Unnecessary antibiotic use is a threat to public health and to each individual patient. Reducing unnecessary
use, or antibiotic stewardship, is essential to preserving the effectiveness of antibiotics now and for future
generations. Recent national mandates underscore the importance of establishing antibiotic stewardship
programs in hospitals and nursing homes, but we do not know the best way to implement antibiotic
stewardship on a wide scale and under real-world conditions. Asymptomatic bacteriuria (ASB), a condition in
which the patient has bacteria colonizing the bladder without any urinary symptoms, is very common condition
in hospitalized patients and nursing home residents. ASB is often confused with urinary tract infection (UTI),
but ASB, unlike UTI, is clinically insignificant and should not be treated with antibiotics. Unnecessary screening
for and treatment of ASB is a major driver of unnecessary antibiotic use in hospitals and nursing homes. We
have developed an effective intervention to implement evidence-based antibiotic stewardship guidelines for
ASB through successive research projects. We now propose to use this tool to assess the relative merits of
two large-scale implementation strategies, a virtual learning collaborative (with group learning opportunities)
compared to technical assistance (individualized support available on request). These two implementation
strategies are widely used, but randomized, controlled trials of their effectiveness compared to each other are
rare. In this trial we will test the two implementation strategies and observe clinical outcomes. We will
randomize VA hospitals that provide both hospital and nursing home care to one of the two implementation
strategies. VA hospitals will be recruited in partnership with the VA Antimicrobial Stewardship Task Force
(ASTF), an organization dedicated to expanding antibiotic stewardship activities across all VA sites. We base
our plans on a learning health cycle, in which we share data about urine culture orders and antibiotic use with a
lead person at each hospital to generate knowledge, which leads to fewer urine culture orders and fewer days
of antibiotics, and behavior change leads to improved performance. Our five-year project will take
approximately 20-25 hospitals through one cycle of change, while building capacity for cycles to continue after
the project ends. The work will occur through three aims: (Aim 1) Assess context and resources for
implementation. (Aim 2) Compare a virtual learning collaborative versus technical assistance as
implementation strategies in a cluster randomized trial. The primary outcome is minutes spent in delivery of
the intervention, but we will also assess effectiveness through decreased urine cultures and antibiotic use. We
will explore stakeholder satisfaction with and sustainability of implementation strategies through qualitative
methods. (Aim 3) is to assess the cost implications of the implementation strategies through budget impact
analysis. Through this trial, we will add to knowledge about using wide scale implementation strategies and
making antibiotic stewardship programs successful in real-world settings.
