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Patient Safety Tip of the Week
April 23, 2024
Prompting
Improves Antibiotic Stewardship
Inappropriate use of
antimicrobials can give rise to bacterial antibiotic resistance, allergies,
complications like diarrhea and C. difficile infections, and unnecessary
healthcare expenses. So, antibiotic stewardship is important in hospitals and
other healthcare venues.
Results just
published from the INSPIRE (Intelligent Stewardship Prompts to Improve
Real-time Empiric Antibiotic Selection) clinical trials are very encouraging
for use of prompts in CPOE as a way to improve antibiotic selection.
The INSPIRE Pneumonia Trial cluster-randomized trial
comparing the effect of routine antibiotic stewardship vs. the INSPIRE CPOE
stewardship bundle in non-critically ill adults hospitalized with pneumonia (Gohil 2024a).
Hospitals were randomly assigned to the routine or CPOE bundle groups. The CPOE
bundle group received the same educational material for maintaining national
antibiotic stewardship guidance as did the routine group and monthly coaching
calls. They also received prompts during CPOE recommending standard-spectrum
instead of extended-spectrum antibiotics during the first 3 hospital days
(empiric period) for patients with a low absolute risk of MDRO pneumonia. They
also received clinician education and feedback reports.
The primary outcome, empiric extended-spectrum days of
therapy per 1000 empiric days. For the CPOE bundle group, extended-spectrum
days of therapy decreased from 613.9 during the baseline period to 428.5 during
the intervention period. For the routine group, extended-spectrum days of
therapy decreased from 633.0 during the baseline period to 615.2. This represented
a 28.4% significantly lower rate of empiric extended-spectrum days of therapy
in the CPOE bundle group compared with routine stewardship. Secondary outcomes
of vancomycin and antipseudomonal days of therapy showed similar reductions. Hospital
length of stay and days to ICU transfer were unchanged.
The INSPIRE UTI Trial was a cluster-randomized trial
comparing the effect of the INSPIRE stewardship CPOE bundle vs. routine
antibiotic stewardship on empiric extended-spectrum antibiotic selection in non-critically
ill adults hospitalized with urinary tract infections (Gohil 2024b).
As in the pneumonia trial, those in the INSPIRE CPOE stewardship group received
CPOE prompts recommending standard-spectrum instead of extended-spectrum
antibiotics for patients with a low absolute risk for MDRO UTI for orders
placed during the first 3 days (empiric period). They also received clinician
education and feedback reports.
For the primary outcome, the empiric extended-spectrum days
of therapy per 1000 empiric days was 431.1 and 446.0 during the baseline and
intervention periods, respectively, for the routine stewardship group. For the
CPOE bundle group, extended-spectrum days of therapy decreased from 392.2
during the baseline period to 326.0 during the intervention period. That
represented a 17.4% significantly lower rate of empiric extended-spectrum days
of therapy in the CPOE bundle group compared with the routine stewardship
group. Secondary outcomes of vancomycin and antipseudomonal days of therapy
showed similar reductions. There was no significant change in hospital length
of stay or days to ICU transfers.
Neither study reported cost outcomes, changes in C. diff incidence,
or changes in hospital drug resistance patterns. They also did not mention clinician
satisfaction with the program. Hopefully, extended followup
may address some of those issues.
In summary, both INSPIRE trials demonstrated the CPOE prompts
resulted in better empirical antibiotic selection without adverse impacts on
safety parameters.
In the accompanying editorial (Malani
2024) it is pointed out that hospital-based
stewardship efforts tend to emphasize de-escalation of
antibiotics after microbiologic
testing results return, and few focus on initial empiric prescribing as was done in the
INSPIRE trials. The editorialists hope for replication of these results at
other hospitals and with different EHR vendors and perhaps further improvement
with data from centralized repositories containing information about multiple
drug-resistant organisms.
Some of our prior
columns on antibiotic stewardship:
·
October 14, 2014 Antibiotic Stewardship
·
November
2015 Medications
Most Likely to Harm the Elderly Are
·
July
2016 NQF/CDC Guideline on
Antibiotic Stewardship
·
August
2016 Some Reassurance on
Antibiotic Stewardship
·
November
2016 C. Diff and Your
Predecessors Room
·
December
2016 Update on Ambulatory
Antibiotic Stewardship
·
July
2017 Antibiotics and Adverse
Events
·
July
2019 Dental Prescribing Called
Into Question
·
July 21,
2020 Is This Patient Allergic to
Penicillin?
·
March
30, 2021 Need for Better Antibiotic
Stewardship
·
August
2021 Antibiotic Stewardship in
Pediatrics
·
May 24,
2022 Requiring Indication for
Antibiotic Prescribing
·
August
2022 Resistant Infections Up
During COVID-19 Pandemic
References:
Gohil SK, Septimus E, Kleinman K, et al. Stewardship Prompts
to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical
Trial. JAMA 2024; Published online April 19, 2024
https://jamanetwork.com/journals/jama/fullarticle/2817976
Gohil SK, Septimus E, Kleinman K, et al. Stewardship Prompts
to Improve Antibiotic Selection for Urinary Tract Infection: The INSPIRE
Randomized Clinical Trial. JAMA 2024; Published online April 19, 2024
https://jamanetwork.com/journals/jama/fullarticle/2817975
Malani AN, Malani PN. Harnessing the Electronic Health
Record to Improve Empiric Antibiotic Prescribing. JAMA 2024; Published online
April 19, 2024
https://jamanetwork.com/journals/jama/article-abstract/2817977
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