Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial
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 empi...
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| Veröffentlicht in: | JAMA : the journal of the American Medical Association 2024-06, Vol.331 (23), p.2007-2017 |
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| creator | Gohil, Shruti K Septimus, Edward Kleinman, Ken Varma, Neha Avery, Taliser R Heim, Lauren Rahm, Risa Cooper, William S Cooper, Mandelin McLean, Laura E Nickolay, Naoise G Weinstein, Robert A Burgess, L. Hayley Coady, Micaela H Rosen, Edward Sljivo, Selsebil Sands, Kenneth E Moody, Julia Vigeant, Justin Rashid, Syma Gilbert, Rebecca F Smith, Kim N Carver, Brandon Poland, Russell E Hickok, Jason Sturdevant, S. G Calderwood, Michael S Weiland, Anastasiia Kubiak, David W Reddy, Sujan Neuhauser, Melinda M Srinivasan, Arjun Jernigan, John A Hayden, Mary K Gowda, Abinav Eibensteiner, Katyuska Wolf, Robert Perlin, Jonathan B Platt, Richard Huang, Susan S |
| description | 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 ( |
| doi_str_mv | 10.1001/jama.2024.6248 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_11185977</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><ama_id>2817976</ama_id><sourcerecordid>3043073883</sourcerecordid><originalsourceid>FETCH-LOGICAL-a268t-c2330220748ac744399870e84eca1021de8d4885ea9706eac70d2e070bd81cb53</originalsourceid><addsrcrecordid>eNpdkUFvEzEQRi0EomnhyoEDssSFy4axvbv2ckFVVCBSBVETzpbjnRBHu3awd4vor8ertBUwlznMm08zeoS8YjBnAOz9wfRmzoGX85qX6gmZsUqoQlSNekpmAI0qZKnKM3Ke0gFyMSGfkzOhatFI3szIfj3gLxPbtHdHuoqhPw6JDoEu-2MMt0gv_eC2LgzO0jV2aAcXPN2FSFcexz54Zz7QzR7p8ut6tby5ojfGt6F3d9jSRee8s6ajm-hM94I825ku4cv7fkG-f7raLL4U198-LxeX14XhtRoKy4UAziFfbawsS9E0SgKqEq1hwFmLqi2VqtA0EmrMDLQcQcK2VcxuK3FBPp5yj-O2x9aiH6Lp9DG63sTfOhin_514t9c_wq1mjKmqkTInvLtPiOHniGnQvUsWu854DGPSAkoBUiglMvr2P_QQxujzf5lSILMLrjI1P1E2hpQi7h6vYaAni3qyqCeLerKYF978_cMj_qAtA69PwLT3MOWKyUbW4g8B0aEj</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>3080753828</pqid></control><display><type>article</type><title>Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial</title><source>MEDLINE</source><source>American Medical Association Journals</source><creator>Gohil, Shruti K ; Septimus, Edward ; Kleinman, Ken ; Varma, Neha ; Avery, Taliser R ; Heim, Lauren ; Rahm, Risa ; Cooper, William S ; Cooper, Mandelin ; McLean, Laura E ; Nickolay, Naoise G ; Weinstein, Robert A ; Burgess, L. Hayley ; Coady, Micaela H ; Rosen, Edward ; Sljivo, Selsebil ; Sands, Kenneth E ; Moody, Julia ; Vigeant, Justin ; Rashid, Syma ; Gilbert, Rebecca F ; Smith, Kim N ; Carver, Brandon ; Poland, Russell E ; Hickok, Jason ; Sturdevant, S. G ; Calderwood, Michael S ; Weiland, Anastasiia ; Kubiak, David W ; Reddy, Sujan ; Neuhauser, Melinda M ; Srinivasan, Arjun ; Jernigan, John A ; Hayden, Mary K ; Gowda, Abinav ; Eibensteiner, Katyuska ; Wolf, Robert ; Perlin, Jonathan B ; Platt, Richard ; Huang, Susan S</creator><creatorcontrib>Gohil, Shruti K ; Septimus, Edward ; Kleinman, Ken ; Varma, Neha ; Avery, Taliser R ; Heim, Lauren ; Rahm, Risa ; Cooper, William S ; Cooper, Mandelin ; McLean, Laura E ; Nickolay, Naoise G ; Weinstein, Robert A ; Burgess, L. Hayley ; Coady, Micaela H ; Rosen, Edward ; Sljivo, Selsebil ; Sands, Kenneth E ; Moody, Julia ; Vigeant, Justin ; Rashid, Syma ; Gilbert, Rebecca F ; Smith, Kim N ; Carver, Brandon ; Poland, Russell E ; Hickok, Jason ; Sturdevant, S. G ; Calderwood, Michael S ; Weiland, Anastasiia ; Kubiak, David W ; Reddy, Sujan ; Neuhauser, Melinda M ; Srinivasan, Arjun ; Jernigan, John A ; Hayden, Mary K ; Gowda, Abinav ; Eibensteiner, Katyuska ; Wolf, Robert ; Perlin, Jonathan B ; Platt, Richard ; Huang, Susan S</creatorcontrib><description>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</description><identifier>ISSN: 0098-7484</identifier><identifier>ISSN: 1538-3598</identifier><identifier>EISSN: 1538-3598</identifier><identifier>DOI: 10.1001/jama.2024.6248</identifier><identifier>PMID: 38639729</identifier><language>eng</language><publisher>United States: American Medical Association</publisher><subject>Adults ; Aged ; Aged, 80 and over ; Anti-Bacterial Agents - therapeutic use ; Antibiotics ; Antimicrobial Stewardship ; Comorbidity ; Drug Resistance, Multiple, Bacterial ; Education ; Feedback ; Female ; Health risks ; Hospitalization ; Hospitals ; Humans ; Infections ; Intervention ; Length of stay ; Male ; Medical Order Entry Systems ; Middle Aged ; Multidrug resistance ; Multidrug resistant organisms ; Online First ; Original Investigation ; Patients ; Pneumonia ; Pneumonia - drug therapy ; Pneumonia, Bacterial - drug therapy ; Real time ; Risk ; Therapy ; United States ; Vancomycin</subject><ispartof>JAMA : the journal of the American Medical Association, 2024-06, Vol.331 (23), p.2007-2017</ispartof><rights>Copyright American Medical Association Jun 18, 2024</rights><rights>Copyright 2024 American Medical Association. All Rights Reserved.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-a268t-c2330220748ac744399870e84eca1021de8d4885ea9706eac70d2e070bd81cb53</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://jamanetwork.com/journals/jama/articlepdf/10.1001/jama.2024.6248$$EPDF$$P50$$Gama$$H</linktopdf><linktohtml>$$Uhttps://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2024.6248$$EHTML$$P50$$Gama$$H</linktohtml><link.rule.ids>64,230,314,776,780,881,3327,27901,27902,76231,76234</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/38639729$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Gohil, Shruti K</creatorcontrib><creatorcontrib>Septimus, Edward</creatorcontrib><creatorcontrib>Kleinman, Ken</creatorcontrib><creatorcontrib>Varma, Neha</creatorcontrib><creatorcontrib>Avery, Taliser R</creatorcontrib><creatorcontrib>Heim, Lauren</creatorcontrib><creatorcontrib>Rahm, Risa</creatorcontrib><creatorcontrib>Cooper, William S</creatorcontrib><creatorcontrib>Cooper, Mandelin</creatorcontrib><creatorcontrib>McLean, Laura E</creatorcontrib><creatorcontrib>Nickolay, Naoise G</creatorcontrib><creatorcontrib>Weinstein, Robert A</creatorcontrib><creatorcontrib>Burgess, L. Hayley</creatorcontrib><creatorcontrib>Coady, Micaela H</creatorcontrib><creatorcontrib>Rosen, Edward</creatorcontrib><creatorcontrib>Sljivo, Selsebil</creatorcontrib><creatorcontrib>Sands, Kenneth E</creatorcontrib><creatorcontrib>Moody, Julia</creatorcontrib><creatorcontrib>Vigeant, Justin</creatorcontrib><creatorcontrib>Rashid, Syma</creatorcontrib><creatorcontrib>Gilbert, Rebecca F</creatorcontrib><creatorcontrib>Smith, Kim N</creatorcontrib><creatorcontrib>Carver, Brandon</creatorcontrib><creatorcontrib>Poland, Russell E</creatorcontrib><creatorcontrib>Hickok, Jason</creatorcontrib><creatorcontrib>Sturdevant, S. G</creatorcontrib><creatorcontrib>Calderwood, Michael S</creatorcontrib><creatorcontrib>Weiland, Anastasiia</creatorcontrib><creatorcontrib>Kubiak, David W</creatorcontrib><creatorcontrib>Reddy, Sujan</creatorcontrib><creatorcontrib>Neuhauser, Melinda M</creatorcontrib><creatorcontrib>Srinivasan, Arjun</creatorcontrib><creatorcontrib>Jernigan, John A</creatorcontrib><creatorcontrib>Hayden, Mary K</creatorcontrib><creatorcontrib>Gowda, Abinav</creatorcontrib><creatorcontrib>Eibensteiner, Katyuska</creatorcontrib><creatorcontrib>Wolf, Robert</creatorcontrib><creatorcontrib>Perlin, Jonathan B</creatorcontrib><creatorcontrib>Platt, Richard</creatorcontrib><creatorcontrib>Huang, Susan