Alerting prescribers to a patient's specific risk for developing multidrug-resistant organism (MDRO) infections through prompts within the ordering function of the electronic health record (EHR) helped to reduce empiric use of broad-spectrum antibiotics in two trials, one conducted in patients with pneumonia and the other with urinary tract infection (UTI).1,2
In an editorial accompanying the 2 separate but concurrently published trials, Anurag Malani, MD Section of Infectious Diseases, Trinity Health Michigan, Ann Arbor, and Preeti Malani, MD, MSJ, Department of Medicine, University of Michigan, Ann Arbor, appreciated both the use of technology and the timing within the process of antibiotic prescribing.3
"Hospital-based stewardship efforts tend to emphasize de-escalation of antibiotics after microbiologic testing results return, and few focus on initial empiric prescribing," they observed.3
What You Need to Know
The trials demonstrated that integrating prompts within the electronic health record (EHR) to alert prescribers about a patient's specific risk for multidrug-resistant organism (MDRO) infections led to a significant reduction in the empiric use of broad-spectrum antibiotics for both pneumonia and urinary tract infections.
The editorial highlighted the significance of focusing on initial empiric prescribing of antibiotics rather than just de-escalation after microbiologic testing results return.
The intervention, which involved a combination of EHR prompts, education, and feedback, received praise for its adaptability and potential for broader implementation across diverse community hospitals.
Both INSPIRE trials compare an antibiotic stewardship "bundle" consisting of the computerized provider order entry (CPOE) prompts to use standard-spectrum antibiotics for patients at low risk for MDRO infection coupled with education and feedback, to hospitals' routine antibiotic stewardship program.The primary endpoint in both trials is reduction in empiric extended-spectrum antibiotic selection.The lead author of both trial reports is Shruti Gohill, MD, MPH, School of Medicine, University of California Irvine, Irvine, CA.3
The trials randomized 59 hospitals to either the routine stewardship group (n=30) or to the CPOE bundle group (29 hospitals). The cohort admitted with pneumonia comprised 47.029 with routine stewardship and 49,422 in the CPOE intervention group.There were 64,244 patients with UTI in the routine stewardship group and 63,159 in the CPOE intervention group.3
In the trial with treating pneumonia, Gohill and colleagues reported that 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). Safety outcome measures of mean days to ICU transfer (6.5 vs 7.1) and the hospital length of stay (6.8 vs 7.1) were not significantly different between the groups.3
With the antibiotic selection for UTI, the investigators reported that the group using CPOE prompts had a 17.4% reduction in empiric extended-spectrum days of therapy (rate ratio 0.83 [0.77-0.89]). There were also no significant difference in the safety outcomes between the groups.33
"Both the safety outcomes and sensitivity analyses offer helpful reassurance that the observed reductions in extended-spectrum antibiotic use did not compromise patient safety or result in adverse clinical outcome," observed Malani and Malani.3
They also noted in their editorial that although the intervention required strong support from hospital administrative and medical leadership and broad collaboration among different groups of practitioners, it appeared suitable for others to adapt.They noted that Gohill and colleagues were able to introduce these interventions at a diverse group of community hospitals, and to sustain the program even during the early days of the pandemic.
"The aptly named INSPIRE trials do just that—provide inspiration and imagination, along with a powerful paradigm to harness the EHR to optimize antibiotic prescribing and improve human health," Malani and Malani enthused.3
References
1. Gohil SK, Septimus E, Kleinman K, et al. Stewardship prompts to improve antibiotic selection for pneumonia. The INSPIRE randomized clinical trial. JAMA 2024; published online April 19. doi:10.1001/jama.2024.6248. Accessed April 22, 2024.
2. Gohil SK, Septimus E, Kleinman K, et al. Stewardship prompts to improve antibiotic selection for urinary tract infection. JAMA 2024; published online April 19. doi:10.100/jama.2024.6259. Accessed April 22, 2024.
3. Malani AN, Malani PN. Harnessing the electronic health record to improve empiric antibiotic prescribing. JAMA 2024; published online April 19. doi:10.1001/jama.2024.6554. Accessed April 22, 2024.
