Gohil SK, Septimus E, Kleinman K, et al. Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial. JAMA. 2024 Apr 19. doi: 10.1001/jama.2024.6248. (Original study)

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.

Discipline Area Score
Hospital Doctor/Hospitalists 6 / 7
Internal Medicine 6 / 7
Infectious Disease 6 / 7
Respirology/Pulmonology 5 / 7
Comments from MORE raters

Internal Medicine rater

Perhaps less important outside of the USA where using wide-spectrum antibiotics is less common. A large cluster RCT and one of the few to show an impact on important patient outcomes with a CPOE intervention.

Respirology/Pulmonology rater

This cluster RCT finds that patients admitted with community-acquired pneumonia in hospitals that implemented a computerized provider order entry prompt, bundled together with monthly coaching and clinician education and feedback reports, received less extended-spectrum antibiotics with no difference in length-of-stay or ICU admission, compared with patients at hospitals where providers received educational materials alone. Results support the efficacy of implementing prompts into electronic medical record systems.

Respirology/Pulmonology rater

This study confirms that real-time clinical decision aids decrease presumptive anti-MRSA and antipseudomonal antibiotic use in pneumonia. The measured patient outcomes were the same, whether or not decision support was used. The "so what?" question remains. The ultimate question is: did the lessened use of presumptive anti-MRSA and antipseudomonal antibiotics decrease the emergence rate of MDROs?
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