Antibiotic Stewardship - Auswirkungen eines Computerized Decision Support Systems auf die Leitlinienadhärenz in der Behandlung der ambulant erworbenen Pneumonie
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Philipps-Universität Marburg
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Abstract
Background
Given both the increasing occurrence of antimicrobial resistance to available antibiotic drugs and low rate of new antibiotic development, there is a clear need for antibiotic stewardship (ABS) in the clinical routine. Responsible handling of antibiotics means to avoid unnecessary use of antibiotics and to optimize essential treatments. ABS interventions cover various clinical aspects, ranging from diagnosis to discharge management. It is important to implement a bundle of ABS measures, all of which should be effective, practicable, and economically viable. A computerized decision support system (CDSS) represents an implementation method that also takes advantage of the increasing digitalisation of health care systems. For example, a given CDSS can combine various aspects of suitable prescribing methods, including the selection of antibiotics, dose optimisation, de-escalation, and duration of therapy.
This study evaluated the implementation of a CDSS designed to facilitate initial antibiotic prescribing in cases of community acquired pneumonia, with a focus on guideline adherence. The integration into the computerized physician order entry (CPOE) of the electronic patient record was expected to improve access to guidelines and increase acceptance among practitioners.
Methods
We conducted a prospective monocentric study in the pneumology department at Klinikum Fulda gAG. The control phase (P0) and the intervention phase (P1) were performed consecutively from April 2017 up to December 2020. For the inclusion criteria, we considered patients who were diagnosed with either CAP or community acquired aspiration pneumonia.
During P0, the paper-based patient chart was the standard and internal clinic information on guideline-based therapy was exclusively available on the local intranet, which was accessible to all clinic employees. The CDSS was based on the in-house recommendation for initial antibiotic therapy. It was developed and implemented by the clinical pharmacist. A multilevel decision tree led the prescriber to the proposed therapy options. Additional notes provided background information on the criteria of the CRB65 score and patient-specific risk factors. Adjusted doses to renal impairment were stored as options. Both the provisional duration of therapy and de-escalation measures were defined by a stop-order function.
We considered the primary endpoint as the percentage of guideline-compliant initial calculated therapy for CAP. As for secondary endpoints, we noted the duration of therapy, antibiotic consumption, length of stay (LOS), de-escalation on initial combination therapy of macrolides, rate of changing to pathogen-directed therapy and switch from intravenous to oral therapy as well as the number of fulfilled criteria of stability and use of the CDSS.
Results
During the study period a number of 97 patients in P0 and 53 patients in P1 were analyzed. From control to intervention phases, the proportion of guideline adherence increased (25% to 38%). There was no statistically significant difference in guideline adherence in relation to the entire study population and subgroup of the intervention phase with CDSS orders (p=0.095, 95%-confidence interval of difference = -2,1 - 28,4). During intervention phase, the CDSS was used by a frequency of 30% (ntotal=53).
The duration of antibiotic therapy during hospitalization decreased significantly from an average duration of 9,2 days of therapy (DOT) during P0 to 8,1 DOT during P1 and 7,3 DOT in the subgroup P1CDSS (p<0.05). The average LOS was 9,5 days during P0 compared to 8,6 days during P1 and 7,7 days in the subgroup P1CDSS. The positive trend of decrease was without statistical significance. Post-intervention, antibiotic consumption fell significantly from 162 defined daily doses per 100 inpatient days (DDD/100 PT) to 132 DDD/100 PT and 113 DDD/100 PT in the subgroup P1CDSS (p<0.05). In case of initial combination therapy with macrolides, the duration of macrolide therapy was reduced significantly from 7,2 DOT during P0 to 4,8 DOT during P1 (p<0.05).
The rate of changing to pathogen-directed therapy and switch from intravenous to oral therapy as well as the number of fulfilled criteria of stability did not change after implementation of the CDSS.
Conclusion
Although CDSS introduction did not significantly improve guideline adherence of initial CAP therapy, we did reveal a trend towards therapy optimisation. The significant reductions in duration of therapy and antibiotic consumption and duration of macrolides therapy can be considered as areas of interventional success. Moreover, our findings highlight the potential for both continued improvement and additional ABS interventions. Future studies should aim to improve CDSS design elements while seeking ways to increase acceptance rates. This constitutes a unique challenge due to the existence of different technical, structural, and personal requirements between clinics. We also conclude that a CDSS cannot replace on-site interpersonal cooperation, especially in complex cases not covered by guidelines.
In summary, a CDSS can be regarded as a complement but not a substitute for human resources in the field of ABS interventions to improve guideline adherence.
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Dates
Created: 2022Issued: 2023-03-09Updated: 2023-03-09
Faculty
Fachbereich Pharmazie
Publisher
Philipps-Universität Marburg
Language
ger
Data types
DoctoralThesis
DDC-Numbers
615
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Kiel, Simone: Antibiotic Stewardship - Auswirkungen eines Computerized Decision Support Systems auf die Leitlinienadhärenz in der Behandlung der ambulant erworbenen Pneumonie. : Philipps-Universität Marburg 2023-03-09. DOI: https://doi.org/10.17192/z2023.0081.
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This item has been published with the following license: In Copyright