Skelton Felicia, Martin Lindsey Ann, Evans Charlesnika T, Kramer Jennifer, Grigoryan Larissa, Richardson Peter, Kunik Mark E, Poon Ivy Oiyee, Holmes S Ann, Trautner Barbara W
Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States.
H Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States.
JMIR Res Protoc. 2019 Feb 14;8(2):e12272. doi: 10.2196/12272.
Bacteriuria, either asymptomatic (ASB) or symptomatic, urinary tract infection (UTI), is common in persons with spinal cord injury (SCI). Current Veterans Health Administration (VHA) guidelines recommend a screening urinalysis and urine culture for every veteran with SCI during annual evaluation, even when asymptomatic, which is contrary to other national guidelines. Our preliminary data suggest that a positive urine culture (even without signs or symptoms of infection) drives antibiotic use.
Through a series of innovative studies utilizing mixed methods, administrative databases, and focus groups, we will gain further knowledge about the attitudes driving current urine testing practices during the annual exam, as well as quantitative data on the clinical outcomes of these practices.
Aim 1 will identify patient, provider, and facility factors driving bacteriuria testing and subsequent antibiotic use after the SCI annual evaluation through qualitative interviews and quantitative surveys. Aim 2 will use national VHA databases to identify the predictors of urine testing and subsequent antibiotic use during the annual examination and compare the clinical outcomes of those who received antibiotics with those who did not. Aim 3 will use the information gathered from the previous 2 aims to develop the Test Smart, Treat Smart intervention, a combination of patient and provider education and resources that will help stakeholders have informed conversations about urine testing and antibiotic use; feasibility will be tested at a single site.
This protocol received institutional review board and VHA Research and Development approval in July 2017, and Veterans Affairs Health Services Research and Development funding started on November 2017. As of submission of this manuscript, 10/15 (67%) of the target goal of provider interviews were complete, and 77/100 (77%) of the goal of surveys. With regard to patients, 5/15 (33%) of the target goal of interviews were complete, and 20/100 (20%) of the target goal of surveys had been completed. Preliminary analyses are ongoing; the study team plans to present these results in April 2019. Database analyses for aim 2 will begin in January 2019.
The negative consequences of antibiotic overuse and antibiotic resistance are well-documented and have national and even global implications. This study will develop an intervention aimed to educate stakeholders on evidence-based management of ASB and UTI and guide antibiotic stewardship in this high-risk population. The next step will be to refine the intervention and test its feasibility and effectiveness at multiple sites as well as reform policy for management of this common but burdensome condition.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12272.
菌尿症，无论是无症状菌尿（ASB）还是有症状的尿路感染（UTI），在脊髓损伤（SCI）患者中都很常见。美国退伍军人健康管理局（VHA）目前的指南建议，在年度评估时，对每一位SCI退伍军人进行尿分析筛查和尿培养，即使无症状时也需如此，这与其他国家指南相悖。我们的初步数据表明，尿培养阳性（即使没有感染迹象或症状）会促使抗生素的使用。
通过一系列采用混合方法、行政数据库和焦点小组的创新性研究，我们将进一步了解在年度检查中推动当前尿液检测实践的态度，以及这些实践临床结果的定量数据。
目标1将通过定性访谈和定量调查，确定在SCI年度评估后推动菌尿症检测及随后抗生素使用的患者、提供者和机构因素。目标2将使用VHA全国数据库来确定年度检查期间尿液检测及随后抗生素使用的预测因素，并比较接受抗生素治疗者与未接受者的临床结果。目标3将利用从之前两个目标收集的信息来开发“明智检测、明智治疗”干预措施，这是一种患者和提供者教育及资源的组合，将帮助利益相关者就尿液检测和抗生素使用进行明智的对话；将在单个地点测试其可行性。
本方案于2017年7月获得机构审查委员会和VHA研发部门的批准，退伍军人事务部卫生服务研究与发展基金于2017年11月开始提供。截至提交本手稿时，提供者访谈的目标已完成10/15（67%），调查目标已完成77/100（77%）。关于患者，访谈目标已完成5/15（33%），调查目标已完成20/100（20%）。初步分析正在进行；研究团队计划于2019年4月公布这些结果。目标2的数据库分析将于2019年1月开始。
抗生素过度使用和抗生素耐药性的负面后果有充分记录，并具有国家乃至全球影响。本研究将开发一种干预措施，旨在教育利益相关者关于ASB和UTI的循证管理，并指导这一高风险人群的抗生素管理。下一步将是完善干预措施，在多个地点测试其可行性和有效性，并改革针对这种常见但负担沉重疾病的管理政策。
国际注册报告识别码（IRRID）：DERR1-10.2196/12272。