S</creatorcontrib><title>Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial</title><title>JAMA : the journal of the American Medical Association</title><addtitle>JAMA</addtitle><description>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</description><subject>Adults</subject><subject>Aged</subject><subject>Aged, 80 and over</subject><subject>Anti-Bacterial Agents - therapeutic use</subject><subject>Antibiotics</subject><subject>Antimicrobial Stewardship</subject><subject>Comorbidity</subject><subject>Drug Resistance, Multiple, Bacterial</subject><subject>Education</subject><subject>Feedback</subject><subject>Female</subject><subject>Health risks</subject><subject>Hospitalization</subject><subject>Hospitals</subject><subject>Humans</subject><subject>Infections</subject><subject>Intervention</subject><subject>Length of stay</subject><subject>Male</subject><subject>Medical Order Entry Systems</subject><subject>Middle Aged</subject><subject>Multidrug resistance</subject><subject>Multidrug resistant organisms</subject><subject>Online First</subject><subject>Original Investigation</subject><subject>Patients</subject><subject>Pneumonia</subject><subject>Pneumonia - drug therapy</subject><subject>Pneumonia, Bacterial - drug therapy</subject><subject>Real time</subject><subject>Risk</subject><subject>Therapy</subject><subject>United States</subject><subject>Vancomycin</subject><issn>0098-7484</issn><issn>1538-3598</issn><issn>1538-3598</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2024</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNpdkUFvEzEQRi0EomnhyoEDssSFy4axvbv2ckFVVCBSBVETzpbjnRBHu3awd4vor8ertBUwlznMm08zeoS8YjBnAOz9wfRmzoGX85qX6gmZsUqoQlSNekpmAI0qZKnKM3Ke0gFyMSGfkzOhatFI3szIfj3gLxPbtHdHuoqhPw6JDoEu-2MMt0gv_eC2LgzO0jV2aAcXPN2FSFcexz54Zz7QzR7p8ut6tby5ojfGt6F3d9jSRee8s6ajm-hM94I825ku4cv7fkG-f7raLL4U198-LxeX14XhtRoKy4UAziFfbawsS9E0SgKqEq1hwFmLqi2VqtA0EmrMDLQcQcK2VcxuK3FBPp5yj-O2x9aiH6Lp9DG63sTfOhin_514t9c_wq1mjKmqkTInvLtPiOHniGnQvUsWu854DGPSAkoBUiglMvr2P_QQxujzf5lSILMLrjI1P1E2hpQi7h6vYaAni3qyqCeLerKYF978_cMj_qAtA69PwLT3MOWKyUbW4g8B0aEj</recordid><startdate>20240618</startdate><enddate>20240618</enddate><creator>Gohil, Shruti K</creator><creator>Septimus, Edward</creator><creator>Kleinman, Ken</creator><creator>Varma, Neha</creator><creator>Avery, Taliser R</creator><creator>Heim, Lauren</creator><creator>Rahm, Risa</creator><creator>Cooper, William S</creator><creator>Cooper, Mandelin</creator><creator>McLean, Laura E</creator><creator>Nickolay, Naoise G</creator><creator>Weinstein, Robert A</creator><creator>Burgess, L. 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G</creatorcontrib><creatorcontrib>Calderwood, Michael S</creatorcontrib><creatorcontrib>Weiland, Anastasiia</creatorcontrib><creatorcontrib>Kubiak, David W</creatorcontrib><creatorcontrib>Reddy, Sujan</creatorcontrib><creatorcontrib>Neuhauser, Melinda M</creatorcontrib><creatorcontrib>Srinivasan, Arjun</creatorcontrib><creatorcontrib>Jernigan, John A</creatorcontrib><creatorcontrib>Hayden, Mary K</creatorcontrib><creatorcontrib>Gowda, Abinav</creatorcontrib><creatorcontrib>Eibensteiner, Katyuska</creatorcontrib><creatorcontrib>Wolf, Robert</creatorcontrib><creatorcontrib>Perlin, Jonathan B</creatorcontrib><creatorcontrib>Platt, Richard</creatorcontrib><creatorcontrib>Huang, Susan S</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>Calcium & Calcified Tissue Abstracts</collection><collection>Neurosciences Abstracts</collection><collection>Physical Education Index</collection><collection>Toxicology Abstracts</collection><collection>Virology and AIDS Abstracts</collection><collection>Technology Research