A new analysis of four randomized clinical trials provides evidence that a stewardship prompt embedded in a hospital’s electronic health record to improve empiric antibiotic prescribing in the early days of hospitalization can help reduce unnecessary use of extended-spectrum antibiotics in patients throughout their hospital stay.
The findings are from a research letter published yesterday in JAMA by the team of researchers who conducted the INSPIRE (Intelligent Stewardship Prompts to Improve Real-Time Antibiotic Selection) trials. In those cluster-randomized trials, the investigators evaluated the impact of computerized provider order entry (CPOE) prompts for patients receiving empiric antibiotics for four common bacterial infections: pneumonia, urinary tract infection (UTI), intra-abdominal infection (IAI), and skin or other soft-tissue infection (SSTI).
The purpose of the CPOE prompt is to inform clinicians within the first 3 days of hospitalization—when empiric antibiotics are typically prescribed—that the patient has a less than 10% risk for infection with a multidrug-resistant organism (MDRO) and can be prescribed a standard-spectrum antibiotic. The prompt is based on an algorithm that uses a host of variables to assess a patient’s risk for having an MDRO infection.
“What the physician will get is a risk estimate that tells them—for the specific antibiotic they have chosen—whether or not the patient has the antibiotic-resistant organism that the physician is worried about,” lead investigator Shruti Gohil, MD, MPH, of the University of California, Irvine School of Medicine, explained to CIDRAP News in 2024. “If it’s a low-risk patient, then and only then will the physician see the prompt.”
Altogether, the four INSPIRE trials found that hospitals where clinicians used the CPOE prompts, compared with those that practiced routine antibiotic stewardship activities, reduced initial extended-spectrum antibiotic use in the first 3 days of hospitalization by 17%, 28%, 28% and 35% in UTI, pneumonia, SSTI, and IAI patients, respectively.
Sustained reductions
For the current study, Gohil and colleagues from Harvard Pilgrim Healthcare Institute, the University of Massachusetts, and Belmont University set out to see whether those initial reductions were sustained during the patients’ remaining hospitalization.
Using data from the hospitals in which the four INSPIRE trials were conducted (59 in the UTI and pneumonia trials and 92 in the IAI and SSTI trials), they evaluated extended-spectrum antibiotic days of therapy after the third hospital day (the post-empiric period). Separate analyses were conducted for each INSPIRE trial.
Of the patients included in the four INSPIRE trials, 413,901 were hospitalized for 3 or more days. During the baseline period across all four trials, 38% to 44% of all antibiotic doses were given during the empiric period, with 79% to 94% of extended-spectrum antibiotics initiated during the empiric period.
Compared with hospitals that used routine stewardship, the CPOE hospitals saw post-empiric extended-spectrum days of therapy fall by 22% among patients in the pneumonia trial, by 11% in the UTI trial, by 23% in the IAI trial, and by 23% in the SSTI trial. Of the reductions that were achieved in empiric antibiotic use in the initial trials, 65% to 84% were maintained throughout the remainder of the hospitalization.
“Patient-specific CPOE prompts to reduce empiric extended-spectrum antibiotic use resulted in sustained reductions for the entire hospital stay,” the study authors wrote. “These findings suggest that investing in stewardship for initial antibiotic selection, rather than primarily focusing on de-escalating antibiotics once started, would reduce unnecessary extended-spectrum antibiotics for millions of patients in US hospitals annually.”