Empowerment Program to Reduce Treatment of Asymptomatic Bacteriuria in Veterans With Spinal Cord Injury

Antimicrobial resistance is a major public health concern that worsens healthcare outcomes. Antibiotic resistant organisms occur more often in Veterans with spinal cord injury or disease (SCI/D) given their frequent exposure to antibiotics, recurrent hospitalizations, and common use of urinary catheter devices. Veterans with SCI/D are also at risk for overtreatment with antibiotics when they do not need them, particularly for over-diagnosed urinary tract infections. The investigators plan to create a patient empowerment program with input of Veterans with SCI/D \[and their providers\] to help guide their decisions and next steps when they have a change in bladder symptoms. The program will give Veterans with SCI/D the tools to speak up to their provider and advocate for themselves to avoid receiving unnecessary antibiotics. This program is highly innovative, as it puts Veterans with SCI/D in charge of thoughtful antibiotic use, or antibiotic stewardship.

It is estimated that 42,000 Veterans are living with spinal cord injury or disease (SCI/D), 27,000 of whom are cared for by the VA each year. Individuals with SCI/D and neurogenic bladder are at increased risk for infections from antibiotic-resistant bacteria due to many factors, including repeated exposure to healthcare settings, healthcare-associated pathogens, and antibiotics, as well as the frequent presence of medical devices (e.g., urinary catheters).\] These issues are a cause for concern, as rising rates of antibiotic resistance are a major public health issue, and healthcare outcomes are worse in patients with infections from antibiotic-resistant organisms. A primary reason for high rates of antibiotic usage among those with SCI/D and neurogenic bladder is bacterial colonization of the bladder (i.e., bacteriuria), which is common in these individuals due to urinary retention and urinary catheters and often treated with antibiotics despite guidelines recommending against this practice. In particular, treatment of bladder colonization without signs/symptoms of infection, known as asymptomatic bacteriuria (ASB), is not recommended as antibiotics do not improve clinical outcomes and contribute to antibiotic resistance. However, despite efforts to reduce the frequency of treatment for ASB among providers, treatment rates remain high, and nearly half of the courses of antibiotics prescribed for suspected UTIs in those with neurogenic bladders are for the inappropriate treatment of ASB. Innovation and Impact: The investigators propose to address this problem by developing an empowerment intervention for Veterans with SCI/D and neurogenic bladder to help them interact with their providers about their bladder health and advocate for themselves when they do not need antibiotics. This intervention will include direct-to-consumer marketing material to engage Veterans with SCI/D and empowerment training via role-playing for Veterans to use when discussing suspected UTI with their providers. Specific Aims: The investigators will develop and pilot this Veteran-focused, Veteran-led antibiotic stewardship program through a mixed-methods research design. The investigators will pilot test the direct-to-consumer patient empowerment program, role-playing activities, and marketing materials among Veterans with SCI/D and neurogenic bladders and their providers. Methodology: This study employs qualitative and quantitative data techniques, such as semi-structured interviews, focus groups, quantitative surveys and outcome measures, and a pilot study. The primary outcome of the pilot study is the assessment of Veterans' self-reported quality of life specific to urinary incontinence via the Incontinence Quality of Life Questionnaire. Secondary outcomes include bladder symptom burden via Neurogenic Bladder Symptom Score, feasibility and acceptability of the intervention to Veterans with SCI/D via the Weiner survey, functional outcomes (with emphasis on bladder function), knowledge and attitudes about antibiotics, communication with providers, and response to marketing materials. Path to Translation/ Implementation: This work will lay the groundwork for a future randomized controlled trial testing the program's effectiveness at reducing unnecessary antibiotic treatment of ASB in Veterans with SCI/D. More broadly, empowering Veterans and their caregivers to engage with their providers and advocate for their health is integral to the PI's long-term goal of becoming a VA clinician-investigator recognized for advancing innovative approaches to antimicrobial stewardship in rehabilitation populations.