Promoting Antibiotic Stewardship in Primary Care Setting: An Evaluation Process of Treatment Practices for Uncomplicated Urinary Tract Infections in Premenopausal Non-Pregnant Women

Ira Amayun

Date of Graduation

Spring 5-28-2021

Document Type

Project

Degree Name

Doctor of Nursing Practice (DNP)

College/School

School of Nursing and Health Professions

Department/Program

Nursing

Program

DNP Completion

First Advisor

Dr. Alexa Curtis

Second Advisor

Dr. Nancy Selix

Abstract

Problem

Inappropriate antibiotic prescribing increases the prevalence of antibiotic resistance. While evidence-based practice guidelines can reduce antibiotic use, inconsistent adherence to these guidelines results in ineffective treatment, increased cost, and increasing antibiotic resistance.

Context

At Athena Med-Monterey, a multi-provider primary care clinic where approximately 90% of the patients are women, written guidelines for uncomplicated urinary tract infections (uUTIs) in premenopausal non-pregnant women (PrMNPW) are lacking. In addition, there are no processes for assessing adherence to clinical guidelines.

Interventions

The advanced practice nurse (APN) led a quality improvement process to assess and promote adherence to practice guidelines using a small test of change and the plan-do-study-act (PDSA) method. Qualitative assessment and retrospective chart review were performed to measure outcomes.

Measures

This project examined the clinicians’ adherence to evidenced-based guidelines and use of first-line agents to treat uUTIs in PrMNPW, and evaluated opportunities for ongoing practice improvement in treating uUTIs and adherence to clinical practice guidelines.

Results

The quality improvement process successfully evaluated and promoted adherence to evidence-based practice guidelines. Both the qualitative assessment and retrospective chart reviews found that the clinicians used evidence-based guidelines and first-line agents to treat uUTIs in PrMNPW. No practice improvement intervention was needed for antibiotic treatment of this specific condition.

Conclusions

The clinicians’ adherence to the guidelines yielded desired practice and patient outcomes. The APN-driven small test of change and PDSA method demonstrated success in implementing a process to evaluate and promote evidence-based guidelines and first-line agents to treat infections in primary care.

Comments

Appendix

Statement 1

DNP Statement of Non-Research Determination Form

Student Name: Ira Amayun_____________________________________

Title of Project:

A Quality Improvement Project: Utilizing Clinical Practice Guidelines for Women Presenting with Symptoms of Uncomplicated Urinary Tract Infections

Brief Description of Project:

A) Aim:

The overall goal of the proposed project is to promote adherence to evidence-based guidelines for treating uncomplicated urinary tract infections (uUTIs) for premenopausal non-pregnant women.

B) Description of Intervention:

The proposed project will use the 2011 IDSA clinical practice approach for treating uUTIs in pre-menopausal non-pregnant women, as well as the clinicians’ practice preferences, to set or modify practice guidelines. The plan-do-study-act method will be used to guide the small tests of practice change.

C) How will this intervention change the practice?

The proposal will examine whether integrating the 2011 IDSA approach into a primary clinic’s current uUTI management practices (vs. the clinic’s current practices alone) will increase adherence to evidence-based guidelines and evaluate opportunities to improve the quality of clinical decisions and patient outcomes over a few weeks’ series of small tests of change.

C) Outcome measurements:

The following measures could be used to evaluate the proposal’s outcomes:

Clinicians who prescribed antibiotics in the four weeks after the implementation of the small tests of change referenced the clinical practice guidelines in the treatment of 80% of all the PrMNPW seen with UTI symptoms.
Out of all the PrMNPWs seen with UTI symptoms in the four weeks after the implementation of the small tests of change, 80% are prescribed the appropriate first-line agents for AUC.
Out of all the PrMNPWs seen with UTI symptoms in the four weeks after the implementation of the small tests of change, 80% are prescribed the appropriate first-line agents for acute pyelonephritis.

This proposal will also attempt to quantify improvement in the quality of clinical decisions using clinical practice guidelines and measure symptom resolution at 28 days post uUTI treatment.

To qualify as an evidence-based change in practice project, rather than a research project, the following criteria outlined in federal guidelines will be used (http://answers.hhs.gov/ohrp/categories/1569):

☐ This project meets the guidelines for an evidence-based change in practice project as outlined in the project checklist (attached). Students may proceed with implementation.

☐ This project involves research with human subjects and must be submitted for IRB approval before project activity can commence.

Comments:

EVIDENCE-BASED CHANGE OF PRACTICE PROJECT CHECKLIST *

Instructions: Answer YES or NO to each of the following statements:

Project Title:

YES

NO

The aim of the project is to improve the process or delivery of care with established/accepted standards or to implement evidence-based change. There is no intention of using the data for research purposes.

X

The specific aim is to improve performance on a specific service or program and is a part of usual care. ALL participants will receive standard care.

X

The project is NOT designed to follow a research design (e.g., hypothesis testing or group comparison, randomization, control groups, prospective comparison groups, cross-sectional, case control). The project does NOT follow a protocol that overrides clinical decision-making.

