1053. De-Implementing Low-Value Antibiotic Prescribing Across Levels of Care

Abstract

Background. Performing urinalyses and urine cultures in asymptomatic patients is one of the most common reasons for inappropriate antibiotic use. However, de-implementing this practice has been difficult, especially for clinical scenarios deemed to be high risk for infectious complications, such as among patients with delirium or those undergoing orthopedic implant surgery. Methods. Using the dual-process theory framework “Developing De-Implementation Strategies Based on Un-Learning and Substitution,” an educational intervention citing new IDSA guidelines and providing a pneumonic “ABCs of ASB” was created and delivered didactically to providers. The goal was to increase performance of evidence-based prevention actions in place of low-value urine screening and treating of asymptomatic patients. Clinical providers and staff (MD, RN, APRN, trainees) in 3 different levels of care (acute inpatient, long-term, and outpatient) were included. A web-based anonymous and confidential pre- and post-question format was delivered to assess influence on provider behavior. Results. Responses from a range of 250-279 unique providers were collected. For scenario #1 (patient with delirium and a positive urine culture and no other infectious symptoms), the option to give antibiotics was reduced by 45% pre to 4% post, Chisquare P < 0.01). For scenario #2 (patient having a knee replacement and positive preoperative urine culture, no other symptoms) the option to give antibiotics was reduced by the same magnitude (∼50%) but a lower absolute number (67% pre and 33% post, chi-square P < 0.01). Changes in predicted behavior were similar across levels of care. Conclusion. Substituting evidence-based practices in place of low-value practices is an appealing framework for influencing provider behavior. Our work demonstrates that education can successfully reduce the intention to use antibiotics for asymptomatic patients with positive urine cultures.