Survey finds improvement in cognitive biases that drive overtreatment of asymptomatic bacteriuria after a successful antimicrobial stewardship intervention

Grigoryan, Larissa; Naik, Aanand D.; Horwitz, Deborah; Cadena, José; Patterson, Jan E.; Zoorob, Roger; Trautner, Barbara W.

doi:10.1016/j.ajic.2016.04.238

Cited by 12 publications

(15 citation statements)

References 24 publications

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“…For example, cloudy urine, foul smelling urine, and pyuria have been identified in other surveys projects as drivers for unnecessary urine cultures or antibiotics. [4][5][6][7] Previous surveys have likewise reported that ASB is assumed to be more harmful and thus more likely to be treated with antibiotics in older patients 7 or in patients with a multidrugresistant organism in the urine. 6 The knowledge gaps we identified among nurses and CNAs in both acute and long-term care units are likewise consistent with those identified through a AHRQfunded survey in 184 non-VA nursing homes.…”

Section: Discussionmentioning

confidence: 99%

“…The Kicking CAUTI survey was created and validated in 3 versions for the different types of healthcare professionals (1) providers, (2) nurses, and (3) clinical nurse assistants (Appendix online). 4,5 The provider version contained 17 questions about knowledge of how to manage ASB (when to test and when to treat), assessed through very brief case scenarios, 15 questions about behavioral constructs (eg, self-efficacy, social norms about how the provider would behave, in the context of cases of ASB), and 1 question on guidelines acceptance. Examples of the behavioral construct questions are included in Table 1.…”

Section: Survey Instrumentsmentioning

confidence: 99%

“…3 Prior surveys of physicians and prescribing providers describe knowledge gaps, lack of awareness of guidelines, social norms, and unease with leaving ASB untreated as reasons for why physicians treat ASB. [4][5][6][7] A nationwide survey of 1,626 nursing personnel in long-term care facilities found that knowledge gaps regarding the difference between ASB and urinary tract infection drove inappropriate requests for urine cultures. 8 Additionally, a survey of nurses' knowledge of and adherence to infection control practices revealed that nurses' attitudes about infection control practices were associated with compliance with infection control best practices, whereas knowledge was not.…”

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confidence: 99%

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Teamwork and safety climate affect antimicrobial stewardship for asymptomatic bacteriuria

Drekonja

Grigoryan

Lichtenberger

et al. 2019

Infect. Control Hosp. Epidemiol.

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Objective:In preparation for a multisite antibiotic stewardship intervention, we assessed knowledge and attitudes toward management of asymptomatic bacteriuria (ASB) plus teamwork and safety climate among providers, nurses, and clinical nurse assistants (CNAs).Design:Prospective surveys during January–June 2018.Setting:All acute and long-term care units of 4 Veterans’ Affairs facilities.Methods:The survey instrument included 2 previously tested subcomponents: the Kicking CAUTI survey (ASB knowledge and attitudes) and the Safety Attitudes Questionnaire (SAQ).Results:A total of 534 surveys were completed, with an overall response rate of 65%. Cognitive biases impacting management of ASB were identified. For example, providers presented with a case scenario of an asymptomatic patient with a positive urine culture were more likely to give antibiotics if the organism was resistant to antibiotics. Additionally, more than 80% of both nurses and CNAs indicated that foul smell is an appropriate indication for a urine culture. We found significant interprofessional differences in teamwork and safety climate (defined as attitudes about issues relevant to patient safety), with CNAs having highest scores and resident physicians having the lowest scores on self-reported perceptions of teamwork and safety climates (P < .001). Among providers, higher safety-climate scores were significantly associated with appropriate risk perceptions related to ASB, whereas social norms concerning ASB management were correlated with higher teamwork climate ratings.Conclusions:Our survey revealed substantial misunderstanding regarding management of ASB among providers, nurses, and CNAs. Educating and empowering these professionals to discourage unnecessary urine culturing and inappropriate antibiotic use will be key components of antibiotic stewardship efforts.

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Section: Discussionmentioning

confidence: 99%

Section: Survey Instrumentsmentioning

confidence: 99%

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confidence: 99%

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Teamwork and safety climate affect antimicrobial stewardship for asymptomatic bacteriuria

Drekonja

Grigoryan

Lichtenberger

et al. 2019

Infect. Control Hosp. Epidemiol.

