5 results
Organizational Readiness to Change Assessment Highlights Differential Readiness for Antibiotic Stewardship
- Melanie Goebel, Barbara Trautner, Yiqun Wang, John Van, Laura Dillon, Payal Patel, Dimitri Drekonja, Christopher Graber, Paola Lichtenberger, Christian Helfrich, Larissa Grigoryan
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s492-s493
- Print publication:
- October 2020
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Background: Targeted antibiotic stewardship interventions are needed to reduce unnecessary treatment of asymptomatic bacteriuria (ASB). Organizational readiness for change is a precursor to successful change implementation. The Organizational Readiness to Change Assessment (ORCA) is a validated survey instrument that has been used to detect potential obstacles and tailor interventions. In an outpatient stewardship study, primary care practices with high readiness to change trended toward greater improvements in antibiotic prescribing. We used the ORCA to assess barriers to change before implementing a multicenter inpatient stewardship intervention for ASB. Methods: Surveys were self-administered by healthcare professionals in inpatient medicine and long-term care units at 4 geographically diverse Veterans’ Affairs facilities during January–December 2018. Participants included providers (physicians, physician assistants, and nurse practitioners), nurses, pharmacists, infection preventionists, and quality managers. The survey included 7 subscales: evidence (perceived evidence strength) and 6 context subscales (favorability of the organizational context to support change). Responses were scored on a 5-point Likert scale, with 1 meaning very weak or strongly disagree. Scores were compared between professional types and sites. We also measured allocated employee effort for stewardship at each site. Results: Overall, 104 surveys were completed, with an overall response rate of 69.3%. For all sites combined, the evidence subscale had the highest score of the 7 subscales (mean, 4; SD, 0.9); the resources subscale was significantly lower than other subscales (mean, 2.8; SD, 0.9; P < .001). Scores for budget and staffing resources were lower than scores for training and facility resources (P < .001 for both comparisons). Pharmacists had lower scores than providers for the staff culture subscale (P = .04). Comparing subscales between sites, ORCA scores were significantly different for leadership behavior (communication and management), measurement (goal setting and accountability), and general resources (Fig. 1). The site with the lowest scores for resources (mean, 2.4) also had lower scores for leadership behavior and measurement, and lower pharmacist effort devoted to antibiotic stewardship. Conclusions: Although healthcare professionals endorsed the evidence about nontreatment of ASB, perceived barriers to antibiotic stewardship included inadequate resources and lack of leadership support. These findings provide targets for tailoring the intervention to maximize the success of our stewardship program. Our support to sites with lower leadership scores includes training of local champions who are dedicated to supporting the intervention. For sites with low scores for resources, our targeted implementation strategies include analyzing local needs and avoiding increased workload for existing personnel.
Funding: None
Disclosures: None
A Conceptual Framework for Understanding How and Why People Take Antibiotics Without a Prescription
- Larissa Grigoryan, Osvaldo Alquicira, Susan Nash, Melanie Goebel, Barbara Trautner
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, p. s93
- Print publication:
- October 2020
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Background: The reported prevalence of nonprescription antibiotic use in the United States varies from 5% among socioeconomically and ethnically diverse primary care patients to 66% among Latino migrant workers. Reports indicate that people obtain and take antibiotics from stores or flea markets in the United States, friends or relatives, and leftover antibiotics from previous prescriptions. This unsafe practice may lead to unnecessary and inappropriate antibiotic use and increases the risk of antibiotic resistance. As groundwork to develop an intervention to decrease nonprescription antibiotic use, we mapped reported drivers of nonprescription use to the Kilbourne conceptual framework for advancing health disparities research. Methods: The Kilbourne framework consists of 3 phases: (1) detection of health disparities and identification of vulnerable populations, (2) understanding why disparities exist, and (3) reducing or eliminating disparities through interventions. We focused on the first 2 phases and mapped the identified drivers of nonprescription antibiotic use onto the key domains of the Kilbourne conceptual framework: patient, healthcare system, and clinical encounter factors. We also conducted brief field research to explore anecdotal reports regarding availability of nonprescription antibiotics in our community. Results: We found 8 studies addressing factors related to nonprescription antibiotic use in the United States. These studies were primarily qualitative and included Spanish-speaking Hispanic and Latino immigrants. Figure 1 shows the proposed factors that may directly or indirectly predict nonprescription antibiotic use. Key potential factors are individual factors, psychosocial factors, resources, healthcare system factors, and clinical-encounter factors. For example, patients with inadequate health literacy may have poor access to care because of difficulty finding providers and choosing or navigating insurance plans; thus, they may be at risk for nonprescription use. At the same time, patients with inadequate health literacy may be at risk for using nonprescription antibiotics for a viral infection because of difficulty understanding medication labels or package inserts. The relevance of resources (availability) to nonprescription antibiotic use was supported by our research team’s purchase of amoxicillin, tetracycline, and metronidazole without prescriptions from a flea market in Houston, Texas. Conclusions: The Kilbourne conceptual framework provides a strong, comprehensive basis for research and intervention in the challenging problem of nonprescription antibiotic use. Ongoing research will test the proposed relationships between patient, healthcare system, and clinical-encounter factors and nonprescription antibiotic use outcomes. We are conducting a survey among both indigent and insured patient populations to identify the relative importance of these factors and to validate our proposed conceptual framework of nonprescription antibiotic use.
