A qualitative evaluation of a program to implement antimicrobial stewardship for asymptomatic bacteriuria: how site attributes affected uptake

OBJECTIVE: Determine site attributes affecting uptake of a national, multi-site antimicrobial stewardship project focused on reducing unnecessary urine culture orders and antibiotic prescriptions for asymptomatic bacteriuria (ASB). METHODS: Forty-one United States Veterans Affairs Medical Centers (VAMCs) were randomized into two arms: "Technical Assistance" (TA) or the "Virtual Learning Collaborative" (VLC). TA sites could request one-on-one guidance from the coordinating center, and VLC sites participated in semimonthly informational webinars. Otherwise, we provided TA and VLC sites with the same resources to educate healthcare professionals on proper ASB management. At the intervention's conclusion, we conducted 45-60-minute semi-structured interviews with local site leads and focus groups with their teams. TA and VLC sites were sampled based on time spent on intervention implementation, resulting in 19 participants across varying roles (e.g., pharmacists, physicians). We iteratively coded transcripts using thematic analysis. RESULTS: We propose five considerations for how site attributes informed uptake of our stewardship initiative: (1) existing connections with leadership and important contacts; (2) workplace structure and culture; (3) previous and concurrent antimicrobial stewardship initiatives; (4) availability of existing resources (e.g., time); and (5) personnel turnover (e.g., daily provider transition, job turnover). CONCLUSIONS: We recommend conducting pre-intervention interviews to identify site-specific obstacles and then tailoring the intervention to site-specific needs. Additionally, we stress the importance of sites' prior experiences with antibiotic stewardship and the availability of personnel to work on stewardship initiatives. Ultimately, a better understanding of sites' unique environments is an essential step for improving uptake of antimicrobial stewardship projects.