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: 9761321
• 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 2021-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9761321
• 关键词: Adverse event; Advisory Committees; Age; Americas; 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; 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; Lead; Life; Methods; Modeling; Nurses; Operative Surgical Procedures; Oral; Organizational Culture; Patient-Focused Outcomes; Patients; 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; Variant; Veterans; Visit; Work; antibiotic resistant infections; antimicrobial; base; cohort; comparative effectiveness study; cost; cost effective; data warehouse; design; economic evaluation; economic impact; effective intervention; fungus; implementation strategy; infection rate; innovation; insight; joint infection; 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：退伍军人管理局承诺减少抗生素的过度使用，并且是国家行动的合作伙伴 计划对抗抗生素耐药细菌。过度使用抗生素可导致艰难梭菌感染 在接受抗生素的个体中，以及抗生素耐药性可能会使治疗复杂化 所有患者未来的感染。慢性抗生素抑制（CAS）被定义为无限期使用口服抗生素 抗生素遵循最初的指南建议静脉注射和口服抗生素。有证据表明CAS 可能会被不当使用和过度使用。因此，迫切需要检查 CAS 的处方方式， CAS 治疗中谁受益最大，谁受到伤害。这些知识可用于开发 干预以取消和优化 CAS 使用。在本研究中，我们将检查 CAS 治疗 假体关节感染（PJI）。 PJI 发生在髋关节、膝关节或肩关节置换手术后，并且与 具有较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手术 每年都会进行手术，并且这个数字以及相关的 PJI 数量持续增加 增加。髋关节、膝关节或肩关节置换手术后 PJI 的治疗对于 VA 来说非常重要，因为 骨关节炎是进行手术的最常见原因，也是退伍军人中第五大常见疾病。 我们的试点数据和其他研究发现，许多 PJI 患者在指南之外接受了 CAS 处方 建议，可能是由于医生担心复发。这种不恰当的使用可能会导致不良 患者的预后（例如，艰难梭菌感染、抗生素耐药性）没有任何益处。 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 确定哪些患者将从取消 CAS 中受益； (2) 定义当前provider CAS 通过访谈来规定流程并评估改变这些做法的障碍和促进因素 医疗保健提供者； (3) 创建一个决策模型来对 CAS 的使用进行经济评估 采取不同的干预措施来消除 CAS 的不当使用。我们希望记录显着的变化 CAS 规定并确定具有成本效益的干预措施，以取消 CAS 的实施或缩短其持续时间。 我们提议进行一项为期 3 年的混合方法研究，为 CAS 取消实施的工作提供信息。目标 1 将使用 公司数据仓库 (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，以确定识别这些特征的具体特征 PJI 患者将从 CAS 取消实施中受益。这些特征可能包括年轻、 感染无毒力病原体，最初接受适当的抗生素治疗 PJI 引起的 金黄色葡萄球菌，或接受二阶段交换手术。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，并引出变革的障碍和促进因素 规定做法。目标 3 将创建一个潜在干预措施的创新决策分析模型，以消除 实施 CAS 或缩短其持续时间。我们的研究结果将提供给 VA 抗菌管理任务 强制协助抗生素取消实施工作，并将提供设计未来所需的数据 在不需要 CAS 的患者中进行取消 CAS 干预的随机对照试验。 启示：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。 与手术后感染过度使用抗生素相关的环境（例如专业、社会）。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 取消实施。鉴于假肢关节、心脏起搏器和左心室等植入物的使用越来越多 心室辅助装置，CAS 的使用预计会增加。我们的研究将帮助 VA 提供商解决 为不需要的患者使用抗生素，以减少 VHA 中的抗生素耐药性 并预防不良事件，例如艰难梭菌感染。