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

假体关节感染后慢性抗生素抑制：取消实施的目标

• 批准号: 10872990
• 负责人: Marin Leigh Schweizer
• 金额: --
• 依托单位: IOWA CITY VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-09-01 至 2022-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10872990
• 关键词: Adverse event; Advisory Committees; Age; Antibiotic Resistance; Antibiotic-resistant organism; Antibiotics; Bacteria; Cardiac pacemaker; Characteristics; Chronic; Clinic; Clinical; Clostridium difficile; Combating Antibiotic Resistant Bacteria; Communicable Diseases; Data; Data Set; Databases; Decision Making; Decision Modeling; Degenerative polyarthritis; Deimplementation; Fright; Funding; Future; Goals; Guidelines; Health Personnel; Hip region structure; Hospitals; Immunocompetent; Implant; Incidence; Individual; Infection; Intervention; Intervention Trial; Interview; Intravenous; Joint Prosthesis; K-Series Research Career Programs; Knee; Knowledge; Life; Methods; Modeling; Nurses; Operative Surgical Procedures; Oral; Organizational Culture; Patient-Focused Outcomes; Patients; Periprosthetic joint infection; Physical therapy; Physicians; Positioning Attribute; Process; Provider; Randomized, Controlled Trials; Recommendation; Relapse; Repeat Surgery; Research; Resistance to infection; Retrospective cohort; Risk; Role; Shoulder; Societies; Staphylococcus aureus; System; Testing; Treatment Failure; United States Department of Veterans Affairs; Variant; Veterans; Visit; Work; antibiotic resistant infections; antimicrobial; cohort; comparative effectiveness study; cost; cost effective; cost effective intervention; data warehouse; design; economic evaluation; economic impact; fungus; implementation efforts; implementation intervention; implementation questions; implementation strategy; infection rate; innovation; insight; left ventricular assist device; mathematical model; operation; pathogen; patient population; patient subsets; prevent; social; treatment risk

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.

背景：VA承诺减少抗生素的过度使用，并且是国家行动的合作伙伴。 对抗抗药性细菌的计划。过度使用抗生素会导致艰难梭菌感染 在接受抗生素的个体中，以及抗生素耐药性， 所有患者的未来感染。慢性抗生素抑制（CAS）定义为无限期使用口服抗生素。 抗生素遵循最初指南推荐的静脉注射和口服抗生素。有证据表明， 可能会被滥用和滥用。因此，迫切需要研究CAS是如何规定的， 谁受益最大，谁又受到CAS治疗的伤害。这些知识可以用来开发一个 干预以取消实施和优化CAS的使用。在这项研究中，我们将检查CAS治疗， 人工关节感染（PJIs）。PJIs发生在髋关节、膝关节或肩关节置换手术后， 具有很高的临床和经济影响。在VHA系统中，超过10，000例髋关节、膝关节或肩关节置换术 每年都有手术进行，这个数字以及相关的PJIs数量继续增加， 增加髋关节、膝关节或肩关节置换术后PJI的治疗对VA很重要， 骨关节炎是手术最常见的原因，是退伍军人中第五常见的疾病。 我们的试点数据和其他研究发现，许多PJI患者的CAS处方超出了指南 建议，可能是由于医生担心复发。这种不恰当的使用会导致不良的 患者结果（例如，C.艰难梭菌感染，抗生素耐药性），没有任何好处。 研究计划：本研究的具体目标是：（1）定义患者、感染和治疗特征 识别将从取消CAS中受益的患者;（2）定义当前提供者CAS 规定流程，并通过访谈评估改变这些做法的障碍和促进因素， 医疗保健提供者;（3）创建决策模型，对CAS的使用进行经济评估， 不同的干预措施，以取消不适当的CAS使用。我们希望记录下 CAS处方和确定具有成本效益的干预措施，以取消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CAS的努力提供信息。目标1将使用 企业数据仓库（CDW）数据库，包含在所有VA医院接受治疗的约7，500名PJI患者， 回顾性队列比较有效性研究，以确定识别那些 将受益于取消CAS的PJI患者。这些特征可能包括年轻， 感染非致病性病原体，首次接受适当的抗生素治疗由以下原因引起的PJI 金黄色葡萄球菌，或接受2期交换手术。在目标2中，我们将访问8家不同的医院， 定性地探索有助于CAS使用的背景，并找出变革的障碍和促进因素 处方实践。目标3将建立一个创新的决策分析模型，分析潜在的干预措施， 实施CAS或缩短其持续时间。我们的研究结果将提供给VA抗菌药物管理任务 协助抗生素去执行工作的力量，并将提供所需的数据，以设计未来 在不需要CAS的患者中进行干预以取消CAS的随机对照试验。 影响：我们的研究将提供重要的见解，组织文化和更广泛的外部 上下文（例如，专业的，社会的）与手术后过度使用抗生素治疗感染有关。我们 将确定抗菌药物管理的目标，并确定可以使用抗生素的临床情况， 取消执行。鉴于越来越多地使用植入物，如人工关节，心脏起搏器，左 心室辅助装置，预计CAS的使用将增加。我们的研究将帮助VA供应商去- 为不需要抗生素的患者使用抗生素，以减少VHA中的抗生素耐药性 并预防不良事件如C.艰难感染。