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已承诺减少过度使用抗生素，并且是国家行动的合作伙伴 计划对抗抗生素耐药菌。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以及抗生素耐药性，可能使治疗的治疗复杂 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 抗生素根据初始指南建议静脉注射和口服抗生素。有证据表明CAS 可能不当使用和过度使用。因此，有迫切需要检查CAS的处方， 谁受益于CAS治疗最大，受到伤害的人。这些知识可用于开发 干预以消除实施并优化CAS使用。在这项研究中，我们将检查CAS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，并且相关 具有很大的临床和经济影响。在VHA系统中，超过10,000个臀部，膝盖或肩部置换 每年进行手术，此数量以及相关PJI的数量继续进行 增加。髋关节，膝盖或肩部置换手术后的PJI治疗对VA很重要，因为 骨关节炎是该手术的最常见原因，是退伍军人中第五大常见状况。 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，可能是由于医生担心复发的原因。这种不当使用可能导致贫穷 患者结局（例如，艰难梭菌感染，抗生素耐药性），没有任何益处。 研究计划：本研究的具体目的是：（1）定义患者，感染和治疗特征 确定将受益于CAS的消耗而受益的患者； （2）定义当前提供商CAS 开处方程序并评估障碍和促进者，以通过面试来改变这些做法 医疗保健提供者； （3）创建一个决策模型，以对CAS使用和 消除实施不当使用的不同干预措施。我们希望记录有关的重大变化 CAS处方并确定具有成本效益的干预措施，以减少CAS或减少其持续时间。 我们提出了一项为期3年的混合方法研究，以告知CAS Demplitation的努力。 AIM 1将使用 公司数据仓库（CDW）数据库的〜7,500名PJI患者在所有VA医院接受治疗 回顾性队列比较有效性研究，以确定确定这些特征的特定特征 PJI患者将受益于CAS De-flimentation。这些特征可能包括年轻， 感染非刺激性病原体，初始收到适当的抗生素对PJI引起的抗生素 金黄色葡萄球菌或接受2阶段交换手术的接收。在AIM 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，并引起障碍和促进者的改变 处方实践。 AIM 3将创建一个创新的决策分析模型，以实现潜在干预措施以进行干预措施 实施CAS或减少其持续时间。我们的发现将提供给VA抗菌管理任务 武力协助抗生素去实现工作，并将提供所需的数据以设计未来 在不需要的患者中，干预措施进行干预的随机对照试验。 含义：我们的研究将为组织文化和更广泛的外部提供重要的见解 语境（例如，专业，社会）与手术后感染过度处方抗生素有关。我们 将确定抗菌管理的靶标，并确定使用抗生素的临床情况 去实施。鉴于植入物的使用越来越多，例如假肢，心脏起搏器和左 心室辅助设备，CAS的使用预计将上升。我们的研究将帮助VA提供商脱颖而出 为不需要它们的患者实施抗生素，以降低VHA中的抗生素耐药性 并防止不良事件，例如艰难梭菌感染。