Компьютерные подсказки снизили неоправданное применение антибиотиков у онкобольных

Computer prompts can significantly reduce needless broad-spectrum antibiotic use in cancer Key takeaways: - Computer prompts indicating patients have low risk for antimicrobial-resistant infections significantly reduced broad-spectrum antibiotic use. - Lower use did not result in more ICU admissions or mortality. Patients with cancer frequently receive broad-spectrum antibiotics, even if they are at low risk for antimicrobial-resistant infections. A computer prompt that notifies clinicians that a patient would not benefit from these extended-spectrum drugs could significantly curtail their use. A subgroup analysis of the four randomized Intelligent Stewardship Prompts to Improve Real-Time Empiric Antibiotic Selection (INSPIRE) trials showed that most patients with cancer have low risk for multidrug-resistant organisms, and prompts alerting prescribers to those patients decreased extended-spectrum antibiotic use between 17% and 27%. “The more judicious we are with our antibiotic use, the more likely that patients will do better long term,” Shruti K. Gohil, MD, MPH, an infectious disease specialist at University of California Irvine Health, told Healio. ‘The No. 1 issue’ Estimates suggest between 30% and 50% of patients hospitalized with pneumonia, urinary tract infection or community-acquired skin and soft tissue infection (SSTI) — and most diagnosed with abdominal infection — receive extended-spectrum antibiotics, according to previous studies from Gohil and colleagues. Broad-spectrum antibiotics effectively treat those infections, but these antibiotics cause adverse effects, including liver and kidney toxicity, as well as impact on the microbiome. “We’re only beginning to scratch the surface on the unintended consequences of antibiotic overuse,” Gohil said. “A single antibiotic, that’s all you need to hit your microbiome and obliterate the good bacteria that keep us healthy. Antibiotics are indiscriminate in that way. They will kill all bacteria, both the ones that keep us healthy and those that make us sick. That’s why it’s important that we use these antibiotics carefully. It’s the best way to preserve our healthy microbes.” And then there are multidrug-resistant organisms. “That’s the No. 1 issue here,” Gohil said. “When we use broad-spectrum antibiotics, we make more antibiotic-resistant organisms.” Prior research published in The Lancet found that antimicrobial resistance directly led to 1.27 million deaths around the world in 2019, and contributed to nearly 5 million. Prevention efforts reduced deaths from antimicrobial resistance by 18% in the U.S. in 2019, according to CDC. Gohil and colleagues previously conducted the INSPIRE trials, a set of four trials to investigate whether computerized provider order entry prompts recommending standard-spectrum antibiotics for patients at low risk for multidrug-resistant organisms effectively reduced extended-spectrum antibiotic use. Researchers randomly assigned hospitals to routine antibiotic prescription practices or the use of the prompt to guide antibiotic selection. The trials, which included almost 550,000 patients from across the nation, showed use of broad-spectrum antibiotics fell between 17.4% and 35% for treatment of pneumonia, UTI, abdominal infection and SSTI, and did not result in increased ICU transfers or extended hospitalizations. “With this robust trial data, we wondered where else we might be able to improve antibiotic use,” Gohil said. “Patients with cancer are a critically important group to study. They are among the sickest patients we treat and there is little data available about successful antibiotic stewardship strategies in this group. Although they constitute a relatively small subset of patients, they disproportionately account for the greatest use of extended-spectrum antibiotic in the hospital.” Healio previously reported that outpatients with cancer had up to three times higher prevalence of certain antimicrobial pathogens than individuals without cancer. “We overuse antibiotics in patients with cancer for a number of reasons, but often it’s because we don’t think we have time to wait,” Gohil said. “Culture results for bacteria may not come until 2, 3 days later. Meanwhile, the patient is sick, their immune system is compromised. It’s easy for physicians to think it’s better to err on the side of caution and just go ahead and give patients broad-spectrum antibiotics up front even if they don’t need them.” Between all four INSPIRE studies, 36,861 patients (mean age, 69 years; standard deviation, 13.6; 52% women) had cancer. The cohort included 18,272 patients treated at baseline, before the intervention, and 18,589 treated after. The abdominal infection trial had the most patients with cancer (n = 12,677), followed by UTI (n = 10,074), pneumonia (n = 9,923) and SSTI (n = 4,187) trials. Extended-spectrum antibiotic days of therapy served as the primary endpoint. Days to ICU transfer, length of hospitalization, hospital readmissions and in-hospital mortality served as secondary endpoints. ‘Better than we expected’ Overall, 84.7% of patients had site-specific cultures sent within 3 days of admission. In that group, 9.1% had a multidrug-resistant organism. Across trials, between 54.7% and 73.3% of patients received extended-spectrum antibiotics during the baseline period. However, the prompt algorithm classified most patients as low risk. In the pneumonia and abdominal infection trials, 98.3% were predicted to be low risk for MRSA. Among these, less than 1.4% actually had it. Similarly, 95.4% were predicted to be low risk for Pseudomonas and fewer than 1.9% had it. In the UTI trial, 93.7% had low risk for Pseudomonas and less than 3.5% grew it. In the SSTI study, 55.2% had low risk for MRSA and 2.1% had it, and 93.4% had low risk for Pseudomonas and less than 4.8% had positive cultures. During the intervention portion of the investigations, use of any broad-spectrum antibiotic decreased from 72.3% to 60.3% in the pneumonia trial, 54.7% to 49.4% in the UTI study, 64.7% to 51.2% in the SSTI trial, and 61.5% to 47.5% in the abdominal infection study. Extended-spectrum days of therapy significantly decreased in intervention hospitals for all four trials (pneumonia: RR = 0.73; 95% CI, 0.67-0.8; UTI: RR = 0.76; 95% CI, 0.68-0.84; abdominal infection: RR = 0.76; 95% CI, 0.69-0.84; SSTI: RR = 0.83; 95% CI, 0.74-0.92). “The results were better than we expected,” Gohil said. “During the four trials, we had expected only a 12% reduction for all patients, and we far exceeded that. In this subset of patients with cancer, I thought that clinicians would not be ready to use more narrow-spectrum antibiotics. A decrease of 17% to 27% exceeds the reductions we expected. That kind of reduction strongly suggests that we should be able to begin the conversation with clinicians on using narrower-spectrum antibiotics in patients with cancer, when possible.” Gohil and colleagues did not observe significant differences in days to ICU transfer, length of hospitalizations, readmissions or in-hospital mortality. Researchers acknowledged study limitations, including conducting trials at community hospitals, which may have lower rates of multidrug-resistant organisms. Gohil highlighted future research evaluating “stewardship strategies” to reduce broad-spectrum antibiotic use, specifically in patients with cancer. Analyzing clinicians themselves is critical, too. “What factors are at play in the minds of our physicians when they make these decisions?” Gohil asked. “What physician attitudes and beliefs are associated with an increased likelihood of choosing broad-spectrum antibiotics, or not taking advice, even when we know this is a low-risk patient. What makes them reach for it? These are all things that, if understood better, would allow us to design interventions appropriately.” Gohil described herself as “optimistic” about decreasing unnecessary extended-spectrum antibiotic use in the future. “Doctors care about patients. We’re so worried that we’ll do the wrong thing, and that’s the crux of antibiotic overuse,” she said. “National efforts in the last decade have been successful. We are using fewer antibiotics. The attention that the public and health care workers have gotten on the untoward consequences of antibiotics has also made an impact, but there’s much more work to be done.” For more information: Shruti K. Gohil, MD, MPH, associate professor in infectious disease and associate medical director for health epidemiology and infection prevention at UCI Health, can be reached at [email protected].