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“…Continual provider-level education combined with effective communication strategies by the ASST were essential for compliance with recommendations. Managing provider perceptions of and potential biases against complying with institutional guidelines or stewardship recommendations is a key element to a successful ASP (22,23).…”

Section: Discussionmentioning

confidence: 99%

Cumulative Effect of an Antimicrobial Stewardship and Rapid Diagnostic Testing Bundle on Early Streamlining of Antimicrobial Therapy in Gram-Negative Bloodstream Infections

Bookstaver

Nimmich

Smith³

et al. 2017

Antimicrob Agents Chemother

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The use of rapid diagnostic tests (RDTs) enhances antimicrobial stewardship program (ASP) interventions in optimization of antimicrobial therapy. This quasi-experimental cohort study evaluated the combined impact of an ASP/RDT bundle on the appropriateness of empirical antimicrobial therapy (EAT) and time to de-escalation of broad-spectrum antimicrobial agents (BSAA) in Gram-negative bloodstream infections (GNBSI). The ASP/RDT bundle consisted of system-wide GNBSI treatment guidelines, prospective stewardship monitoring, and sequential introduction of two RDTs, matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and the FilmArray blood culture identification (BCID) panel. The preintervention period was January 2010 through December 2013, and the postintervention period followed from January 2014 through June 2015. The postintervention period was conducted in two phases; phase 1 followed the introduction of MALDI-TOF MS, and phase 2 followed the introduction of the FilmArray BCID panel. The interventions resulted in significantly improved appropriateness of EAT (95% versus 91%; = 0.02). Significant reductions in median time to de-escalation from combination antimicrobial therapy (2.8 versus 1.5 days), antipseudomonal beta-lactams (4.0 versus 2.5 days), and carbapenems (4.0 versus 2.5 days) were observed in the postintervention compared to the preintervention period ( < 0.001 for all). The reduction in median time to de-escalation from combination therapy (1.0 versus 2.0 days; = 0.03) and antipseudomonal beta-lactams (2.2 versus 2.7 days; = 0.04) was further augmented during phase 2 compared to phase 1 of the postintervention period. Implementation of an antimicrobial stewardship program and RDT intervention bundle in a multihospital health care system is associated with improved appropriateness of EAT for GNBSI and decreased utilization of BSAA through early de-escalation.

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“…Despite guidelines that place nominal emphasis on the importance of education in antimicrobial stewardship [51], there is still clearly a great need for education among providers who treat infections, as evidenced by several recent studies [64, 65]. …”

Section: Antibiotic Stewardshipmentioning

confidence: 99%

The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship

et al. 2017

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Purpose: To concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to the management of multidrug-resistant (MDR) bacteria, antibiotic use, and antimicrobial stewardship in the intensive care unit (ICU) setting. Methods: Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion. Results: The prevalence of infection of critically ill patients by MDR bacteria is rapidly evolving. Clinical studies aimed at improving understanding of the changing patterns of these infections in ICUs are urgently needed. Ideal antibiotic utilization is another area of uncertainty requiring additional investigations aimed at better understanding of dose optimization, duration of therapy, use of combination treatment, aerosolized antibiotics, and the integration of rapid diagnostics as a guide for treatment. Moreover, there is an imperative need to develop non-antibiotic approaches for the prevention and treatment of MDR infections in the ICU. Finally, clinical research aimed at demonstrating the beneficial impact of antimicrobial stewardship in the ICU setting is essential. Conclusions: These and other fundamental questions need to be addressed over the next decade in order to better understand how to prevent, diagnose, and treat MDR bacterial infections. Clinical studies described in this research agenda provide a template and set priorities for investigations that should be performed in this field.

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Survey finds improvement in cognitive biases that drive overtreatment of asymptomatic bacteriuria after a successful antimicrobial stewardship intervention

Cited by 12 publications

References 24 publications

Teamwork and safety climate affect antimicrobial stewardship for asymptomatic bacteriuria

Teamwork and safety climate affect antimicrobial stewardship for asymptomatic bacteriuria

Cumulative Effect of an Antimicrobial Stewardship and Rapid Diagnostic Testing Bundle on Early Streamlining of Antimicrobial Therapy in Gram-Negative Bloodstream Infections

The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship

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