X

The project involves the implementation of established and tested quality standards and/or systematic monitoring, assessment, or evaluation of the organization to ensure that existing quality standards are being met. The project will NOT develop paradigms, untested methods, or new untested standards.

X

The project involves the implementation of care practices and interventions that are consensus-based or evidence-based. The project does NOT seek to test an intervention that is beyond current science and experience.

X

The project will be conducted by the staff where the project will take place and involves staff who are working at an agency that has an agreement with USF SONHP.

X

The project has NO funding from federal agencies or research-focused organizations and is not receiving funding for implementation research.

X

The agency or clinical practice unit agrees that this is a project that will be implemented to improve the process or delivery of care, i.e., not a personal research project that is dependent upon the voluntary participation of colleagues, students, and/or patients.

X

If there is an intent to, or possibility of publishing your work, you and supervising faculty and the agency oversight committee are comfortable with the following statement in your methods section: “This project was undertaken as an evidence-based change of practice project at X hospital or agency and as such was not formally supervised by the Institutional Review Board.”

X

ANSWER KEY: If the answer to ALL of these items is yes, the project can be considered an evidence-based activity that does NOT meet the definition of research. IRB review is not required. Keep a copy of this checklist in your files. If the answer to ANY of these questions is NO, you must submit for IRB approval.

*Adapted with permission of Elizabeth L. Hohmann, MD, Director and Chair, Partners Human Research Committee, Partners Health System, Boston, MA.

STUDENT NAME (Please print): Ira Amayun

_______________________________________________________________________

Signature of Student:

______________________________________________DATE: Oct. 31, 2020____ _

SUPERVISING FACULTY MEMBER (CHAIR) NAME (Please print):

___Dr. Alexa Curtis______________________________________________________

Signature of Supervising Faculty Member (Chair):

______________________________________________DATE_______________

Letter 1

Letter of Support from the Agency: Athena Med-Monterey

Table 1

Synthesis Table

Study

Design

Sample

Outcomes/Findings

Qualitative analysis of PCPs’ prescribing decisions for urinary tract infections

Grigoryanet al. (2019)

Qualitative semi-structured interviews and thematic analysis

Eighteen PCPs practicing in two family medicine clinics in a large urban area in Texas between July 2017 and November 2017

Few providers relied on the IDSA guidelines for treating uUTIs.

Antibiotic prescribing in New York State Medicare Part B beneficiaries diagnosed with cystitis between 2016 and 2017

Yu et al. (2020)

Retrospective cohort study of Medicare Part B enrollees in New York State

There were 23,981 and 26,677 prescriptions written for cystitis across New York State in 2016 and 2017, respectively.

SMX-TMP, fosfomycin, and B-lactamase prescriptions increased, and FQ use decreased in older female and male adults.

The results suggested that the widespread prevalence of FQ and B-lactamase prescriptions necessitates outpatient antimicrobial stewardship.

Preferential use of NTF over FQ for AUC and outpatient E. coli resistance in an integrated healthcare system

Pedela et al. (2017)

Retrospective pre-intervention post-intervention study

An urban setting in Colorado, a 477-bed hospital, an emergency department, an urgent care department, eight community health clinics, and 15 school-based clinics

This study included 5,714 adults treated for acute cystitis and 11,367 outpatient E. coli isolates.

After a change in institutional guidelines, there was an immediate 26% reduction in FQ use and stabilization of FQ-resistant E. coli. NTF use increased without any change in NTF resistance.

Evaluation of the trends and appropriateness of FQ use in the outpatient treatment of AUC at five family practice clinics

Robinson et al. (2019)

Retrospective study

Women aged 19–64 years old were seen at five family medicine clinics and prescribed NTF, ciprofloxacin, or levofloxacin for uncomplicated cystitis.

Of the 567 women included in this study, 395 were given NTF, and 172 were given FQ; 343 (86.8%) and 18 (10.5%) were appropriately prescribed NTF and FQ, respectively. Of the women who were inappropriately prescribed FQ, 15 (87.8%) lacked contraindication to NTF.

Improvement in adherence to antibiotic duration of therapy recommendations for uncomplicated cystitis: A quasi-experimental study

Giancola et al. (2019)

Quasi-experimental study

Women aged 18–64 years old who were prescribed NTF, SMX-TMP, or ciprofloxacin within seven days of encounters at five family medicine clinics

Clinics that received education increased adherence from 22.1% to 58.8% (p < 0.01). Revising/adding default prescription instructions to targeted antimicrobials and DOT, and staff in-service increased clinician adherence to uncomplicated cystitis first-line antibiotic DOT guidelines.

Diagram 1

Reviews based on Prisma Diagram

PRISMA 2009 Flow Diagram©

Criteria: Literature in English, published between 2017 and February 21, 2020, meeting medical search terms.

