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

## TL;DR

This study explores how doctors decide to use long-term antibiotics after joint infections, highlighting the need for better evidence and collaboration.

## Contribution

The study identifies key decision-makers and timing in suppressive antibiotic therapy decisions for joint infections, suggesting stewardship strategies.

## Key findings

- Surgeons and infectious disease physicians primarily decide on suppressive antibiotic therapy for joint infections.
- Decision-making involves patient-specific factors and is influenced by limited evidence of benefits and risks.
- Stewardship interventions should consider multiple decision-makers and timing points across patient care.

## Abstract

How do clinicians make decisions about suppressive antibiotic therapy for patients who had prosthetic joint infections (PJIs) when there is limited evidence about benefits and risks?

This qualitative study found that surgeons and infectious diseases physicians often made initial decisions about suppressive antibiotic therapy; other decision-makers over time included patients, primary care physicians, and pharmacists. Clinicians identified significant time points that occur before or after the suppressive antibiotic therapy prescribing decision, including PJI treatment decisions and follow-up appointments.

Suppressive antibiotic therapy stewardship interventions should be made with awareness of decision points for patients with PJI across time as well as the range of potential decision-makers, including patients, across time.

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 occured 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.

This qualitative study characterizes clinical decision-making about suppressive antibiotic therapy after prosthetic joint infection and identifies stewardship intervention opportunities to stop or reduce suppressive antibiotic therapy for patients who may not benefit.