Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial.

Autor:	Gohil SK; Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine., Septimus E; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts., Kleinman K; Biostatistics and Epidemiology, University of Massachusetts, Amherst., Varma N; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts., Avery TR; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts., Heim L; Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine., Rahm R; HCA Healthcare, Nashville, Tennessee., Cooper WS; HCA Healthcare, Nashville, Tennessee., Cooper M; HCA Healthcare, Nashville, Tennessee., McLean LE; HCA Healthcare, Nashville, Tennessee., Nickolay NG; HCA Healthcare, Nashville, Tennessee., Weinstein RA; Rush University Medical Center, Cook County Health, Chicago, Illinois., Burgess LH; HCA Healthcare, Nashville, Tennessee., Coady MH; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts., Rosen E; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts., Sljivo S; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts., Sands KE; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts.; HCA Healthcare, Nashville, Tennessee., Moody J; HCA Healthcare, Nashville, Tennessee., Vigeant J; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts., Rashid S; Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine., Gilbert RF; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts., Smith KN; HCA Healthcare, Nashville, Tennessee., Carver B; HCA Healthcare, Nashville, Tennessee., Poland RE; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts.; HCA Healthcare, Nashville, Tennessee., Hickok J; HCA Healthcare, Nashville, Tennessee., Sturdevant SG; National Institutes of Health, Bethesda, Maryland., Calderwood MS; Section of Infectious Disease and International Health, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire., Weiland A; Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine., Kubiak DW; Brigham and Women's Hospital, Boston, Massachusetts., Reddy S; Centers for Disease Control and Prevention, Atlanta, Georgia., Neuhauser MM; Centers for Disease Control and Prevention, Atlanta, Georgia., Srinivasan A; Centers for Disease Control and Prevention, Atlanta, Georgia., Jernigan JA; Centers for Disease Control and Prevention, Atlanta, Georgia., Hayden MK; Rush University Medical Center, Chicago, Illinois., Gowda A; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts., Eibensteiner K; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts., Wolf R; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts., Perlin JB; HCA Healthcare, Nashville, Tennessee.; Now with The Joint Commission, Oakbrook Terrace, Illinois., Platt R; Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts., Huang SS; Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine.
Jazyk:	angličtina
Zdroj:	JAMA [JAMA] 2024 Jun 18; Vol. 331 (23), pp. 2007-2017.
DOI:	10.1001/jama.2024.6248
Abstrakt:	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.
Databáze:	MEDLINE
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