■肺炎是需要住院治疗的最常见感染,也是过度使用超广谱抗生素的主要原因。尽管多重耐药菌(MDRO)感染的风险较低,临床不确定性通常会驱动初始抗生素选择。对于肺炎患者,需要采取限制经验性抗生素过度使用的策略。
评估计算机化提供者订单输入(CPOE)提示提供患者和病原体特异性MDRO感染风险评估是否可以减少非重症肺炎患者的经验性广谱抗生素。
■在59家美国社区医院中进行的集群随机试验,比较了CPOE管理捆绑的效果(教育,反馈,和实时基于MDRO风险的CPOE提示;n=29家医院)与常规管理(n=30家医院)在住院的非危重成人(≥18岁)肺炎住院期间的抗生素选择。从2017年4月1日至2018年9月30日为18个月的基线期,从2019年4月1日至2020年6月30日为15个月的干预期。
■CPOE提示在经验性期间被命令接受广谱抗生素的患者中推荐标准谱抗生素,这些患者估计的MDRO肺炎绝对风险较低(<10%),再加上反馈和教育。
■主要结局是经验性(住院前3天)超广谱抗生素治疗天数。次要结局包括经验性万古霉素和抗伪治疗天数,安全性结局包括重症监护病房(ICU)转院天数和住院时间。结果比较了不同策略的基线期和干预期之间的差异。
■在59家医院中,有96451例(基线期51671例,干预期44780例)成年肺炎患者入院,患者的平均年龄(SD)为68.1(17.0)岁,48.1%是男性,Elixhauser合并症计数中位数(IQR)为4(2-6)。与常规管理相比,使用CPOE提示的组的经验性超广谱治疗天数减少了28.4%(比率,0.72[95%CI,0.66-0.78];P<.001)。常规和CPOE干预组之间,ICU转移平均天数(6.5vs7.1天)和住院时间(6.8vs7.1天)的安全性结果没有显着差异。
■在接受教育的医院中,非ICU环境的肺炎成年人中,经验性广谱抗生素的使用明显较低,反馈,CPOE提示为MDRO感染风险较低的患者推荐标准谱抗生素,与常规管理实践相比。住院时间和转至ICU的天数没有变化。
■ClinicalTrials.gov标识符:NCT03697070。
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.
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.
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.
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.
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.
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.
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.
ClinicalTrials.gov Identifier: NCT03697070.