美国加州大学欧文分校Shruti K. Gohil团队研究了管理改进尿路感染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。

尿路感染（UTI）是导致住院的第二常见感染，通常与革兰氏阴性多重耐药菌（MDRO）有关。临床医生过度使用广谱抗生素，尽管大多数患者感染MDRO的风险较低。仍需要安全的策略来限制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风险估计是否可以减少经验性广谱抗生素治疗尿路感染的使用，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管理包（教育、反馈、实时和基于风险的CPOE提示；29家医院）与常规管理（n = 30家医院）在前3个住院日（基线期）对因尿路感染住院的非危重成人（≥18岁）进行的抗生素选择，基线为18个月（2017年4月1日至2018年9月30日），干预期为15个月（2019年4月1日至2020年6月30日）。

CPOE提示对MDRO UTI估计绝对风险较低（<10%）的患者推荐经验标准谱抗生素，并进行反馈和教育。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。使用广义线性混合效应模型评估结果，以评估基线期和干预期之间的差异。

在59家医院因尿路感染入院的127403名成年患者（71991名基线患者和55412名干预期患者）中，平均（SD）年龄为69.4（17.9）岁，30.5%为男性，Elixhauser合并症指数中位数为4（IQR，2-5）。与常规管理相比，使用CPOE提示的组的经验延长治疗天数减少了17.4%（95%CI，11.2%-23.2%）（优势比为0.83[95%CI，0.77-0.89]；P < .001）。常规组和干预组的平均ICU转移天数（6.6天vs 7.0天）和住院时间（6.3天vs 6.5天）的安全性结局分别没有显著差异。

与常规管理相比，CPOE提示为MDRO风险较低的患者提供标准谱抗生素的实时建议，再加上反馈和教育，在不改变住院时间或转入ICU的天数的情况下，显著减少了因尿路感染入院的非危重成人的经验增谱抗生素使用。

附：英文原文

Title: Stewardship Prompts to Improve Antibiotic Selection for Urinary Tract Infection: 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  Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed.

Objective  To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI.

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 and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n=30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017–September 30, 2018) and 15-month intervention period (April 1, 2019–June 30, 2020).

Interventions  CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, 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. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods.

Results  Among 127403 adult patients (71991 baseline and 55412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P<.001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively.

Conclusions and Relevance  Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers.

DOI: 10.1001/jama.2024.6259

Source: https://jamanetwork.com/journals/jama/fullarticle/2817975