Computer-administered prompts associated with improved antibiotic prescribing in two trials

Pneumonia and urinary tract infections (UTIs) are the two most common infection-related illnesses that result in U.S. adults being hospitalized each year. And in at least 40% of cases, patients are unnecessarily given broad-spectrum antibiotics upon admission to treat these infections.

The reason many doctors prescribe broad-spectrum or broad-spectrum antibiotics to treat pneumonia or urinary tract infections a few days before bacterial culture results are available is because the patient is infected with multidrug-resistant organisms (MDROs). This is because there is a fear that there may be. Without effective antibiotics, the condition may worsen.

“This is a very uncertain time for physicians,” Shruti Gohil, MD, assistant professor of infectious diseases and associate medical director of epidemiology and infection prevention at the University of California, Irvine School of Medicine, told CIDRAP News. “We're nervous. We want our patients to get better.”

If the culture shows that the pathogen causing the infection is not an MDRO, your doctor can downgrade to a standard-spectrum antibiotic. Still, short-term exposure to broad-spectrum antibiotics can increase a patient's risk for future MDROs and antibiotic-related side effects such as: Clostridioides difficile.

But today, results from two large randomized clinical trials led by Gohil jam, With computerized administrative prompts in a hospital system's electronic health record (EHR), physicians can have more confidence in prescribing standard-spectrum antibiotics to patients with pneumonia and urinary tract infections in the first place. This suggests that it may be possible. And she believes it could have a significant impact on antibiotic stewardship and patient safety.

Assessing patient MDRO risk

Two INSPIRE (Intelligent Stewardship Prompts to Improve Real-Time Empiric Antibiotic Selection) trials included adults hospitalized with pneumonia and urinary tract infections at 59 hospitals within HCA Healthcare, the largest private community hospital system in the United States. Patients participated. Both trials had a baseline period of 18 months and an intervention period of 15 months, and were conducted from April 2017 to June 2020.

In both trials, one group of hospitals was randomly assigned to routine antibiotic stewardship activities. This includes providing hospital guidelines and protocols for selecting antibiotics, requesting a documented reason for antibiotics, and prospectively evaluating antibiotic use with clinician feedback to reduce antibiotic usage. This includes a gradual reduction in Return of microbiological results. Hospital staff received educational materials and quarterly coaching calls to maintain these activities.

In addition to practicing routine administrative activities, physicians at other hospital groups also practice routine administrative activities whenever extended-spectrum antibiotics are ordered in a non-intensive care unit (ICU) setting for a patient with pneumonia or a urinary tract infection. I received a computerized provider order entry (CPOE) prompt. Within 72 hours of admission (empirical prescription period). This prompt was triggered when the patient's CPOE algorithm determined that her MDRO risk was below her 10% and that standard-spectrum antibiotics could be safely used. CPOE hospitals also received clinician education and feedback reports.

Gohil explained that the CPOE algorithm uses a number of variables to assess a patient's risk of MDRO infection. This takes into account the individual patient's risk for a particular MDRO, the type of infectious syndrome being treated, and the antibiotic selected by the physician.

“So what the doctor can get is a risk estimate for the particular antibiotic that the doctor selects that indicates whether the patient has the antibiotic-resistant bacteria that the doctor is concerned about,” she said. Ta. “For low-risk patients, physicians will only see the prompt in those cases.”

Significant reduction in extended spectrum therapy

Gohil said the idea behind the trial was to find a way to help doctors choose antibiotics that were as targeted to their patients as possible. The primary endpoint was her prolonged treatment in a non-ICU setting during her first 3 calendar days after admission.

In both trials, CPOE bundles were associated with significant reductions in extended-spectrum therapy.inside INSPIRE pneumonia trialWith 96,451 patients (51,671 at baseline and 44,780 during the intervention period), 29 hospitals assigned to the CPOE group had fewer days of empiric extended spectrum therapy compared to 30 hospitals assigned to the CPOE group. It decreased by 28.4% from baseline. Routine Stewardship Group (Rate Ratio) [RR]0.72; 95% confidence interval [CI]0.66 to 0.78).

inside INSPIRE UTI TrialWith 127,403 patients (71,991 at baseline and 55,412 during the intervention period), the 29 hospitals that used the CPOE prompt and the 30 regularly managed hospitals (RR, 0.83; 95% CI, 0.77 to 0.89).

“This is a pretty significant reduction,” Gohil said. “This shows that if you give physicians the right information at the right time, you can actually inform their prescribing habits.”

In both trials, reductions were evident within the first 3 months after the prompts were published. Similar decreases were seen in the use of vancomycin and antipseudomonal antibiotics, which are frequently prescribed during hospitalization for pneumonia and urinary tract infections. And this decline in empiric broad-spectrum antibiotic prescribing was maintained during the first months of the COVID-19 pandemic, when many hospitals saw an increase.

This shows that providing physicians with the right information at the right time can actually inform their prescribing habits.

Gohil and his colleagues found that in both trials, the decline in extended-spectrum antibiotic prescribing over time was due to physicians deciding to prescribe standard-spectrum antibiotics before receiving the order. It was also found that this partially contributed.

“The initial costs have decreased, but [antibiotic] We chose to launch fewer prompts,” she added.

Additionally, analysis of the primary safety outcomes in both trials showed that reducing the dose of empiric extended-spectrum antibiotics in patients with pneumonia and urinary tract infections is safe. For INSPIRE pneumonia, mean days to ICU transition (6.5 days vs. 7.1 days) and length of hospital stay (6.8 days vs. 7.1 days) were not significantly different between hospitals in the CPOE and routine stewardship groups. The INSPIRE UTI results were similar.

Paradigm change

Gohil said this is important because many antibiotic stewardship interventions in hospitals aim to shorten the duration of antibiotics or narrow the spectrum of antibiotics once more information is available about the causative pathogen. He said the research results were important. However, the INSPIRE trial is one of the largest efforts to address empirical prescription.

“This study significantly shifts the paradigm toward early initiation of standard-spectrum antibiotics, as opposed to current antibiotic management strategies that rely heavily on starting broad and gradually narrowing the scope later. It’s a transformational thing,” she said.

with accessories Editorinfectious disease expert Anurag Malani, M.D., of Trinity Michigan Health, and Preeti Malani, M.D., of the University of Michigan, suggest that other institutions are also looking at and considering similar EHR-based interventions to improve empiric prescribing. He says he wants it.

“The aptly named INSPIRE study will do just that, providing inspiration and imagination and a powerful tool to leverage EHRs to optimize antibiotic prescribing and improve human health.” “provides a paradigm,” the researchers wrote. “rigorous studies that build on the success reported by Gohil et al. are urgently needed.”