Cochrane

https://www.cochranelibrary.com/advanced-search

(n = 25)

Records after duplicates removed

n56- 19duplicates = 37 (n = 37)

Records screened

n=37 (n = )

Records excluded (n =18)

2 recurrent cystitis

1 green tea treatment

1 kidney transplant

3 pregnant women

1 cefditoren pivoxil

1 uroprofit, chronic cystitis

1 phytotherapeutic med

1 overactivity/incontinence

1 mecillinenam

1 complicated cystitis (DM)

1 article not available

4 no full text available

Full-text articles assessed for eligibility (n=19)

Full-text articles excluded,

with reasons (n = 8)

1 Not specific to prescribing first-line antibiotics.

1 Cepodoxime study

1 recurrent infection and MDR

1 Urine culture cost effectiveness

1 Generic vs brand name antibiotics

1 pharmacokinetics of nitrofurantoin

1 Guideline review

1 Guideline Update

Studies included in synthesis

4 quantitative

1 qualitative

(n = 5)

PubMed https://pubmed.ncbi.nlm.nih.gov/ (n = 31)

Table 2

Gap Analysis

Focus Area

Current Situation

Desired Situation

Gap Factor/ Deficiency

Action Plan

Use of clinical practice guidelines, such as the 2011 IDSA, in the treatment of uUTIs.

No available data

Use of the 2011 IDSA approach to uUTI treatment is evident and available for reference.

A diagram of the 2011 IDSA approach to uUTI treatment is available for clinicians to reference.

No available data

Perform clinician survey.

The 2011 IDSA approach to AUC treatment is available for reference. This may be modified according to survey results and according to the PDSA method to reflect what would work with the current practice.

PrMNPWs with symptoms of AUC are prescribed appropriate first-line agents in accordance with the 2011 IDSA guidelines.

No data

PrMNPWs with symptoms of AUC will be prescribed appropriate first-line agents in accordance with the 2011 IDSA guidelines.

No available data

Recommend use of clinical practice guidelines and quality measurement tools and/or evaluation process.

PrMNPWs with symptoms of acute pyelonephritis will have their urine sent for culture in accordance with the 2011 IDSA guidelines.

No data

Clinicians wait for urine culture results and prescribe first-line agents in accordance with the 2011 IDSA guidelines.

No available data

Recommend use of clinical practice guidelines and quality measures.

Patients with uncertain diagnoses will have their urine sent for culture to confirm antibiotic treatment.

No data

Patients with uncertain diagnoses will have their urine sent for culture to confirm antibiotic treatment.

No available data

Continue practice.

PrMNPW treated for symptoms of uUTI report symptom relief within 48 hours after being seen at the clinic, and symptom resolution at 28-days post uUTI treatment.

No data

Patients report symptom relief within 48 hours after being seen at the clinic or symptom resolution at 28-days post-uUTI treatment.

No available data

Recommend use of quality measurement tools and/or evaluation process.

Table 3

Timeline (Gantt Chart)

Year 1 Tasks

Sept

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Formation of one clinician team for a small test of change using the PDSA method

Four-week retrospective chart review of the target population treated for UTI symptoms

Integration of the 2011 IDSA Approach to uUTI Treatment into the clinic’s current practices

Initial small test of change begins

Use of the PDSA method

Initial small test of change evaluation Plan second small test of change

Outcome measurement and report

Full implementation

First-year post-implementation survey

Report distribution

Year 2 Tasks

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Full implementation of the PDSA method

Outcome measurement and report

Second-year post-implementation survey

Outcome measurement and report

Report distribution

Year 3 Tasks

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Full implementation of the PDSA method

Outcome measurement and report

Third-year post-implementation survey

Outcome measurement and report

Report distribution

Figure 1

Urine Culture Smart Phrase Box

Table 4

Small Test of Change Work Breakdown Structure

Project clinic leadership: Allied Health Education Director

Change agents: APN and APNS

Participants: All of the clinic’s prescribing clinicians

Responsible (R): Member is responsible for completing the task

Consulted (C): Member was communicated with regarding the decision and task

Informed (I): Member was updated on decisions and actions

Role

Deliverable/Activity

Project Leader

APN and FNP student

Initialization Phase

Review the 2011 IIDSA Approach to uUTI Treatment vs Athena Med-Monterey clinicians’ resource/guidelines

I/C

R

Planning Phase

Perform a four-week retrospective chart review of the target population treated for UTI symptoms.

Print and laminate the modified approach diagram and place it in a visible position for reference.

Staff in-service sessions given prior to implementation.

I/C

R

Implementation Phase of the Small Test of Change

Prescribers refer to guidelines.

Conduct the PDSA method in cycles as needed for the desired quality practice.

I

R

Evaluation and Assessment Phase

Analyze and report outcomes to the medical director.

I

R

Review Phase

Create lessons learned.

I

R

Make the decision to continue or terminate the initiative.

R

I

Create a project closure report and present recommendations.

I/C

R

Table 5

Responsibility/Communication Matrix

Communication

Method

Frequency

Goal

Owner

Audience

Project Plan

Face-to-face meeting, clinic or university email

Once

Present project for approval and planning

Clinic leadership and change agents (APN, APNS)