Anticipated Impacts on Veterans'Healthcare: Urinary tract infection (UTI) is the single most common hospital-acquired infection. However, the majority of cases of nosocomial catheter- associated urinary tract infection (CAUTI) are really asymptomatic bacteriuria (ABU). ABU is not a clinically significant condition, and treatment is unlikely to confer benefit. Overtreatment of ABU is a quality, safety, and cost issue, particularly as unnecessary antibiotics lead to emergence of resistant flora. Our proposal to bring clinical practice in line with published guidelines has significant potential to decrease CAUTI and associated inappropriate antibiotic use in VA hospitals. Our study will also provide information about how to maximize effectiveness of audit- feedback to achieve guideline adherence in the inpatient VA setting. Project Background/Rationale: Evidence-based guidelines recommend that providers neither screen for nor treat ABU in most catheterized patients. However, a significant gap between these guidelines and clinical practice has been documented at our VA hospital and throughout the world. Since many VA patients in both acute care settings and sub-acute care settings, such as intermediate and long-term care, have a legitimate need for a urinary catheter, the issue of overtreatment of catheter-associated ABU is an active problem for the VA. Project Objectives: We hypothesize that implementing the existing evidence-based guidelines about non-treatment of ABU will dramatically reduce the unnecessary use of antibiotics to treat ABU and the incidence of incorrectly diagnosed CAUTI. Our first objective is to improve quality of care concerning ABU in terms of specific clinical outcomes (inappropriate screening for and treatment of ABU) through implementation of an audit-feedback strategy. We also hypothesize that successful implementation of an audit-feedback strategy will result in measurable changes in clinicians'knowledge and attitudes concerning ABU practice guidelines. Our second objective is to assess through surveys the effect of the implementation on clinicians'guideline awareness, familiarity, acceptance, and outcome expectancy. Project Methods: Our guidelines implementation strategy will employ audit-feedback, applied as a post-prescription antimicrobial review based on established guidelines. The study population for the clinical outcomes is all inpatients on certain wards at the intervention site (Houston VA) and the control site (San Antonio VA). Our study population for the audit-feedback intervention and surveys is the health care providers on these wards. We propose a 3-year study. During the first year we will observe the baseline incidence of inappropriate screening for and treatment of ABU at both sites. Blinded monitoring of clinical outcomes will continue during the next 2 years of the study. During the second year, we will distribute the guidelines at both sites. Clinicians at the intervention site will receive individualized feedback, either by telephone or in person, about whether their management of bacteriuria was guideline-compliant. Unit-level feedback will also be provided. During the third year, individualized feedback will cease, but unit-level feedback will continue as this constitutes a sustainable intervention. Clinicians will complete pre/post surveys of awareness, familiarity, acceptance, and outcome expectancy at the intervention site in year 2 and at both sites in year 3. Differences in outcomes between the individualized intervention in year 2 and the group-level intervention in year 3 will help to determine the necessary intensity of intervention for dissemination and implementation in other VA facilities.

Public Health Relevance

Overtreatment of ABU is a quality, safety, and cost issue, particularly as unnecessary antibiotics lead to emergence of resistant pathogens. Our proposal to bring clinical practice in line with published guidelines has significant potential to reduce unnecessary antibiotic use for asymptomatic bacteriuria in the VA healthcare system, thus improving the quality and safety of veterans'healthcare. Our study will also provide important insights about how to implement and sustain evidence-based clinical practice within VA hospitals.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HSR-4 Mental and Behavioral Health (HSR4)
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Michael E Debakey VA Medical Center
United States
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Grigoryan, Larissa; Naik, Aanand D; Horwitz, Deborah et al. (2016) Survey finds improvement in cognitive biases that drive overtreatment of asymptomatic bacteriuria after a successful antimicrobial stewardship intervention. Am J Infect Control 44:1544-1548
Trautner, Barbara W; Grigoryan, Larissa; Petersen, Nancy J et al. (2015) Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter-Associated Asymptomatic Bacteriuria. JAMA Intern Med 175:1120-7
Trautner, Barbara W; Petersen, Nancy J; Hysong, Sylvia J et al. (2014) Overtreatment of asymptomatic bacteriuria: identifying provider barriers to evidence-based care. Am J Infect Control 42:653-8
Naik, Aanand D; Trautner, Barbara W (2014) Doing the right thing for asymptomatic bacteriuria: knowing less leads to doing less. Clin Infect Dis 58:984-5
Grigoryan, Larissa; Abers, Michael S; Kizilbash, Quratulain F et al. (2014) A comparison of the microbiologic profile of indwelling versus external urinary catheters. Am J Infect Control 42:682-4
Trautner, Barbara W; Patterson, Jan E; Petersen, Nancy J et al. (2013) Quality gaps in documenting urinary catheter use and infectious outcomes. Infect Control Hosp Epidemiol 34:793-9
Kizilbash, Quratulain F; Petersen, Nancy J; Chen, Guoqing J et al. (2013) Bacteremia and mortality with urinary catheter-associated bacteriuria. Infect Control Hosp Epidemiol 34:1153-9
Lin, Eugene; Bhusal, Yogesh; Horwitz, Deborah et al. (2012) Overtreatment of enterococcal bacteriuria. Arch Intern Med 172:33-8
Trautner, Barbara W; Gupta, Kalpana (2012) The advantages of second best: comment on ""Lactobacilli vs antibiotics to prevent urinary tract infections"". Arch Intern Med 172:712-4
Burns, Allison C; Petersen, Nancy J; Garza, Armandina et al. (2012) Accuracy of a urinary catheter surveillance protocol. Am J Infect Control 40:55-8

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