Harnessing the Electronic Health Record to Improve Empiric Antibiotic Prescribing

Abstract

Approximately half of hospitalized adults in the US receive antibiotics, with pneumonia and urinary tract infection (UTI) being the 2 most frequent indications. 1 Estimates suggest about 30% of all antibiotics prescribed in US hospitals are either unnecessary or suboptimal, 2 and extended-spectrum antibiotic use is common. 3 Unnecessary antibiotic use contributes to numerous harms, including drug-related adverse effects, increased risk of drug resistance, and higher costs.Antimicrobial stewardship aims to optimize antimicrobial use, minimize associated harms, and improve clinical outcomes, and over the past 2 decades, the field of stewardship has emerged and evolved. In 2014, the US Centers for Disease Control and Prevention introduced the Core Elements of Hospital Antibiotic Stewardship Programs to help hospitals with implementation. 2 Among these Core Elements are hospital leadership commitment, accountability, pharmacy expertise, action, tracking, reporting, and education.In 2015, the US National Action Plan for Combating Antibiotic-Resistant Bacteria set an implementation goal of the Centers for Disease Control and Prevention's Core Elements in all hospitals that receive federal funding. By 2022, an impressive 97% of approximately 5100 US acute care hospitals reported meeting all 7 Core Elements of effective antimicrobial stewardship programs compared with only 41% in 2014. 4 With much of the low-hanging fruit of stewardship interventions already picked (eg, guideline development and formulary restrictions), the demand for novel, scalable, sustainable strategies remains, especially addressing the empiric use of extended-spectrum antibiotic therapy.In this issue of JAMA, Gohil and colleagues report the results of 2 related trials examining the use of computerized provider order entry (CPOE) prompts to reduce empiric use of extended-spectrum antibiotics among adults admitted for either pneumonia or UTI. 5,6 The INSPIRE Pneumonia and INSPIRE UTI trials were conducted at a network of 59 geographically diverse community hospitals across the US. Using a cluster-randomized design, the investigators compared routine stewardship (ie, education, feedback) with the CPOE bundle composed of routine stewardship plus CPOE entry prompts that recommended standard-spectrum instead of extended-spectrum antibiotics during the first 3 hospital days (empiric period) for patients with a low absolute risk (<10%) of infections associated with multidrug-resistant organisms.