More than three million illnesses and 48,000 deaths are caused by antibiotic-resistant bacteria each year with an annual impact of $35 billion in excess health care costs. A newly funded multi-tiered VA grant seeks to directly counterattack growing threats of emerging pathogens and antimicrobial resistance (AMR).

Eli Perencevich, MD, MS, professor in General Internal Medicine and of Epidemiology, and other VA researchers will jumpstart a four-year, $3.2 million VA QUERI project. Titled after its predecessor, Combating Antimicrobial Resistance through Rapid Implementation of Available Guidelines and Evidence, this new program, CARRIAGE II, aims to target the growing threats of antimicrobial resistance and emerging infectious diseases across VA patient care. CARRIAGE II will partner with three National VA Program Offices, along with VISN 23 and the Centers for Disease Control and Prevention (CDC). VISN 23 is the health care network of dozens of sites throughout the Upper Midwest.

The CARRIAGE II program will explore strategies that support the adoption of new and present evidence-based practices (EPBs), policies, and programs that target preventing the spread of antibacterial-resistant pathogens and improved antimicrobial stewardship. Focused on the intersection of infectious diseases, infection prevention, public health and patient safety, the program plans to support a series of related research projects that will unite to potentially reverse the spread of antimicrobial resistance.

CARRIAGE II has three interdependent EBPs focused on targeting behaviors that facilitate antimicrobial resistance spread. The first study strives to overcome barriers to Ultraviolet-C (UVC) no-touch room disinfection, the second study aims to improve implementation strategies to prevent carbapenem-resistant organisms from spreading, and the third study will estimate the impact of two different implementation strategies on antimicrobial prescribing practices.

As co-PI on this project, Perencevich will collaborate with Michael Rubin, MD, PhD, professor of Internal Medicine at the University of Utah; Makoto Jones, MD, MS, associate professor of Internal Medicine at the University of Utah; and Charlesnika Evans, MPH, PhD, associate professor of Preventative Health at Northwestern University.

CARRIAGE I
The CARRIAGE II program is the successor of CARRIAGE I, which aimed to implement quality improvement projects that improve the use of antibiotics and reduce the burden of healthcare-associated infections across VA care settings. CARRIAGE I conducted three implementation programs, five evaluations co-funded by VA and CDC, and developed the national VA research agenda for advancing science and implementation of AMR prevention.

The core of CARRIAGE I focused on a VISN 23 Audit-and-Feedback strategy that improved hand hygiene monitoring along with improving antimicrobial stewardship and infection control. CARRIAGE I’s study findings were presented during 22 national meetings and numerous publications.

Implementation Core
CARRIAGE II’s Implementation Core includes a multidisciplinary team led by Cassie Goedken, MPH; Jorie Butler, PhD, adjunct assistant professor of Biomedical Informatics, research associate professor of Internal Medicine, and adjunct assistant professor of Psychology at the University of Utah; and Rubin. Comprised of implementation experts in psychology, social sciences, qualitative methods, anthropology, and health services research, the team also includes Kimberly Dukes, PhD, research assistant professor in General Internal Medicine, as well as Katie Suda, PharmD, MS, professor of General Internal Medicine at the University of Pittsburgh, and Marylou Guihan, PhD, research assistant professor of Physical Medicine and Rehabilitation at Northwestern University.

The Implementation Core oversees all the implementation-related program activities, and provides input, guidance, and direction on the project. They will provide personnel for the Rapid Response Teams and participate in the Mentoring Core.

Perencevich was clear to distinguish implementation research from health services and biomedical research. “Biomedical science is when you invent a new diabetes drug and ask, ‘does the intervention work?’ Health services research is, ‘how does it work if it’s implemented in a community?’ But implementation sciences asks, ‘what’s the best way to implement it in the community?’ How do you get the veterans to take the new diabetes drug that was invented, but no one is taking?”

He pointed to a recent hand hygiene study as an example. Although hand hygiene is crucial for preventing hospital-borne pathogens, researchers found only 50% compliance among nurses. Qualitative interviews revealed nurses could not use the hand sanitizer pumps outside the rooms because they usually had their hands full. With implementation science, Perencevich says research is able to take a step toward reducing these barriers.

“We know we need to get hand hygiene to 100% compliance,” Perencevich said. “We know what works: alcohol hand rub. You’ve got to ask them, ‘what’s stopping you [from using it]?’ Observe, ask, and then react. Implementation science really relies on the mixed methods of qualitative interviews and quantitative analysis.”

Rapid Response Team
In response to emerging infectious disease threats, such as COVID-19, CARRIAGE II’s Rapid Response Team was developed to fulfill the need for a dynamic multidisciplinary team. Led by Rubin, the team is composed of investigators and staff with proven track records of working with operational partners on time-sensitive projects.

CARRIAGE Mentorship
CARRIAGE II also plans to implement a mentorship team, co-directed by Marin Schweizer, PhD, associate professor in General Internal Medicine, and Rubin. While the mentorship aspect of this QUERI grant is just beginning, the team plans to train the next generations of CARRIAGE researchers. Schweizer currently mentors Ana-Monica Racila, PhD, a Nephrology postdoctorate working under a T23 grant. Racila will also be engaged with Rapid Response projects and the Implementation Core team to gain experience working with time-sensitive tasks.

This Mentoring Core will help connect mentees like Racila with resources to supplement their development, support their career development, and expand the VA workforce.

About VA’s QUERI grant program
The VA’s Quality Enhancement Research Initiative (QUERI) program was established in 1998 to accelerate the application of research discoveries to clinical settings, including clinics that treat U.S. Military Veterans. In addition to the CARRIAGE investigators, the QUERI program supports more than 200 investigators and 40 centers nationally.