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Decisions About Suppressive Antibiotics Among Clinicians at Veterans Affairs Hospitals After Prosthetic Joint Infection
Journal article   Open access   Peer reviewed

Decisions About Suppressive Antibiotics Among Clinicians at Veterans Affairs Hospitals After Prosthetic Joint Infection

Kimberly C Dukes, Julia Friberg Walhof, Stacey Hockett Sherlock, Dan Suh, Poorani Sekar, Hiroyuki Suzuki, Heather Schacht Reisinger, Bruce Alexander, Kelly Richardson Miell, Brice Beck, …
JAMA network open, Vol.8(3), e251152
03/03/2025
DOI: 10.1001/jamanetworkopen.2025.1152
PMCID: PMC11923720
PMID: 40105839
url
https://doi.org/10.1001/jamanetworkopen.2025.1152View
Published (Version of record) Open Access

Abstract

Indefinite suppressive antibiotic therapy (SAT) is sometimes prescribed after initial antibiotic treatment for prosthetic joint infection (PJI). Limited evidence on outcomes after SAT exists, and using SAT for patients at low risk who may not need it could be associated with antibiotic resistance and adverse events. To characterize clinical decision-making about SAT after PJI and identify stewardship intervention opportunities to stop or reduce SAT for patients who may not benefit. In this qualitative study, interviews were conducted with 41 clinicians involved in decision-making about SAT after PJI at 8 US Veterans Affairs hospitals between November 1, 2019, and July 31, 2021. Analysis was conducted from June 9, 2020, to August 31, 2022. Systematic thematic analysis of transcripts of semistructured interviews was conducted to assess the decision-making process for SAT after PJI, including identifying decision-makers, risks and benefits of SAT, and significant time points that occur before or after the SAT prescribing decision. A total of 41 clinicians were interviewed. Interviewees reported a complex, usually patient-specific, sometimes collaborative decision-making process. Decisions were emotionally charged because of serious possible repercussions for patients and limited evidence about benefits and risks associated with SAT. Surgeons and infectious diseases physicians were the primary SAT prescribers. Their initial risk-benefit calculation for SAT usually included whether revision surgery could be performed and what type, the organism, patient factors, and clinical signs of infection, as well as their perception of the existing evidence base for SAT after PJI. Interviewees identified significant time points that occurred before or after the SAT prescribing decision, including PJI treatment decisions and follow-up appointments. Other potential decision-makers over time included patients, primary care physicians, and pharmacists. Interviewees identified opportunities to discuss SAT-associated benefits and risks with patients as well as other clinicians. Interviewees wanted more evidence about patient outcomes to inform prescribing decisions and emphasized the importance of clinician autonomy and buy-in for practice change. This qualitative study found that surgeons and infectious diseases physicians often made initial decisions about SAT and identified other potential decision-makers (patients, primary care physicians, pharmacists) and significant time points that occur before or after the SAT prescribing decision, including PJI treatment decisions and follow-up appointments. Stewardship interventions should take into account decision points for patients with PJI across time and the range of decision-makers, including patients, across time.
 United States Anti-Bacterial Agents - therapeutic use Antimicrobial Stewardship - methods Clinical Decision-Making Female Hospitals, Veterans Humans Male Middle Aged Practice Patterns, Physicians' - statistics & numerical data Prosthesis-Related Infections - drug therapy Qualitative Research

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