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):2007-2017. doi: 10.1001/jama.2024.6248.
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.
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.
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.
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.
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.
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.
ClinicalTrials.gov Identifier: NCT03697070.
肺炎是最常见的需要住院治疗的感染病，也是过度使用广谱抗生素的主要原因。尽管多药耐药菌（MDRO）感染的风险较低，但临床不确定性常常会影响初始抗生素的选择。因此，需要采取策略来限制肺炎患者经验性抗生素的过度使用。
评估计算机医嘱录入（CPOE）提示提供患者和病原体特异性 MDRO 感染风险估计是否可以减少非危重症肺炎患者入院后经验性使用广谱抗生素。
设计、设置和参与者：在 59 家美国社区医院进行的一项群组随机试验，比较了 CPOE 管理包（教育、反馈和实时基于 MDRO 风险的 CPOE 提示；n = 29 家医院）与常规管理（n = 30 家医院）对非危重症成人（≥18 岁）肺炎患者入院后前 3 天（经验期）抗生素选择的影响。从 2017 年 4 月 1 日至 2018 年 9 月 30 日有 18 个月的基线期，从 2019 年 4 月 1 日至 2020 年 6 月 30 日有 15 个月的干预期。
CPOE 提示建议在经验期内为接受广谱抗生素治疗的患者开具标准光谱抗生素，如果患者 MDRO 肺炎的绝对风险（<10%）较低，则建议使用抗生素，同时提供反馈和教育。
主要结果是经验性（入院前 3 天）使用广谱抗生素的天数。次要结果包括经验性万古霉素和抗假单胞菌抗生素的天数以及安全性结果，包括入住重症监护病房（ICU）的天数和住院时间。结果比较了两种策略在基线期和干预期的差异。
在 59 家有 96451 名（基线期 51671 名，干预期 44780 名）成年肺炎患者入院的医院中，患者的平均（SD）年龄为 68.1（17.0）岁，48.1%为男性，中位（IQR）Elixhauser 合并症计数为 4（2-6）。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 28.4%（率比，0.72 [95%CI，0.66-0.78]；P<0.001）。常规和 CPOE 干预组入住 ICU 的平均天数（6.5 天 vs 7.1 天）和住院时间（6.8 天 vs 7.1 天）差异无统计学意义。
与常规管理实践相比，在使用教育、反馈和 CPOE 提示建议低风险 MDRO 感染患者使用标准光谱抗生素的非 ICU 环境中，接受非 ICU 治疗的肺炎成年患者的经验性广谱抗生素使用显著降低。住院时间和入住 ICU 的天数没有变化。
ClinicalTrials.gov 标识符：NCT03697070。
