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Appl Clin Inform 2024; 15(04): 679-688
DOI: 10.1055/a-2341-8823
Research Article

Effects of a Pharmacist-Designed Clinical Decision Support System on Antimicrobial Stewardship

Miguel Ángel Amor-García
1   Pharmacy Service, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain
,
Esther Chamorro-de-Vega
2   Pharmacy Service, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
,
Carmen Guadalupe Rodríguez-González
2   Pharmacy Service, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
,
Irene Iglesias-Peinado
3   Department of Pharmacology, Pharmacognosy and Botany, Faculty of Pharmacy, Complutense University of Madrid, Madrid, Spain
,
Raquel Moreno-Díaz
1   Pharmacy Service, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain
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Abstract

Background Clinical decision support systems (CDSSs) are computer applications, which can be applied to give guidance to practitioners in antimicrobial stewardship (AS) activities; however, further information is needed for their optimal use.

Objectives Our objective was to analyze the implementation of a CDSS program in a second-level hospital, describing alerts, recommendations, and the effects on consumption and clinical outcomes.

Methods In October 2020, a pharmacist-driven CDSS designed for AS was implemented in a second-level hospital. The program provides a list of alerts related to antimicrobial treatment and microbiology, which were automatized for revision by the AS professionals. To analyze the implementation of the CDSS, a pre–post-intervention, retrospective study was designed. AS-triggered alerts and recommendations (total number and rate of acceptance) were compiled. The effect of the CDSS was measured using antimicrobial consumption, duration of antimicrobial treatments, in-hospital mortality, and length of stay (LOS) for patients admitted for infectious causes.

Results The AS team revised a total of 7,543 alerts and 772 patients had at least one recommendation, with an acceptance rate of 79.3%. Antimicrobial consumption decreased from 691.1 to 656.8 defined daily doses (DDD)/1,000 beds-month (p = 0.04) and the duration of antimicrobial treatment from 3.6 to 3.3 days (p < 0.01). In-hospital mortality decreased from 6.6 to 6.2% (p = 0.46) and mean LOS from 7.2 to 6.2 days (p < 0.01).

Conclusion The implementation of a CDSS resulted in a significant reduction of antimicrobial DDD, duration of antimicrobial treatments, and hospital LOS. There was no significant difference in mortality.

Keywords

clinical decision support system - antimicrobial stewardship - alert - optimization

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed by the Hospital Universitario Puerta de Hierro Institutional Review Board.




