Chronic Antibiotic Suppression after Prosthetic Joint Infection: A Target for De-implementation

背景：退伍军人管理局承诺减少抗生素的过度使用，并是国家行动的合作伙伴 计划打击抗药性细菌。过度使用抗生素可导致艰难梭菌感染 在接受抗生素治疗的个体中，以及可能使治疗复杂化的抗生素耐药性 所有患者的未来感染。慢性抗生素抑制(CAS)定义为无限期口服 遵循最初指南的抗生素推荐静脉注射和口服抗生素。有证据表明，中科院 可能被不适当地使用和过度使用。因此，迫切需要审查CAS是如何规定的， 谁从CAS治疗中受益最多，谁受到伤害。这些知识可以用来开发一个 取消实施和优化CAS使用的干预。在这项研究中，我们将检查CAS的治疗 假体关节感染(PJIs)。PJI发生在髋关节、膝盖或肩部置换手术后，并与 具有很高的临床和经济影响。在VHA系统中，超过10,000个髋关节、膝盖或肩部置换 每年都会进行手术，这一数字以及相关的PJI数量继续增加 增加。髋关节、膝关节或肩部置换术后PJI的治疗对退伍军人管理局很重要，因为 骨性关节炎是进行这种手术的最常见原因，在退伍军人中排名第五。 我们的试点数据和其他研究发现，许多PJI患者在指南之外开了CAS 建议，可能是因为医生担心复发。这种不适当的使用会导致不良后果 没有任何益处的患者结果(例如艰难梭菌感染、抗生素耐药性)。 研究计划：本研究的具体目标是：(1)明确患者、感染和治疗特征 确定将从取消实施CAS中受益的患者；(2)定义当前提供者CAS 通过采访制定流程并评估改变这些做法的障碍和促进者 卫生保健提供者；和(3)创建决策模型，对CAS的使用进行经济评估并 不同的干预措施，以杜绝不适当的CAS使用。我们预计将在以下方面记录重大变化 CA规定并确定具有成本效益的干预措施，以取消实施CAS或缩短其持续时间。 我们建议进行一项为期3年的混合方法研究，为取消实施CAS提供信息。AIM 1将使用 企业数据仓库(CDW)数据库，包含在退伍军人事务部所有医院接受治疗的约7,500名PJI患者 回溯性队列比较有效性研究，以确定确定 将从CAS取消实施中受益的PJI患者。这些特征可能包括年轻， 感染非致病性病原体，最初接受适当的抗生素治疗由以下引起的PJI 金黄色葡萄球菌，或接受二期交换手术。在目标2中，我们将参观8家不同的医院， 定性地探索有助于CAS使用的环境，并引出改变的障碍和促进者 开药方的做法。目标3将创建潜在干预的创新决策分析模型，以消除 实施CAS或缩短其持续时间。我们的发现将被提供给退伍军人管理局的抗微生物管理任务 协助抗生素停用工作的部队，并将提供设计未来所需的数据 在不需要的患者中取消实施CAS的干预的随机对照试验。 影响：我们的研究将为组织文化和更广泛的外部环境提供重要的见解 与过度开抗生素治疗术后感染有关的背景(例如，职业、社会)。我们 将确定抗菌药物管理的目标，并确定抗生素使用的临床情况 取消实施。鉴于假体关节、心脏起搏器和左 随着心脏辅助装置的使用，CAS的使用率有望上升。我们的研究将帮助退伍军人管理局 对不需要的患者使用抗生素，以减少VHA的抗生素耐药性 并预防艰难梭菌感染等不良事件。

Background: The VA has pledged to reduce overuse of antibiotics, and is a partner in the National Action Plan to combat antibiotic-resistant bacteria. Overuse of antibiotics can lead to Clostridium difficile infections among the individuals receiving antibiotics, as well as antibiotic resistance that can complicate treatment of future infections for all patients. Chronic antibiotic suppression (CAS) is defined as indefinite use of oral antibiotics following initial guideline recommended intravenous and oral antibiotics. There is evidence that CAS may be inappropriately used and overused. Thus, there is a critical need to examine how CAS is prescribed, and who benefits the most, and who is harmed, from CAS therapy. This knowledge can be used to develop an intervention to de-implement and optimize CAS use. In this study, we will examine CAS treatment for prosthetic joint infections (PJIs). PJIs occur after hip, knee or shoulder replacement surgery and are associated with a high clinical and economic impact. In the VHA system, over 10,000 hip, knee or shoulder replacement surgeries are performed each year and this number, as well as the number of associated PJIs, continues to increase. Treatment for PJI after hip, knee or shoulder replacement surgery is important to the VA because osteoarthritis, the most common reason for that surgery, is the fifth most common condition among Veterans. Our pilot data and other studies have found that many PJI patients are prescribed CAS outside of guideline recommendations, potentially due to physician fear of a relapse. This inappropriate use can lead to poor patient outcomes (e.g., C. difficile infection, antibiotic resistance) without any benefit. Research Plan: The specific aims of this study are: (1) Define patient, infection, and treatment characteristics that identify patients who would benefit from de-implementation of CAS; (2) Define current provider CAS prescribing processes and evaluate barriers and facilitators to changing those practices through interviews with health care providers; and (3) Create a decision model to conduct an economic evaluation of CAS use and different interventions to de-implement inappropriate CAS use. We expect to document significant variations in CAS prescribing and identify cost-effective interventions to de-implement CAS or reduce its duration. We propose a 3-year mixed methods study to inform efforts for CAS de-implementation. Aim 1 will use a Corporate Data Warehouse (CDW) database of ~7,500 PJI patients treated at all VA hospitals in a retrospective cohort comparative effectiveness study to determine specific characteristics that identify those PJI patients who will benefit from CAS de-implementation. These characteristics may include young age, infection with a non-virulent pathogen, initial receipt of appropriate antibiotics for PJI caused by Staphylococcus aureus, or receipt of 2-stage exchange surgery. In Aim 2, we will visit 8 diverse hospitals, qualitatively explore the contexts that contribute to CAS use, and elicit barriers and facilitators to changing prescribing practices. Aim 3 will create an innovative decision analytical model of potential interventions to de- implement CAS or reduce its duration. Our findings will be provided to the VA Antimicrobial Stewardship Task Force to assist in antibiotic de-implementation efforts and will provide needed data to design a future randomized controlled trial of an intervention to de-implement CAS among patients who do not need it. Implications: Our study will provide important insights into the organizational culture and broader external context (e.g., professional, social) associated with over-prescribing antibiotics for infections after surgery. We will identify targets for antimicrobial stewardship and identify clinical situations in which antibiotic use can be de-implemented. Given the increasing use of implants such as prosthetic joints, cardiac pacemakers, and left ventricular assist devices, the use of CAS is expected to rise. Our research will help VA providers de- implement antibiotics for patients who do not need them, in order to decrease antibiotic resistance in the VHA and prevent adverse events such as C. difficile infections.