P-1130. Promoting De-Implementation of Inappropriate Antimicrobial Use Following Cardiac Device Procedures

TL;DR

This study shows that a bundled de-implementation strategy can significantly reduce inappropriate antibiotic use after cardiac device procedures without increasing infections.

Contribution

A multifaceted de-implementation bundle with infection surveillance effectively reduces prolonged antimicrobial use post-cardiac device procedures.

Findings

Two sites reduced guideline-discordant care from >90% to <15% of procedures.

No increase in CIED infections was observed after reducing antimicrobial use.

Practice changes were sustained for at least one year in intervention sites.

Abstract

Despite a strong evidence base and clinical guidelines specifcally recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device (CIED) procedures, including the VA. The aim of this study was to leverage learning/unlearning theory and de-implementation science to promote uptake of guideline-based care and to reduce inappropriate antimicrobial prophylaxis following CIED procedures.

Formative evaluations conducted by our VA study team suggested that inappropriate antimicrobial use is driven by several factors including concerns about liability if post-procedural antimicrobials are not prescribed (Figure 1).

We conducted a hybrid type III effectiveness-implementation stepped-wedge intervention trial of a bundled de-implementation intervention at three high-volume, high-complexity VA medical centers. The bundled de-implementation intervention included: audit and feedback with benchmarking about guideline concordant care, CIED infection, and antimicrobial harms, education, engagement of local champions, and blended facilitation. Primary outcome was facility uptake of guideline-concordant care. Intervention sites were compared to three matched controls. Qualitative interviews were used to determine factors associated with practice improvement (Figure 2).

Facility rates of guideline discordant practice at the 3 intervention and 3 control sites are presented in Figures 3; days of post-procedural antibiotics are presented in Figure 4.. Two sites demonstrated substantial improvement, with reductions in guideline discordant care from >90% of procedures to < 15% of procedures. In the third site, rates of prolonged prophylaxis remained high but median duration of antimicrobial prophylaxis was reduced. No increases in CIED infections following discontinuation were identified. No improvements were seen in the non-intervention sites. Practice changes were sustained for a least 1 year.

A multifaceted de-implementation bundle that includes infection surveillance to provide assurance that patients are not being harmed by reduced antimicrobial exposure was effective at promoting guideline uptake and reducing inappropriate antimicrobial use.

Westyn Branch-Elliman, MD, MMSc, DLA Piper, LLC/Medtronic: Advisor/Consultant|DLA Piper, LLC/Medtronic: Expert Testimony