美国加州大学欧文分校Shruti K. Gohil团队研究了管理改进肺炎抗生素的选择策略抑制抗生素滥用的效果。相关论文于2024年4月19日发表在《美国医学会杂志》上。

肺炎是最常见的需要住院治疗的感染，也是过度使用广谱抗生素的主要原因。尽管耐多药菌（MDRO）感染的风险很低，但临床的不确定性往往会推动最初的抗生素选择。需要制定策略来限制肺炎患者经验性抗生素的过度使用。

为了评估计算机化提供者医嘱输入（CPOE）提示提供患者和病原体特异性MDRO感染风险估计，是否可以减少肺炎非危重患者的经验性广谱抗生素，研究组在59家美国社区医院进行了一项集群随机试验，比较CPOE管理捆绑包（教育、反馈和实时MDRO基于风险的CPOE提示；n = 29家医院）与常规管理（n = 30家医院）在因肺炎住院的非危重成人（≥18岁）的前3个住院日（基线期）内进行的抗生素选择。2017年4月1日至2018年9月30日，有18个月的基线期；2019年4月1日至2020年6月30日有15个月的干预期。

CPOE提示在基线期内被要求接受广谱抗生素治疗的MDRO肺炎估计绝对风险较低（<10%）的患者推荐标准谱抗生素，并提供反馈和教育。主要结局是经验性的（住院前3天）广谱抗生素治疗天数。次要结局包括经验性万古霉素和抗假单胞菌治疗天数，安全性结局包括转入重症监护室（ICU）的天数和住院时间。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名（基线期51671名，干预期44780名）成年肺炎患者入院，患者的平均（SD）年龄为68.1（17.0）岁，48.1%为男性，Elixhauser合并症的中位数（IQR）为4（2-6）。与常规管理相比，使用CPOE提示的组经验延长治疗天数减少了28.4%（优势比为0.72[95%CI，0.66-0.78]；P < .001）。常规和CPOE干预组的平均ICU转移天数（6.5天与7.1天）和住院时间（6.8天与7.1日）的安全性结局没有显著差异。

研究结果表明，与常规管理实践相比，在医院使用教育、反馈和CPOE提示为MDRO感染风险较低的患者推荐标准谱抗生素的非ICU环境中，因肺炎入院的成年人的经验扩展谱抗生素使用显著较低。住院时间和转入重症监护室的天数没有变化。

附：英文原文

Title: Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial

Author: Shruti K. Gohil, Edward Septimus, Ken Kleinman, Neha Varma, Taliser R. Avery, Lauren Heim, Risa Rahm, William S. Cooper, Mandelin Cooper, Laura E. McLean, Naoise G. Nickolay, Robert A. Weinstein, L. Hayley Burgess, Micaela H. Coady, Edward Rosen, Selsebil Sljivo, Kenneth E. Sands, Julia Moody, Justin Vigeant, Syma Rashid, Rebecca F. Gilbert, Kim N. Smith, Brandon Carver, Russell E. Poland, Jason Hickok, S. G. Sturdevant, Michael S. Calderwood, Anastasiia Weiland, David W. Kubiak, Sujan Reddy, Melinda M. Neuhauser, Arjun Srinivasan, John A. Jernigan, Mary K. Hayden, Abinav Gowda, Katyuska Eibensteiner, Robert Wolf, Jonathan B. Perlin, Richard Platt, Susan S. Huang

Issue&Volume: 2024-04-19

Abstract:

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 96451 (51671 in the baseline period and 44780 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.

DOI: 10.1001/jama.2024.6248

Source: https://jamanetwork.com/journals/jama/fullarticle/2817976