Effective Antimicrobial StewaRdship StrategIES (ARIES): Cluster Randomized Trial of Computerized Decision Support System and Prospective Review and Feedback

Abstract

Background Prospective review and feedback (PRF) of antibiotic prescriptions and compulsory computerized decision support system (CDSS) are 2 strategies of antimicrobial stewardship. There are limited studies investigating their combined effects. We hypothesized that the use of on-demand (voluntary) CDSS would achieve similar patient outcomes compared with automatically triggered (compulsory) CDSS whenever broad-spectrum antibiotics are ordered. Methods A parallel-group, 1:1 block cluster randomized crossover study was conducted in 32 medical and surgical wards from March to August 2017. CDSS use for piperacillin-tazobactam or carbapenem in the intervention clusters was at the demand of the doctor, while in the control clusters CDSS use was compulsory. PRF was continued for both arms. The primary outcome was 30-day mortality. Results Six hundred forty-one and 616 patients were randomized to voluntary and compulsory CDSS, respectively. There were no differences in 30-day mortality (hazard ratio [HR], 0.87; 95% CI, 0.67–1.12), re-infection and re-admission rates, antibiotic duration, length of stay, or hospitalization cost. The proportion of patients receiving PRF recommendations was not significantly lower in the voluntary CDSS arm (62 [10%] vs 81 [13%]; P = .05). Appropriate indication of antibiotics was high in both arms (351/448 [78%] vs 330/433 [74%]; P = .18). However, in geriatric medicine patients where antibiotic appropriateness was <50%, prescription via compulsory CDSS resulted in a shorter length of stay and lower hospitalization cost. Conclusions Voluntary broad-spectrum antibiotics with PRF via CDSS did not result in differing clinical outcomes, antibiotic duration, or length of stay. However, in the setting of low antibiotic appropriateness, compulsory CDSS may be beneficial.

Effects of coronavirus disease 2019 (COVID-19) pandemic on antimicrobial prevalence and prescribing in a tertiary hospital in Singapore

“…These measures were augmented by computerised clinical decision support systems (introduced in 2011) and educational efforts to engage healthcare providers and the public on appropriate use of antimicrobials. [ 13 – 15 ] Results of the PPS were shared with the hospital management and senior doctors to raise awareness on the high prevalence of antimicrobial prescribing. These activities may have driven the improvement in some antimicrobial prescribing quality indicators and reduced the prevalence of antimicrobials among acute inpatients.…”

Effects of Coronavirus Disease 2019 (COVID-19) Pandemic on Antimicrobial Prevalence and Prescribing in a Tertiary Hospital in Singapore

“…These measures were augmented by computerised clinical decision support systems (introduced in 2011) and educational efforts to engage healthcare providers and the public on appropriate use of antimicrobials. [11][12][13] Results of the PPS were shared with the hospital management and senior doctors to raise awareness on the high prevalence of antimicrobial prescribing. These activities may have driven the improvement in some antimicrobial prescribing quality indicators and reduced the prevalence of antimicrobials among acute inpatients.…”

Sustaining Antimicrobial Stewardship in a High–Antibiotic Resistance Setting

“…Details of the CDSS have been described elsewhere. 10 , 11 Briefly, the CDSS is accessed via the electronic medication record; prescribers specify the infection they are treating and enter selected patient parameters in the system and receive a set of recommendations based on empirical hospital guidelines. Prescribers have the autonomy to override the recommendations.…”

“…In March 2017, a 6-month cluster-randomized clinical trial with a crossover design was conducted to compare the effects between compulsory and voluntary use of CDSS for piperacillin-tazobactam and carbapenem prescriptions in 32 acute wards in the main building of the hospital. 10 In the first month, compulsory CDSS was instituted for half of the 32 wards. In the third month, wards assigned to compulsory CDSS use were switched to voluntary CDSS use (intervention 3).…”