April 19, 2024
Stewardship Prompts to Improve Antibiotic Selection for Urinary Tract Infection: The INSPIRE Randomized Clinical Trial
Shruti K. Gohil, Edward Septimus, Ken Kleinman, et al
JAMA. Published online April 19, 2024. doi:10.1001/jama.2024.6259
Key Points
Question Can computerized provider order entry prompts that present patient-specific multidrug-resistant organism (MDRO) risk estimates reduce empiric extended-spectrum antibiotics in patients admitted with urinary tract infection (UTI)?
Findings In a cluster-randomized trial of 59 hospitals (n = 55 412 adults in the intervention period), computerized provider order entry prompts promoting standard-spectrum antibiotics for patients at low risk of infection with MDROs significantly reduced empiric extended-spectrum antibiotic use in hospitalized patients with UTI by 17.4% without increasing intensive care unit transfers or length of stay.
Meaning Real-time electronic health record–generated recommendations for standard-spectrum antibiotics using patient-specific risk for MDRO-associated infections can safely reduce empiric extended-spectrum antibiotic use in patients hospitalized for UTI.
Abstract
Importance 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.
Objective 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).
Interventions 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.
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. 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.
Results 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.
Conclusions and Relevance 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.
Trial Registration ClinicalTrials.gov Identifier: NCT03697096
