IMPORTANCE: Empiric extended-spectrum antibiotics are routinely prescribed for over a million patients hospitalized annually with abdominal infection despite low likelihoods of infection with multidrug-resistant organisms (MDROs).
OBJECTIVE: To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates can reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with abdominal infection.
DESIGN, SETTING, AND PARTICIPANTS: This 92-hospital cluster randomized clinical trial assessed the effect of an antibiotic stewardship bundle with CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults hospitalized with abdominal infection. The trial population included adults (=18 years) treated with empiric antibiotics for abdominal infection in non-intensive care units (ICUs). The trial periods included a 12-month baseline from January to December 2019 and an intervention period from January to December 2023.
INTERVENTION: CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period if the patient's estimated absolute risk of MDRO abdominal infection was less than 10%, coupled with feedback and education.
MAIN OUTCOMES AND MEASURES: The primary outcome was empiric extended-spectrum antibiotic days of therapy. Safety outcomes: days to ICU transfer and hospital length of stay. Analyses compared differences between baseline and intervention periods across strategies.
RESULTS: Among 92 hospitals with 198?480 patients, mean (SD) age was 60 (19) years and 118?723 (59.8%) were female. The trial included 93?476 and 105?004 patients hospitalized with abdominal infection during the baseline and intervention periods, respectively. Receipt of any empiric extended-spectrum antibiotics for the routine care group was 48.2% (22 519 of 46?725) during baseline and 50.5% (27?452 of 54?384) during intervention vs 47.8% (22 367 of 46?751) and 37.6% (19 010 of 50?620) for the CPOE bundle group. The group receiving CPOE prompts had a 35% relative reduction (rate ratio, 0.65; 95% CI, 0.60-0.71; P < .001) in empiric extended-spectrum antibiotic days of therapy vs routine care (raw absolute reduction between baseline and intervention periods was -169 for the CPOE bundle vs -20 for routine care). Hospital length of stay was noninferior to routine care (0.1 days longer during intervention; mean [SD], baseline, 5.4 [3.4] days vs intervention, 5.5 [3.5] days; hazard ratio [HR], 1.02; 90% CI, 0.99-1.06), and mean days to ICU transfer in the CPOE group was indeterminate (both groups 0.2 days longer during intervention; HR, 1.10; 90% CI, 0.99-1.23).
CONCLUSIONS AND RELEVANCE: CPOE prompts recommending empiric standard-spectrum antibiotics (coupled with education and feedback) for patients admitted with abdominal infection who have low risk for MDRO infection significantly reduced extended-spectrum antibiotics without increasing ICU transfers or length of stay.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05423743.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
This seems like a very complex intervention. The multidrug resistant organism risk needs more transparency and simplicity as this would be a useful clinical prediction rule.
Physician rater
Well done pragmatic RCT showing that this intervention can reduce overuse of broad spectrum antibiotics without increasing risk or length-of-stay.
Physician rater
Highly important contribution that has the potential to reduce antibiotic resistance.
Physician rater
An extensive and well-conducted study of antimicrobial stewardship in non-critically ill patients with abdominal infections. Their bundle of interventions reduced antipseudomonal antibiotic use (vancomycin) and extended spectrum days of therapy without showing a change in length of stay or day to ICU transfer. In hospital mortality (secondary outcome) was also not significantly changed between the groups. Although there are some significant limitations(e.g. MDRO prevalence in their hospitals at baseline was not analyzed) and perhaps more importantly, there was no data on the timing or proportion of patients receiving source control or drainage. Overall, this suggests extended spectrum use in this population is higher than it needs to be and amenable to intervention.
Physician rater
In an age of increasing MDROs, this is a big step in the right direction. In our zeal to diagnose and treat sepsis early (warranted given the risk of poor outcomes if not treated appropriately), we may have swung the pendulum too far into the realm of over-treating. The medical literature is now littered with articles regarding over-treatment. If MDROs make up only 2% of intraabdominal infections, a more judicious utilization strategy for broad spectrum antibiotics would certainly seem warranted.
Physician rater
A CPOE alert based on MDRO risk scores helped reduce unnecessary broad-spectrum antibiotic use without compromising outcomes. It offers a practical and scalable strategy to improve empiric antibiotic selection in real-world inpatient care.
, McMaster University