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IIR 19-178 – HSR Study

IIR 19-178
Diagnostic Stewardship as a 'nudge' to reduce inappropriate antibiotic use for urinary tract infections
Daniel Josiah Morgan, MD MS
Baltimore VA Medical Center VA Maryland Health Care System, Baltimore, MD
Baltimore, MD
Funding Period: October 2020 - September 2024


Background: Antibiotic-resistant bacteria are estimated by the Centers for Disease Control and Prevention (CDC) to kill over 23,000 Americans yearly. Overuse of antibiotics is a leading cause, and reducing unnecessary antibiotic use is a national priority. A major factor in antibiotic overuse is inappropriate or unnecessary culturing, particularly unnecessary urine culturing that identifies colonization and leads to overdiagnosis of urinary tract infections (UTI). Significance/ Impact: Diagnostic stewardship is a novel approach to limiting antibiotic use by modifying the ordering, processing, or reporting of a “positive” culture that generally should not be treated. In preliminary work, we found significant reductions in unnecessary urine cultures and associated antibiotic use through diagnostic stewardship. Diagnostic stewardship is synergistic with antimicrobial stewardship by improving the value and accuracy of urine testing before treatment. This proposal addresses gaps including: Defining best UTI diagnostic stewardship methods, informed by experts and clinicians; developing implementation methods for UTI diagnostic stewardship; and, assessing the impact of real life UTI diagnostic stewardship— both benefits and any harms across acute-care, long-term care, and ambulatory care. This meets HSR&D Research priorities of quality/safety, health care value, cross-cutting HSR methods priorities of implementation science/provider behavior and ORD-wide priority of real-world impact of VA research in addition to national priorities from CDC, Centers for Medicare and Medicaid Services (CMS) and the President’s National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB). Innovation: Modifying how tests are ordered, processed, and reported can help improve patient care by using existing technology more effectively. This is a ‘nudge’ approach, developed from psychology and behavioral economics. This work uses the electronic medical record (EMR) in an innovative, mostly behind the scenes fashion to improve appropriateness of ordering and reporting of tests. A pragmatic proof-of- concept study within an existing network of VA health care systems, using automated outcomes from the VA Corporate Data Warehouse (CDW) is efficient and consistent with the VA goal of being a Learning Health System. Our aims are as follows: Aim 1: Define best UTI diagnostic stewardship criteria, based on literature and Delphi method expert panel. Aim 2: Use iterative user-centered design process to develop EMR interface and lab protocols, with clinicians and other stakeholders (nurses, doctors, technicians, and IT representatives). Aim 3: Conduct a pragmatic proof-of-concept hybrid effectiveness implementation study of the UTI diagnostic stewardship interventions in 3 CDC-CREATE Network Healthcare Systems evaluating benefits and any adverse events. Project Methods: Aims 1 and 2 will use expert panels for developing consensus criteria and a user-centered design process, including end-user interviews and focus groups, for creating and refining implementation tools. Aim 3 will conduct a quasi-experimental before-after study in the existing VA CDC-CREATE Network. Next Steps/Implementation: Systematic application of diagnostic stewardship has the potential to limit inappropriate urine culturing; and thereby, reduce unnecessary use of antibiotics for over-diagnosed UTI at a minimal cost and without adverse consequences. If successful, the approaches from this proposal could be readily implemented to reduce antimicrobial resistance across the VA healthcare system and other hospitals; reducing catheter-associated UTI (CAUTI) and C. difficile rates; and improving the care and safety of Veterans.

External Links for this Project

NIH Reporter

Grant Number: I01HX002906-01A1

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Journal Articles

  1. Jent P, Berger J, Kuhn A, Trautner BW, Atkinson A, Marschall J. Antibiotics for Preventing Recurrent Urinary Tract Infection: Systematic Review and Meta-analysis. Open forum infectious diseases. 2022 Jul 1; 9(7):ofac327. [view]
  2. Amenta EM, Jump RLP, Trautner BW. Bacteriuria in older adults triggers confusion in healthcare providers: A mindful pause to treat the worry. Antimicrobial stewardship & healthcare epidemiology : ASHE. 2023 Jan 9; 3(1):e4. [view]
  3. Claeys KC, Weston LE, Pineles L, Morgan DJ, Krein SL. Implementing diagnostic stewardship to improve diagnosis of urinary tract infections across three medical centers: A qualitative assessment. Infection control and hospital epidemiology. 2023 Jul 10; 1-10. [view]
  4. Zulk JJ, Clark JR, Ottinger S, Ballard MB, Mejia ME, Mercado-Evans V, Heckmann ER, Sanchez BC, Trautner BW, Maresso AW, Patras KA. Phage Resistance Accompanies Reduced Fitness of Uropathogenic Escherichia coli in the Urinary Environment. mSphere. 2022 Aug 31; 7(4):e0034522. [view]
  5. Olmeda K, Trautner BW, Laytner L, Salinas J, Marton S, Grigoryan L. Prevalence and Predictors of Using Antibiotics without a Prescription in a Pediatric Population in the United States. Antibiotics (Basel, Switzerland). 2023 Mar 1; 12(3). [view]
  6. Trautner BW, Kaye KS, Gupta V, Mulgirigama A, Mitrani-Gold FS, Scangarella-Oman NE, Yu K, Ye G, Joshi AV. Risk Factors Associated With Antimicrobial Resistance and Adverse Short-Term Health Outcomes Among Adult and Adolescent Female Outpatients With Uncomplicated Urinary Tract Infection. Open forum infectious diseases. 2022 Dec 1; 9(12):ofac623. [view]

DRA: Infectious Diseases
DRE: Treatment - Observational, TRL - Applied/Translational
Keywords: Best Practices, Clinical Diagnosis and Screening, Patient Safety
MeSH Terms: None at this time.

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