Stewardship Prompts to Improve Antibiotic Selection for UTI
Clinical question: Can computerized provider order entry (CPOE) prompts reduce the use of empiric extended-spectrum antibiotics in patients with urinary tract infections (UTI)?
Background: UTIs are a common cause of hospitalization and can be associated with gram-negative multidrug-resistant organisms (MDROs). However, although many patients are at low risk for MDRO UTIs, clinicians often overuse extended-spectrum antibiotics for empiric treatment. This trial evaluated whether CPOE prompts that provide real-time, patient-specific MDRO risk estimates can reduce the use of empiric extended-spectrum antibiotics for the treatment of UTIs.
Study design: Cluster-randomized trial
Setting: 59 U.S. community hospitals
Synopsis: This was a cluster-randomized trial in 59 U.S. community hospitals (n=55,412 adults), where 29 hospitals were randomized to the intervention arm with a CPOE stewardship bundle, and 30 hospitals were randomized to the arm with routine stewardship on antibiotic selection during the first three days of the hospital stay for noncritically ill adults with UTIs. The intervention arm had CPOE prompts that recommended empiric standard-spectrum antibiotics in patients with a <10% risk of MDRO UTI, in addition to feedback and education. The primary outcome was empiric extended-spectrum antibiotic days of therapy within the first three days of hospitalization. Other outcomes included empiric vancomycin and antipseudomonal days of therapy, days to intensive care unit (ICU) transfer, and hospital length of stay. Compared with groups with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2% to 23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83; 95% CI, 0.77 to 0.89; P <.001). The number of mean days to ICU transfer and hospital length of stay did not differ significantly between the routine and intervention groups.
Bottom line: CPOE prompts that provide real-time recommendations for patients with low MDRO risk reduced empiric extended-spectrum antibiotic use in noncritically ill adults admitted with UTI without affecting hospital length of stay or days to ICU transfers.
Citation: Gohil SK, et al. Stewardship prompts to improve antibiotic selection for urinary tract infection: the INSPIRE randomized clinical trial. JAMA. 2024;331(23):2018–2028. doi:10.1001/jama.2024.6259.
Dr. Zhang is a hospitalist and an assistant clinical professor of medicine in the division of hospital medicine, department of medicine at UC San Diego Health at the University of California in San Diego.