Database</collection><collection>Environmental Sciences and Pollution Management</collection><collection>Engineering Research Database</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Algology Mycology and Protozoology Abstracts (Microbiology C)</collection><collection>Nursing & Allied Health Premium</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>Genetics Abstracts</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>JAMA : the journal of the American Medical Association</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Gohil, Shruti K</au><au>Septimus, Edward</au><au>Kleinman, Ken</au><au>Varma, Neha</au><au>Avery, Taliser R</au><au>Heim, Lauren</au><au>Rahm, Risa</au><au>Cooper, William S</au><au>Cooper, Mandelin</au><au>McLean, Laura E</au><au>Nickolay, Naoise G</au><au>Weinstein, Robert A</au><au>Burgess, L. Hayley</au><au>Coady, Micaela H</au><au>Rosen, Edward</au><au>Sljivo, Selsebil</au><au>Sands, Kenneth E</au><au>Moody, Julia</au><au>Vigeant, Justin</au><au>Rashid, Syma</au><au>Gilbert, Rebecca F</au><au>Smith, Kim N</au><au>Carver, Brandon</au><au>Poland, Russell E</au><au>Hickok, Jason</au><au>Sturdevant, S. G</au><au>Calderwood, Michael S</au><au>Weiland, Anastasiia</au><au>Kubiak, David W</au><au>Reddy, Sujan</au><au>Neuhauser, Melinda M</au><au>Srinivasan, Arjun</au><au>Jernigan, John A</au><au>Hayden, Mary K</au><au>Gowda, Abinav</au><au>Eibensteiner, Katyuska</au><au>Wolf, Robert</au><au>Perlin, Jonathan B</au><au>Platt, Richard</au><au>Huang, Susan S</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial</atitle><jtitle>JAMA : the journal of the American Medical Association</jtitle><addtitle>JAMA</addtitle><date>2024-06-18</date><risdate>2024</risdate><volume>331</volume><issue>23</issue><spage>2007</spage><epage>2017</epage><pages>2007-2017</pages><issn>0098-7484</issn><issn>1538-3598</issn><eissn>1538-3598</eissn><abstract>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</abstract><cop>United States</cop><pub>American Medical Association</pub><pmid>38639729</pmid><doi>10.1001/jama.2024.6248</doi><tpages>11</tpages></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0098-7484 |
| ispartof | JAMA : the journal of the American Medical Association, 2024-06, Vol.331 (23), p.2007-2017 |
| issn | 0098-7484 1538-3598 1538-3598 |
| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_11185977 |
| source | MEDLINE; American Medical Association Journals |
| subjects | Adults Aged Aged, 80 and over Anti-Bacterial Agents - therapeutic use Antibiotics Antimicrobial Stewardship Comorbidity Drug Resistance, Multiple, Bacterial Education Feedback Female Health risks Hospitalization Hospitals Humans Infections Intervention Length of stay Male Medical Order Entry Systems Middle Aged Multidrug resistance Multidrug resistant organisms Online First Original Investigation Patients Pneumonia Pneumonia - drug therapy Pneumonia, Bacterial - drug therapy Real time Risk Therapy United States Vancomycin |
| title | Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-08T14%3A17%3A23IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Stewardship%20Prompts%20to%20Improve%20Antibiotic%20Selection%20for%20Pneumonia:%20The%20INSPIRE%20Randomized%20Clinical%20Trial&rft.jtitle=JAMA%20:%20the%20journal%20of%20the%20American%20Medical%20Association&rft.au=Gohil,%20Shruti%20K&rft.date=2024-06-18&rft.volume=331&rft.issue=23&rft.spage=2007&rft.epage=2017&rft.pages=2007-2017&rft.issn=0098-7484&rft.eissn=1538-3598&rft_id=info:doi/10.1001/jama.2024.6248&rft_dat=%3Cproquest_pubme%3E3043073883%3C/proquest_pubme%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=3080753828&rft_id=info:pmid/38639729&rft_ama_id=2817976&rfr_iscdi=true |