Interventions to promote rational antibiotic use can lead to decreased overall antimicrobial use, enhanced patient safety in that patients receive the best agent at the right dose for the most suitable time period, and decreased antimicrobial resistance. The goals of this project are to develop, implement and evaluate algorithms for both the diagnosis and treatment of ventilator-associated pneumonia (VAP) and catheter- associated urinary tract infections (CAUTI) that reduce inappropriate antimicrobial use and enhanced patient outcomes. We propose to do this by developing a systematic approach to optimize decision making regarding antimicrobial usage for VAP and CAUTI at three critical time points: 1) the time of initial suspicion of infection, 2) the time when the availability of microbiological data enable narrowing the antibiotic spectrum or stopping antibiotics, and 3) the time at which duration of therapy is decided. To determine the current patterns of antimicrobial use for VAP and CAUTI we will collect baseline data to establish the extent of inappropriate antimicrobial therapy associated with these infections. To optimize antimicrobial usage for VAP, we will develop and implement diagnostic and treatment algorithms that provide evidence-based approaches for clinical decision making. We will implement different approaches to facilitate adherence to these algorithms in five ICUs and compare their efficacy in reducing inappropriate antimicrobial use. Approached to be studied include enhancing diagnosis by using the mini-brochoalveolar lavage technique to obtain lower respiratory samples for quantitative culture, antimicrobial stewardship interventions, and use of automatic stop orders for antibiotic to impact duration of therapy. For CAUTI, we will implement an interventional program designed both to emphasize the importance of removing unnecessary catheters and to use antibiotics appropriately. Components of the intervention will include development of algorithms for management of bacteriuria and funguria and guidelines for catheter removal and dissemination of these materials via pocket cards and posters as well as feedback both to individual physicians about appropriate use of catheters and antimicrobials and to nurses regarding patients on their units with potentially unnecessary catheters. A quasi-experimental study design will be used in both the VAP and CAUTI studies to evaluate the impact of these interventions. We will compare the baseline rates of antimicrobial use and catheter use to those after the intervention. We will also analyze patient outcomes in both the VAP and CAUTI studies;we will assess length of stay, mortality, hospital costs, rates of emergence of resistance, rates of Clostridium difficile disease and rates of acquisition of MRSA and VRE in the study units during the baseline and intervention periods. We hypothesize that this approach will enhance appropriate use of antimicrobials for both VAP and CAUTI and improve patient outcomes by reducing the known sequelae of antimicrobial overuse.
Antimicrobial agents can be lifesaving but many prescribers use these agents unnecessarily, for extended periods of time and when the diagnosis is not clear. Such use leads to untoward complications such as increasingly resistant organisms, C. difficile-associated diarrhea and contribute to excessive length of hospital stay. This research is designed to use algorithms that encourage the utilization of new data and diagnostic tests to reduce the use of antimicrobials and to better determine antimicrobial use patterns for two common healthcare-associated infections associated with excessive antibiotic use, ventilator-associated pneumonia and catheter-associated urinary tract infections.
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