Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine.
Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts.
JAMA. 2024 Jun 18;331(23):2018-2028. doi: 10.1001/jama.2024.6259.
Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed.
To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI.
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 and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020).
CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education.
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. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods.
Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively.
Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers.
ClinicalTrials.gov Identifier: NCT03697096.
尿路感染（UTI）是导致住院的第二大常见感染，通常与革兰氏阴性多药耐药菌（MDROs）有关。尽管大多数患者感染 MDRO 的风险较低，但临床医生仍过度使用了广谱抗生素。需要采取安全的策略来限制经验性抗生素的过度使用。
评估计算机化医嘱录入（CPOE）提示提供患者和病原体特定的 MDRO 风险估计是否可以减少治疗 UTI 时经验性使用广谱抗生素。
设计、地点和参与者：在 59 家美国社区医院进行的聚类随机试验，比较了 CPOE 管理包（教育、反馈以及实时和基于风险的 CPOE 提示；29 家医院）与常规管理（n=30 家医院）对非危重症成人（≥18 岁）尿路感染患者在医院前 3 天（经验期）的抗生素选择的影响。该试验有 18 个月的基线期（2017 年 4 月 1 日至 2018 年 9 月 30 日）和 15 个月的干预期（2019 年 4 月 1 日至 2020 年 6 月 30 日）。
CPOE 提示建议对接受广谱抗生素治疗的患者使用经验性标准谱抗生素，如果 MDRO UTI 的估计绝对风险（<10%）较低，则同时提供反馈和教育。
主要结局是经验性（住院前 3 天）使用广谱抗生素的天数。次要结局包括经验性万古霉素和抗假单胞菌抗生素的使用天数。安全性结局包括入住重症监护病房（ICU）的时间和住院时间。使用广义线性混合效应模型评估基线期和干预期之间的差异来评估结果。
在 59 家医院中，有 127403 名成年患者（71991 名基线期患者和 55412 名干预期患者）因 UTI 入院，平均（SD）年龄为 69.4（17.9）岁，30.5%为男性，Elixhauser 合并症指数中位数为 4（IQR，2-5）。与常规管理相比，使用 CPOE 提示的组经验性广谱抗生素使用天数减少了 17.4%（95%CI，11.2%-23.2%）（率比，0.83 [95%CI，0.77-0.89]；P<0.001）。常规和干预组之间平均 ICU 转移天数（分别为 6.6 天和 7.0 天）和住院时间（分别为 6.3 天和 6.5 天）的安全性结局没有显著差异。
与常规管理相比，CPOE 提示为低 MDRO 风险患者实时推荐使用标准谱抗生素，并提供反馈和教育，这显著减少了非危重症成人因 UTI 住院期间经验性广谱抗生素的使用，而不会改变住院时间或 ICU 转移时间。
ClinicalTrials.gov 标识符：NCT03697096。
