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

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.

Pathophysiology, Treatment, and Prevention of Catheter-Associated Urinary Tract Infection

“…8 Therefore, antibiotic stewardship initiatives have been developed to reduce the unnecessary use of antibiotics to curb development of resistant pathogens. 119 Current CDC guidelines on management of CAUTI do not recommend the use of routine prophylaxis with systemic antibiotics for prevention of CAUTI in patients requiring shortor long-term urinary catheterization, unless clinical indications exist (e.g., in patients with bacteriuria upon catheter removal post urologic surgery). 108 Additionally, there is no recommendation for use of antimicrobial prophylaxis at the time of catheter removal.…”

Organizational readiness assessment in acute and long-term care has important implications for antibiotic stewardship for asymptomatic bacteriuria

“…The current "Less is More" dissemination project aims to implement a scalable version of the Kicking CAUTI Campaign across four geographically diverse VA facilities, with four control sites. 14 Prior to implementing the Less is More program, we used the ORCA to assess context, culture, and barriers at each intervention site. While the prior studies of organizational readiness for antibiotic stewardship focused on general differences between sites 11 or providers, 12 our study comprehensively evaluated differences in readiness for change between subscales, multiple healthcare provider types, and study sites.…”

A Scoping Review of the Use of Social and Behavioral Change in Acute Care Antimicrobial Stewardship Initiatives

“…We found 2 studies that were not included because they utilized implementation science-based theories, rather than traditional social and behavior theories, and were not conducive to evaluation using the theory coding scheme. 9,10 In addition, we found 2 studies that were based on theoretical ideas, but did not state a specific theory, which also did not allow for full evaluation. 11,12 Data extraction was performed with a coding guide that incorporated information on the study design, funding, participants, and setting along with the validate coding scheme from Michie and Prestwich.…”