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Improving Empiric Antibiotic Selection for Patients Hospitalized With Abdominal Infection: The INSPIRE 4 Cluster
Shruti K Gohil1, Edward Septimus2, Ken Kleinman3
1Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine.
Importance:
Empiric extended-spectrum antibiotics are routinely prescribed for over a million patients hospitalized annually with abdominal infection despite low likelihoods of infection with multidrug-resistant organisms (MDROs).
Objective:
To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates can reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with abdominal infection.
Design, Setting, And Participants:
This 92-hospital cluster randomized clinical trial assessed the effect of an antibiotic stewardship bundle with CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults hospitalized with abdominal infection. The trial population included adults (≥18 years) treated with empiric antibiotics for abdominal infection in non-intensive care units (ICUs). The trial periods included a 12-month baseline from January to December 2019 and an intervention period from January to December 2023.
Intervention:
CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period if the patient's estimated absolute risk of MDRO abdominal infection was less than 10%, coupled with feedback and education.
Main Outcomes And Measures:
The primary outcome was empiric extended-spectrum antibiotic days of therapy. Safety outcomes: days to ICU transfer and hospital length of stay. Analyses compared differences between baseline and intervention periods across strategies.
Results:
Among 92 hospitals with 198 480 patients, mean (SD) age was 60 (19) years and 118 723 (59.8%) were female. The trial included 93 476 and 105 004 patients hospitalized with abdominal infection during the baseline and intervention periods, respectively. Receipt of any empiric extended-spectrum antibiotics for the routine care group was 48.2% (22 519 of 46 725) during baseline and 50.5% (27 452 of 54 384) during intervention vs 47.8% (22 367 of 46 751) and 37.6% (19 010 of 50 620) for the CPOE bundle group. The group receiving CPOE prompts had a 35% relative reduction (rate ratio, 0.65; 95% CI, 0.60-0.71; P < .001) in empiric extended-spectrum antibiotic days of therapy vs routine care (raw absolute reduction between baseline and intervention periods was -169 for the CPOE bundle vs -20 for routine care). Hospital length of stay was noninferior to routine care (0.1 days longer during intervention; mean [SD], baseline, 5.4 [3.4] days vs intervention, 5.5 [3.5] days; hazard ratio [HR], 1.02; 90% CI, 0.99-1.06), and mean days to ICU transfer in the CPOE group was indeterminate (both groups 0.2 days longer during intervention; HR, 1.10; 90% CI, 0.99-1.23).
Conclusions And Relevance:
CPOE prompts recommending empiric standard-spectrum antibiotics (coupled with education and feedback) for patients admitted with abdominal infection who have low risk for MDRO infection significantly reduced extended-spectrum antibiotics without increasing ICU transfers or length of stay.
Trial Registration:
ClinicalTrials.gov Identifier: NCT05423743.
Insights
Computerized provider order entry (CPOE) prompts significantly reduced extended-spectrum antibiotic use in abdominal infections by identifying patients at low risk for multidrug-resistant organisms (MDROs). This approach improved antibiotic stewardship without negatively impacting patient safety outcomes like ICU transfers or hospital stay.
Area of Science:
- Infectious Diseases
- Clinical Informatics
- Antibiotic Stewardship
Background:
- Empiric extended-spectrum antibiotics are frequently prescribed for hospitalized patients with abdominal infections, despite low rates of multidrug-resistant organism (MDRO) infections.
- Overuse of broad-spectrum antibiotics contributes to the development of antimicrobial resistance and increases healthcare costs.
Purpose of the Study:
- To determine if computerized provider order entry (CPOE) prompts can reduce empiric extended-spectrum antibiotic use in non-critically ill patients with abdominal infections.
- To assess the impact of CPOE prompts providing patient- and pathogen-specific MDRO infection risk estimates on antibiotic selection.
Main Methods:
- A 92-hospital cluster randomized clinical trial compared an antibiotic stewardship bundle with CPOE prompts against routine stewardship.
- The intervention involved CPOE prompts recommending standard-spectrum antibiotics for patients with <10% estimated absolute risk of MDRO abdominal infection.
- The study analyzed antibiotic selection during the first 3 hospital days (empiric period) for non-critically ill adults hospitalized with abdominal infection.
Main Results:
- The group receiving CPOE prompts showed a 35% relative reduction in empiric extended-spectrum antibiotic days of therapy compared to routine care.
- No significant increase in intensive care unit (ICU) transfers or hospital length of stay was observed in the CPOE prompt group.
- The CPOE bundle intervention led to a substantial decrease in the use of broad-spectrum antibiotics for abdominal infections.
Conclusions:
- Computerized provider order entry (CPOE) prompts are effective in reducing unnecessary extended-spectrum antibiotic use for abdominal infections in low-risk patients.
- This intervention improves antibiotic stewardship without compromising patient safety, as measured by ICU transfers and hospital length of stay.
- Implementing CPOE-based decision support can be a valuable strategy to combat antimicrobial resistance.
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