Funding: This project was supported by grant number R01HS026901 from the Agency.
Disclosures: None
Creating an Outpatient-Specific Antibiogram to Guide Treatment for Urinary Tract Infections
- Larissa Grigoryan, Melanie Goebel, Samuel Willis, Lisa Danek, Jennifer Matas, Neal Kachalia, Anna Katta, Kenneth Muldrew, Mohammad Zare, Forrest Hudson, Robert Atmar, Barbara Trautner
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s182-s183
- Print publication:
- October 2020
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Background: Outpatients with uncomplicated urinary tract infections (UTIs) are often treated empirically without culture, whereas urine cultures are typically collected from patients with complicated UTI. Susceptibilities for fosfomycin (a first-line agent) are not routinely performed or reported in the antibiogram. Understanding the prevalence of antibiotic resistance for UTI is critical for empiric treatment and antibiotic stewardship in primary care. Methods: We developed a UTI-focused antibiogram from a prospective sample of outpatients (women and men) with UTIs from 2 public family medicine clinics in an urban area with a diverse, international population (November 2018 to present). During the study period, providers ordered a urine culture for any adult patient presenting with UTI symptoms, including uncomplicated and complicated infections. We estimated the prevalence of resistance to UTI-relevant antibiotics in the overall study population and compared it between patients born in the United States and other countries. Results: We collected 678 urine cultures from 644 unique patients (79% female). Of these cultures, 158 (23.3%) had no growth, 330 (48.7%) grew mixed urogenital flora, and 190 (28.0%) were positive (>10,000 CFU/mL). Patients with positive cultures were mostly female (88.2%), and their mean age was 46.6 ± 14.8 years. Among patients with positive cultures, 42.7% were born in the United States and 57.3% were born Mexico or Central America. Escherichia coli was the most commonly isolated organism (Fig. 1). Susceptibility results for E. coli and all gram-negative organisms combined are presented in Fig. 2. Susceptibility of uropathogens to TMP-SMX was significantly higher in patients born in the United States compared to patients from Mexico or Central America (82% vs 61%; P = .03). Susceptibility to ciprofloxacin was similar in patients born in the United States and other countries (79% vs 72%; P = .50). Of 77 E. coli isolates, 11 (14%) were positive for extended-spectrum β-lactamase production, including 8 isolates from patients whose country of origin was Mexico or a Central American country. Conclusions: More than 20% of outpatients presenting with UTI symptoms had a negative urine culture. Among outpatients with uncomplicated and complicated UTI, uropathogens had a high prevalence of resistance to ciprofloxacin and TMP-SMX, but susceptibility to fosfomycin (restricted in our system) was 100%. Resistance rates for TMP-SMX were higher in patients from Mexico and Central America. Our findings question whether TMP-SMX should remain a first-line agent in US primary-care settings.
Funding: This project was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under Award Number UM1AI104681.
