthical approval was obtained from the medical ethics research committee of the Academic Medical Centre (Amsterdam, the Netherlands) with a waiver for informed consent. Local feasibility was obtained by the local institutional review boards of all participating hospitals. Our study aims to reduce inappropriate screening and treatment of ASB in EDs, improve healthcare quality, lower the increase in antimicrobial resistance and save costs. If proven (cost)-effective, this study provides a well-suited strategy for a nationwide approach to reduce overtreatment of ASB. Relevant results of our study will be disseminated through publications in peer-reviewed journals and presentations at relevant (scientific) conferences.Trial registration numberNL8242; Pre-results.

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“…A local ‘champion’ (one of the leading physicians) will be appointed to be responsible for the interventions in his or her department. The intervention period will start with a kick-off meeting, where a list of baseline data of the intervention hospital in comparison with the other study hospitals will be presented as a competitive feedback report [33]. If desired, feedback reports per department could be sent by e-mail to local investigators.…”

Section: Methods and Designmentioning

confidence: 99%

De-implementation strategy to Reduce the Inappropriate use of urinary and intravenous CATheters: study protocol for the RICAT-study

et al. 2017

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BackgroundUrinary and (peripheral and central) intravenous catheters are widely used in hospitalized patients. However, up to 56% of the catheters do not have an appropriate indication and some serious complications with the use of these catheters can occur. The main objective of our quality improvement project is to reduce the use of catheters without an appropriate indication by 25–50%, and to evaluate the affecting factors of our de-implementation strategy.MethodsIn a multicenter, prospective interrupted time series analysis, several interventions to avoid inappropriate use of catheters will be conducted in seven hospitals in the Netherlands. Firstly, we will define a list of appropriate indications for urinary and (peripheral and central) intravenous catheters, which will restrict the use of catheters and urge catheter removal when the indication is no longer appropriate. Secondly, after the baseline measurements, the intervention will take place, which consists of a kick-off meeting, including a competitive feedback report of the baseline measurements, and education of healthcare workers and patients. Additional strategies based on the baseline data and local conditions are optional. The primary endpoint is the percentage of catheters with an inappropriate indication on the day of data collection before and after the de-implementation strategy. Secondary endpoints are catheter-related infections or other complications, catheter re-insertion rate, length of hospital (and ICU) stay and mortality. In addition, the cost-effectiveness of the de-implementation strategy will be calculated.DiscussionThis study aims to reduce the use of urinary and intravenous catheters with an inappropriate indication, and as a result reduce the catheter-related complications. If (cost-) effective it provides a tool for a nationwide approach to reduce catheter-related infections and other complications.Trial registrationDutch trial registry: NTR6015. Registered 9 August 2016.

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A Cluster-Randomized Trial of Two Strategies to Improve Antibiotic Use for Patients with a Complicated Urinary Tract Infection

Cited by 15 publications

References 29 publications

Patient education materials to implement choosing wisely recommendations for internal medicine at the emergency department

Patient education materials to implement choosing wisely recommendations for internal medicine at the emergency department

Deimplementation strategy to reduce overtreatment of asymptomatic bacteriuria: a study protocol for a stepped-wedge cluster randomised trial

De-implementation strategy to Reduce the Inappropriate use of urinary and intravenous CATheters: study protocol for the RICAT-study

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