EHR Prompts Reduce Overuse of Extended-Spectrum Antibiotics for UTI – Renal and Urology News

An antibiotic stewardship program involving individualized risk assessment and electronic health record prompts led to successful de-escalation of extended-spectrum antibiotics in favor of standard-spectrum antibiotics for patients hospitalized with urinary tract infection (UTI) deemed at less than 10% risk (“low-risk”) for multidrug-resistant organisms.

In the INSPIRE trial (Intelligent Stewardship Prompts to Improve Real-time Empiric antibiotic selection; ClinicalTrials.gov Identifier: NCT03697096), investigators compared a novel antibiotic stewardship including computerized provider order entry (CPOE) prompts with routine antibiotic stewardship among 127,403 adults admitted with UTI to 59 private community hospitals. Prompts were tailored to the specific extended-spectrum antibiotic ordered: cefepime orders triggered evaluation for low risk of Pseudomonas UTI; carbapenem orders triggered evaluated for low risk of extended-spectrum β-lactamase-producing Enterobacterales (ESBLs) or resistant Pseudomonas. Although uncommon, prompts were also generated for vancomycin orders for gram-positive pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA) and Enterococcus for UTI. The automated approach included each hospital’s prevalence of syndrome-specific multidrug-resistant organism (MDRO). Mean age of the cohort was 69.4 years, 30.5% were male, and the median Elixhauser Comorbidity Index was 4.

The intervention group experienced a significant 17.4% reduction in the number of days on empiric extended-spectrum antibiotics compared with the routine stewardship group, Shruti K. Gohil, MD, MPH, of the University of California Irvine, and colleagues reported in JAMA. The empiric extended-spectrum days of therapy (per 1000 empiric days) for the CPOE bundle group decreased from a mean 392.2 to 326.0 days, whereas it increased from a mean 431.1 to 446.0 days for the routine stewardship group. Use of antipseudomonal antibiotics decreased by one-fifth.

Only 3.4% or less of urine cultures were positive for Pseudomonas and 8.0% or less for ESBL. Antibiotic escalation was comparable between the intervention and control groups (10.0% vs 10.2%). Less than 6% of patients deemed low risk in the intervention group were found to have a MDRO. ICU transfers (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not increase in the intervention vs control group.

In an accompanying editorial, Anurag N. Malani, MD, and Preeti N. Malani, MD, MSJ, of University of Michigan Health in Ann Arbor, noted the hurdles in implementing the complex system and commented:

“Even with the CPOE bundle and significant reductions, extended-spectrum antibiotic use remained high in both the pneumonia and UTI studies, while the rate of multidrug-resistant organisms isolated in cultures was low. Future studies should also consider cost savings, effects on local antibiograms, the nuances surrounding diagnostic certainty (for both pneumonia and UTI), and how to develop policy that incentivizes this type of innovation.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.