Disclosures: None
Effectiveness of Stewardship Intervention for Urinary Tract Infections in Primary Care: A Difference in Differences Study
- Larissa Grigoryan, George Germanos, Roger Zoorob, Mohamad Sidani, Haijun Wang, Mohammad Zare, Melanie Goebel, Barbara Trautner
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s515-s516
- Print publication:
- October 2020
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Adherence to 2011 Infectious Diseases Society of America (IDSA) guidelines for urinary tract infections (UTIs) remains low in primary care. Fluoroquinolones are commonly prescribed to treat uncomplicated cystitis, and most antibiotic prescriptions have durations that exceed current recommendations. We performed a difference-in-differences study to assess the effectiveness of a stewardship intervention in a family medicine clinic at an academic outpatient center from August 2016 to March 2019. During our intervention period, the FDA released 2 additional warnings about the side effects of fluoroquinolones. Methods: The study had 2 sites (intervention and comparison) and 3 periods: baseline, before the intervention, and the intervention. During the first 2 years, we obtained baseline data and performed interviews (preintervention period) exploring provider prescribing decisions for cystitis at both sites. During the intervention period at the intervention site only, we presented an educational lecture including an overview of the IDSA guidelines, definitions for various UTI syndromes and actual clinical examples, and instruction on use of a decision aid. During the audit and feedback phase, providers were contacted once per month in person or by phone to provide follow-up on whether their treatment decision adhered to the IDSA guidelines. We performed a log-binomial regression analysis of the primary outcome, adherence to the IDSA guidelines for management of uncomplicated cystitis, both to antibiotic choice and duration of therapy. Results: We performed 156 audit-and-feedback sessions with 13 providers during the intervention period (March 2018–2019). Patients in both sites were similar in terms of age and Charlson comorbidity index. Adherence to the guidelines for antibiotic choice and duration increased in the intervention period at both sites (Fig. 1). The treatment of cystitis in the intervention period of the intervention site was 11.5 times (95% CI, 6.1–21.6) as likely to be guideline-adherent as the treatment in the baseline period of the comparison site (Fig. 2). Conclusions: Adherence to IDSA guidelines for the choice of antibiotic and duration increased in both intervention and comparison sites. Even though the intervention site started with higher compliance, improvement was also greater in the intervention site. FDA warnings about the side effects of fluoroquinolones released during the intervention period may have contributed to the avoidance of fluoroquinolones at both sites. Our intervention was effective at improving antibiotic choice and duration, so our future plans include incorporating our decision-support algorithm into the electronic medical record.
Funding: This study was supported by Zambon Pharmaceuticals.
Disclosures: None
Impact of an Assay That Enables Rapid Determination of Staphylococcus Species and Their Drug Susceptibility on the Treatment of Patients with Positive Blood Culture Results
- Mark Parta, Melanie Goebel, Jimmy Thomas, Mahsa Matloobi, Charles Stager, Daniel M. Musher
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 31 / Issue 10 / October 2010
- Published online by Cambridge University Press:
- 02 January 2015, pp. 1043-1048
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- October 2010
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Objective.
To determine whether an earlier determination of staphylococcal species and their antibiotic susceptibility decreases unnecessary antistaphylococcal treatment and/or facilitates earlier appropriate treatment.
Methods.We used the Xpert MRSA/SA BC system (Cepheid) for immediate determination of species and their drug susceptibility in patients whose blood cultures revealed gram-positive cocci in clusters. We compared the treatment of patients whose physicians received early notification of these results (group 1) with the treatment of patients in a historical cohort with delayed reporting after traditional microbiological studies (group 2). Outcomes were analyzed according to whether blood culture was positive for Staphylococcus species other than S. aureus, methicillin-susceptible S. aureus (MSSA), or methicillin-resistant S. aureus (MRSA) and whether the drugs used were appropriate for methicillin-susceptible or methicillin-resistant staphylococci (hereafter referred to as “MSS drug” or “MRS drug” therapy, respectively).
Results.There were 44 (76%) of 58 patients with bacteremia due to Staphylococcus species other than S. aureus in group 1 and 58 (55%) of 106 patients with bacteremia due to Staphylococcus species other than S. aureus in group 2 who received no antistaphylococcal antibiotics (P <.01). Five (6%) of 89 patients in group 1 and 31 (25%) of 123 patients in group 2 received 0-168 hours (0-7 days) of MRS drug therapy (P < .01). Among patients with MSSA bacteremia, the mean time to initiation of appropriate therapy was 5.2 hours in group 1 and 49.8 hours in group 2 (P < = .007). Excluding patients who received MRS drug therapy for unrelated conditions, the mean duration of treatment was 19.7 hours in group 1 and 80.7 hours in group 2 (P = .003). Six (50%) of the 12 patients in group 1 and 39 (81%) of the 48 patients in group 2 received MRS drug therapy for MSSA bacteremia (P = .025). Time to initiation of therapy for MRSA bacteremia did not differ between groups.
Conclusions.The use of an assay with rapid results reduced the use of antistaphylococcal therapy among patients who did not have S. aureus bacteremia; it also decreased the use of MRS drug therapy and led to earlier appropriate therapy among patients with MSSA bacteremia.