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Published on: August 30, 2018
Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial
Shruti K Gohil1, Edward Septimus2, Ken Kleinman3
1Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine.
Importance:
Pneumonia is the most common infection requiring hospitalization and is a major reason for overuse of extended-spectrum antibiotics. Despite low risk of multidrug-resistant organism (MDRO) infection, clinical uncertainty often drives initial antibiotic selection. Strategies to limit empiric antibiotic overuse for patients with pneumonia are needed.
Objective:
To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with pneumonia.
Design, Setting, And Participants:
Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk-based CPOE prompts; n = 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults (≥18 years) hospitalized with pneumonia. There was an 18-month baseline period from April 1, 2017, to September 30, 2018, and a 15-month intervention period from April 1, 2019, to June 30, 2020.
Intervention:
CPOE prompts recommending standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics during the empiric period who have low estimated absolute risk (<10%) of MDRO pneumonia, coupled with feedback and education.
Main Outcomes And Measures:
The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy and safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies.
Results:
Among 59 hospitals with 96 451 (51 671 in the baseline period and 44 780 in the intervention period) adult patients admitted with pneumonia, the mean (SD) age of patients was 68.1 (17.0) years, 48.1% were men, and the median (IQR) Elixhauser comorbidity count was 4 (2-6). Compared with routine stewardship, the group using CPOE prompts had a 28.4% reduction in empiric extended-spectrum days of therapy (rate ratio, 0.72 [95% CI, 0.66-0.78]; P < .001). Safety outcomes of mean days to ICU transfer (6.5 vs 7.1 days) and hospital length of stay (6.8 vs 7.1 days) did not differ significantly between the routine and CPOE intervention groups.
Conclusions And Relevance:
Empiric extended-spectrum antibiotic use was significantly lower among adults admitted with pneumonia to non-ICU settings in hospitals using education, feedback, and CPOE prompts recommending standard-spectrum antibiotics for patients at low risk of MDRO infection, compared with routine stewardship practices. Hospital length of stay and days to ICU transfer were unchanged.
Trial Registration:
ClinicalTrials.gov Identifier: NCT03697070.
Insights
Computerized provider order entry (CPOE) prompts significantly reduced extended-spectrum antibiotic use for pneumonia patients. This strategy improved antibiotic stewardship without impacting patient safety outcomes like ICU transfer or hospital stay.
Area of Science:
- Infectious Diseases
- Hospital Administration
- Clinical Informatics
Background:
- Pneumonia is a leading cause of hospitalization and contributes to the overuse of broad-spectrum antibiotics.
- Clinical uncertainty regarding multidrug-resistant organism (MDRO) infection risk often leads to empiric antibiotic escalation.
- There is a need for strategies to optimize antibiotic selection in pneumonia patients to curb overuse.
Purpose of the Study:
- To assess if computerized provider order entry (CPOE) prompts can decrease empiric extended-spectrum antibiotic use in non-critically ill pneumonia patients.
- To evaluate the impact of MDRO risk estimates integrated into CPOE on antibiotic prescribing practices.
Main Methods:
- A cluster-randomized trial involving 59 US community hospitals over an 18-month baseline and 15-month intervention period.
- Intervention group received CPOE stewardship bundle: education, feedback, and real-time MDRO risk-based CPOE prompts.
- Control group received routine stewardship practices; primary outcome was empiric extended-spectrum antibiotic days of therapy.
Main Results:
- Hospitals using CPOE prompts showed a 28.4% reduction in empiric extended-spectrum antibiotic days of therapy (rate ratio, 0.72; P < .001).
- No significant differences were observed in safety outcomes, including days to ICU transfer and hospital length of stay.
- The study included 96,451 adult patients admitted with pneumonia.
Conclusions:
- Integrating CPOE prompts with MDRO risk estimates effectively reduces empiric extended-spectrum antibiotic use in pneumonia.
- This intervention demonstrates a successful approach to antibiotic stewardship without compromising patient safety.
- The findings support the wider adoption of CPOE-based decision support tools in hospital settings.
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