Infection, Bacterial
Conditions
Keywords
computerized decision support, prospective review and feedback, antimicrobial stewardship
Brief summary
Background Prospective review and feedback (PRF) of antibiotic prescriptions is a labor-intensive core strategy of antimicrobial stewardship (AMS). The investigators hypothesized that a computerized decision support system (CDSS) providing recommendations for antibiotics, investigations and referrals would reduce the requirement for PRF without causing harm. Methods A parallel-group, 1:1 block-cluster randomized, cross-over study was conducted in 32 medical and surgical wards from March to August 2017. The intervention arm comprised voluntary use of CDSS at first prescription of piperacillin-tazobactam or a carbapenem, while the control arm was compulsory CDSS. PRF was continued for both arms. Primary outcome was 30-day mortality.
Detailed description
Increasing antimicrobial resistance due to inappropriate antimicrobial use is a global concern. Multi-disciplinary antimicrobial stewardship teams have become an integral part of the response to this issue. Through prospective review of antibiotic prescriptions and feedback (PRF) to healthcare providers, antimicrobial stewardship has been shown to improve clinical response, reduce adverse effects and mortality. However, this strategy is labor-intensive to implement and skilled healthcare workers are an expensive and scarce resource. Antibiotic computerized decision support systems (CDSS) have been used to facilitate these processes and may circumvent the limitations of lack of manpower. In previous studies, CDSS led to increased susceptibility of Pseudomonas aeruginosa to imipenem and Enterobacteriaceae to gentamicin and ciprofloxacin, and an overall reduction in broad-spectrum antibiotic use. CDSS could improve clinical outcomes. Currently, there are limited studies comparing the combined effects of these two strategies. At Tan Tock Seng Hospital, a university teaching hospital in Singapore, antimicrobial stewardship has focused on PRF by a multi-disciplinary team since 2009. This team reviews piperacillin-tazobactam and carbapenem orders against hospital antibiotic guidelines from day two of antibiotic prescription. In March 2010, we implemented CDSS triggered at the point of antibiotic ordering and compulsory for the prescriber to review. Prescribers are free to accept or reject the CDSS recommendations. While PRF and CDSS are performed following the same institutional guidelines, there may be differences in physicians' acceptance of recommendations and the accessibility to recommendations between these two interventions. In previous studies, PRF recommendations had an acceptance of 60-70% while compulsory CDSS was 40%. The investigators hypothesized that compulsory CDSS and PRF would improve clinical outcomes compared with voluntary CDSS and PRF, and compulsory CDSS would improve appropriate antibiotic practice and reduce the requirement for subsequent PRF.
Interventions
OTHERCompulsory CDSS
Compulsory CDSS use with prospective review feedback in patients prescribed with piperacillin tazobactam or carbapenems
Sponsors
Tan Tock Seng Hospital
Study design
Allocation
RANDOMIZED
Intervention model
CROSSOVER
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Masking description
A parallel-group, 1:1 block-cluster randomized, cross-over study
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patients who are started on the 1st episode of piperacillin-tazobactam or carbapenem during the study period. * Medical and surgical wards
Exclusion criteria
* Intensive care unit (ICU), high dependency and step-down care wards
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| 30-day mortality | Follow-up up to 30 days from the start date of the first episode of piperacillin-tazobactam or carbapenem use | Death at 30 days |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| 30-day re-infection | Re-start of piperacilin-tazobactam or carbapenem 30 days after the cessation of first episode of piperacillin-tazobactam or carbapenem use | Re-start of piperacilin-tazobactam or carbapenem 30 days after the cessation of first episode of piperacillin-tazobactam or carbapenem use |
| 30-day readmission | Readmissions 30 days after the cessation of first episode of piperacillin-tazobactam or carbapenem use | Readmission after the cessation of first episode of piperacillin-tazobactam or carbapenem use |
| length of stay | It is assessed from the date of admission till the date of discharge or up to 6 months | Duration of admission |
| 6-months incidence of multi-drug resistant organisms | up to 6 months (Clinical cultures only) | MRSA, VRE, ESBL, MDR-A. baumannii, XDR- A baumannii, MDR- P. aeruginosa, XDR-P aeruginosa, C difficile , Carbapenem resistant enterobacterales |
| 7-day clinical response | Follow-up up to 7 days from the date of the first episode of piperacillin-tazobactam or carbapenem use | resolution of systemic inflammatory response syndrome |
| Appropriateness of antibiotics | It is assessed only once at the point of the first episode of piperacillin-tazobactam or carbapenem use in the index admission. It is only assessed once till discharge or up to 6 months | first episode of piperacillin-tazobactam or carbapenem use according to hospital guidelines. Appropriateness will be described as yes or no. |
| Index antibiotic days of therapy, | From the start date of the first episode of piperacillin-tazobactam or carbapenem use to the end date of this antibiotic which is followed up till discharge or up to 6 months. | Duration of the first episode of piperacillin-tazobactam or carbapenem use |
| Gross hospitalization costs | Gross hospitalization costs incured from date of admission till date of discharge or up to 6 months | Gross hospitalization costs |
| Diarrhea this admission | From the start date from the first episode of piperacillin-tazobactam or carbapenem use until the discharge date or up to 6 months whichever occurred earlier | Incidence of diarrhea from start of first episode of piperacillin-tazobactam or carbapenem use till discharge |
Countries
Singapore
Outcome results
None listed