Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore.
National Public Health and Epidemiology Unit, National Centre for Infectious Diseases, Singapore, Singapore.
JAMA Netw Open. 2022 May 2;5(5):e2210180. doi: 10.1001/jamanetworkopen.2022.10180.
There is a lack of studies comparing the intended and unintended consequences of prospective review and feedback (PRF) with computerized decision support systems (CDSS), especially in the longer term in antimicrobial stewardship.
To examine the outcomes associated with the sequential implementation of PRF and CDSS and changes to these interventions with long-term use of antibiotics for and incidence of multidrug resistant organisms (MDROs) and other unintended outcomes.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used an interrupted time series with segmented regression analysis of data from January 2007 to December 2018. Data were extracted from the electronic medical records of patients admitted at a large university teaching hospital with high rates of antibiotic resistance in Singapore. Data were analyzed from June 2019 to June 2020.
PRF of piperacillin-tazobactam and carbapenems (intervention 1, April 2009), with the addition of hospital-wide CDSS (intervention 2, April 2011), and lifting of CDSS for half of the hospital wards for 6 months (intervention 3, March 2017).
Monthly antimicrobial use was measured in defined daily doses (DDDs) per 1000 patient-days. The monthly incidence of MDROs was calculated as number of clinical isolates detected per 1000 inpatient-days over a 6-month period. Unintended outcomes examined included in-hospital mortality and age-adjusted length of stay (LOS).
The number of inpatients increased from 56 263 in 2007 to 63 572 in 2018. During the same period, the mean monthly patient days increased from 33 929 in 2007 to 45 603 in 2018, and the proportion of patients older than 65 years increased from 45.5% in 2007 to 56.6% in 2018. After intervention 1, there were 0.33 (95% CI, 0.18 to 0.48) more DDDs per 1000 patient-days per month of piperacillin-tazobactam and carbapenems and -11.05 (95% CI, -15.55 to -6.55) fewer DDDs per 1000 patient-days per month for other broad-spectrum antibiotics. After intervention 2, there were -0.22 (95% CI, -0.33 to -0.10) fewer DDDs per 1000 patient-days per month of piperacillin-tazobactam and carbapenems and -2.10 (95% CI, -3.13 to -1.07) fewer DDDs per 1000 patient-days per month for other broad-spectrum antibiotics. After intervention 3, use of piperacillin-tazobactam and carbapenem increased by 0.28 (95% CI, 0.02 to 0.55) DDDs per 1000 patient-days per month. After intervention 2, incidence of Clostridioides difficile decreased (estimate, -0.02 [95% CI, -0.03 to -0.01] cases per 1000 patient-days per month).
In this cohort study, concurrent PRF and CDSS were associated with limiting the use of piperacillin-tazobactam and carbapenems while reducing use of other antibiotics.
在展望性审查和反馈 (PRF) 与计算机决策支持系统 (CDSS) 的预期和意外后果方面，缺乏研究比较，特别是在抗菌药物管理的长期研究中。
检查与 PRF 和 CDSS 的序贯实施相关的结果，以及随着时间的推移使用抗生素治疗和多药耐药菌 (MDRO) 的发生率以及其他意外结果的变化。
设计、地点和参与者：本队列研究使用了从 2007 年 1 月至 2018 年 12 月的时间序列中断和分段回归分析数据。数据从新加坡一家大型大学教学医院的电子病历中提取，该医院的抗生素耐药率很高。数据分析于 2019 年 6 月至 2020 年 6 月进行。
哌拉西林-他唑巴坦和碳青霉烯类药物的 PRF（干预 1，2009 年 4 月），添加了医院范围的 CDSS（干预 2，2011 年 4 月），并将医院一半的病房 CDSS 停用 6 个月（干预 3，2017 年 3 月）。
每月抗菌药物使用以每 1000 名患者天的定义日剂量 (DDD) 衡量。MDRO 的每月发生率计算为每 1000 名住院患者天中检测到的临床分离株数，持续 6 个月。检查的意外结果包括院内死亡率和年龄调整的住院时间 (LOS)。
住院患者人数从 2007 年的 56263 人增加到 2018 年的 63572 人。同期，平均每月患者天数从 2007 年的 33929 人增加到 2018 年的 45603 人，年龄大于 65 岁的患者比例从 2007 年的 45.5%增加到 2018 年的 56.6%。干预 1 后，哌拉西林-他唑巴坦和碳青霉烯类药物的每 1000 名患者天的 DDD 增加了 0.33（95%CI，0.18 至 0.48），其他广谱抗生素的 DDD 减少了 11.05（95%CI，15.55 至 6.55）。干预 2 后，哌拉西林-他唑巴坦和碳青霉烯类药物的 DDD 减少了 0.22（95%CI，0.33 至 0.10），其他广谱抗生素的 DDD 减少了 2.10（95%CI，3.13 至 1.07）。干预 3 后，哌拉西林-他唑巴坦和碳青霉烯类药物的使用量每月增加 0.28（95%CI，0.02 至 0.55）。干预 2 后，艰难梭菌的发病率下降（估计值，-0.02[95%CI，-0.03 至 -0.01]每 1000 名患者天）。
在这项队列研究中，同时进行 PRF 和 CDSS 与限制哌拉西林-他唑巴坦和碳青霉烯类药物的使用有关，同时减少其他抗生素的使用。
