The prompts recommended standard-spectrum antibiotics for patients at low risk of multidrug-resistant organisms (MDRO) infection, according to a report in the Journal of the American Medical Association.
The researchers from the University of California School of Medicine in Irvine and colleagues advised that 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.”
The study team sought to evaluate how effective CPOE prompts providing patient- and pathogen-specific MDRO infection risk estimates might be in reducing the use of empiric extended-spectrum antibiotics for noncritically ill patients admitted with pneumonia.
To do that, researchers conducted a cluster-randomized trial in 59 U.S. community hospitals. The study sought to compare the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk–based CPOE prompts, tested at 29 hospitals) versus routine stewardship (used at 30 hospitals) on antibiotic selection during the first 3 hospital days in noncritically ill adults hospitalized with pneumonia. The trial included 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.
While the use of extended-spectrum antibiotic use dropped significantly with the use of the CPOE bundle, 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.
Background information in the article points out that more than 1.5 million adults are hospitalized in the United States annually for pneumonia. “Estimates suggest that about half of patients admitted with pneumonia unnecessarily receive extended-spectrum antibiotics,” the authors pointed out. “Identifying effective strategies to curb antibiotic overuse is a national priority; to date, strategies to improve prescribing for inpatient pneumonia have largely focused on shortening antibiotic duration or deescalating extended-spectrum antibiotics after microbiologic test results return and patients are stabilized. However, such strategies do not address unnecessary extended-spectrum antibiotics used before these results are available.”
The study added that even brief exposure to antibiotics can increase a patient’s risk for MDROs, Clostridioides difficile infection, and other antibiotic-associated adverse effects, making the need for additional strategies especially urgent.
Current practice often is for clinicians often prescribe vancomycin and/or antipseudomonal therapy for pneumonia at admission and deescalate to standard-spectrum antibiotics if nasal screening test results are negative for methicillin-resistant Staphylococcus aureus or if cultures do not reveal Pseudomonas or other MDROs, they explained.
“Although most inpatients with pneumonia can be safely treated with standard-spectrum antibiotics, which do not cover Pseudomonas or MDROs, clinicians are reluctant to initially select them because of concern that the patient may be infected with an MDRO,” the authors explained. “Real-time identification of patients with low risk for MDRO pneumonia might therefore reduce empiric extended-spectrum antibiotic exposure.”
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