Publication History

Received: 23 February 2024

Accepted: 06 June 2024

Accepted Manuscript online:
10 June 2024

Article published online:
14 August 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Albarillo FS, Labuszewski L, Lopez J, Santarossa M, Bhatia NK. Use of a clinical decision support system (CDSS) to improve antimicrobial stewardship efforts at a single academic medical center. Germs 2019; 9 (02) 106-109
    CrossrefPubMedGoogle Scholar
  • 2 Heard KL, Hughes S, Mughal N, Azadian BS, Moore LSP. Evaluating the impact of the ICNET® clinical decision support system for antimicrobial stewardship. Antimicrob Resist Infect Control 2019; 8 (01) 51
    CrossrefPubMedGoogle Scholar
  • 3 Cisneros JM, Neth O, Gil-Navarro MV. et al; PRIOAM team. Global impact of an educational antimicrobial stewardship programme on prescribing practice in a tertiary hospital centre. Clin Microbiol Infect 2014; 20 (01) 82-88
    CrossrefPubMedGoogle Scholar
  • 4 Rice LB. Antimicrobial stewardship and antimicrobial resistance. Med Clin North Am 2018; 102 (05) 805-818
    CrossrefPubMedGoogle Scholar
  • 5 Evans CD, Lewis JWS. Collaborative antimicrobial stewardship in the health department. Infect Dis Clin North Am 2020; 34 (01) 145-160
    CrossrefPubMedGoogle Scholar
  • 6 Septimus EJ. Antimicrobial resistance: an antimicrobial/diagnostic stewardship and infection prevention approach. Med Clin North Am 2018; 102 (05) 819-829
    CrossrefPubMedGoogle Scholar
  • 7 Kuper KM, Nagel JL, Kile JW, May LS, Lee FM. The role of electronic health record and “add-on” clinical decision support systems to enhance antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2019; 40 (05) 501-511
    CrossrefPubMedGoogle Scholar
  • 8 Rawson TM, Moore LSP, Hernandez B. et al. A systematic review of clinical decision support systems for antimicrobial management: are we failing to investigate these interventions appropriately?. Clin Microbiol Infect 2017; 23 (08) 524-532
    CrossrefPubMedGoogle Scholar
  • 9 Barlam TF, Cosgrove SE, Abbo LM. et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62 (10) e51-e77
    CrossrefPubMedGoogle Scholar
  • 10 Ozkaynak M, Metcalf N, Cohen DM, May LS, Dayan PS, Mistry RD. Considerations for designing EHR-embedded clinical decision support systems for antimicrobial stewardship in pediatric emergency departments. Appl Clin Inform 2020; 11 (04) 589-597
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Rittmann B, Stevens MP. Clinical decision support systems and their role in antibiotic stewardship: a systematic review. Curr Infect Dis Rep 2019; 21 (08) 29
    CrossrefPubMedGoogle Scholar
  • 12 Ozkaynak M, Wu DTY, Hannah K, Dayan PS, Mistry RD. Examining workflow in a pediatric emergency department to develop a clinical decision support for an antimicrobial stewardship program. Appl Clin Inform 2018; 9 (02) 248-260
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Bond SE, Chubaty AJ, Adhikari S. et al. Outcomes of multisite antimicrobial stewardship programme implementation with a shared clinical decision support system. J Antimicrob Chemother 2017; 72 (07) 2110-2118
    CrossrefPubMedGoogle Scholar
  • 14 Forrest GN, Van Schooneveld TC, Kullar R, Schulz LT, Duong P, Postelnick M. Use of electronic health records and clinical decision support systems for antimicrobial stewardship. Clin Infect Dis 2014; 59 (Suppl. 03) S122-S133
    CrossrefPubMedGoogle Scholar
  • 15 Nichols KR, Petschke AL, Webber EC, Knoderer CA. Comparison of antibiotic dosing before and after implementation of an electronic order set. Appl Clin Inform 2019; 10 (02) 229-236
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Garwan YM, Alsalloum MA, Thabit AK, Jose J, Eljaaly K. Effectiveness of antimicrobial stewardship interventions on early switch from intravenous-to-oral antimicrobials in hospitalized adults: a systematic review. Am J Infect Control 2023; 51 (01) 89-98
    CrossrefPubMedGoogle Scholar
  • 17 Ghamrawi RJ, Kantorovich A, Bauer SR. et al. Evaluation of antimicrobial stewardship-related alerts using a clinical decision support system. Hosp Pharm 2017; 52 (10) 679-684
    CrossrefPubMedGoogle Scholar
  • 18 Kullar R, Goff DA. Transformation of antimicrobial stewardship programs through technology and informatics. Infect Dis Clin North Am 2014; 28 (02) 291-300
    CrossrefPubMedGoogle Scholar
  • 19 Magiorakos AP, Srinivasan A, Carey RB. et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012; 18 (03) 268-281
    CrossrefPubMedGoogle Scholar
  • 20 Chow ALP, Lye DC, Arah OA. Patient and physician predictors of patient receipt of therapies recommended by a computerized decision support system when initially prescribed broad-spectrum antibiotics: a cohort study. J Am Med Inform Assoc 2016; 23 (e1): e58-e70
    CrossrefPubMedGoogle Scholar
  • 21 Jones BE, Collingridge DS, Vines CG. et al. CDS in a learning health care system: identifying physicians' reasons for rejection of best-practice recommendations in pneumonia through computerized clinical decision support. Appl Clin Inform 2019; 10 (01) 1-9
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Berrevoets MAH, Pot JHLW, Houterman AE. et al. An electronic trigger tool to optimise intravenous to oral antibiotic switch: a controlled, interrupted time series study. Antimicrob Resist Infect Control 2017; 6: 81
    CrossrefPubMedGoogle Scholar
  • 23 Akhloufi H, Hulscher M, van der Hoeven CP. et al. A clinical decision support system algorithm for intravenous to oral antibiotic switch therapy: validity, clinical relevance and usefulness in a three-step evaluation study. J Antimicrob Chemother 2018; 73 (08) 2201-2206
    CrossrefPubMedGoogle Scholar
  • 24 Schulz L, Osterby K, Fox B. The use of best practice alerts with the development of an antimicrobial stewardship navigator to promote antibiotic de-escalation in the electronic medical record. Infect Control Hosp Epidemiol 2013; 34 (12) 1259-1265
    CrossrefPubMedGoogle Scholar
  • 25 Antworth A, Collins CD, Kunapuli A. et al. Impact of an antimicrobial stewardship program comprehensive care bundle on management of candidemia. Pharmacotherapy 2013; 33 (02) 137-143
    CrossrefPubMedGoogle Scholar
  • 26 Pogue JM, Mynatt RP, Marchaim D. et al. Automated alerts coupled with antimicrobial stewardship intervention lead to decreases in length of stay in patients with gram-negative bacteremia. Infect Control Hosp Epidemiol 2014; 35 (02) 132-138
    CrossrefPubMedGoogle Scholar
  • 27 Keller SC, Feldman L, Smith J, Pahwa A, Cosgrove SE, Chida N. The use of clinical decision support in reducing diagnosis of and treatment of asymptomatic bacteriuria. J Hosp Med 2018; 13 (06) 392-395
    CrossrefPubMedGoogle Scholar
  • 28 Pereboom M, Mulder IJ, Verweij SL, van der Hoeven RTM, Becker ML. A clinical decision support system to improve adequate dosing of gentamicin and vancomycin. Int J Med Inform 2019; 124: 1-5
    CrossrefPubMedGoogle Scholar
  • 29 Ridgway JP, Robicsek A, Shah N. et al. A randomized controlled trial of an electronic clinical decision support tool for inpatient antimicrobial stewardship. Clin Infect Dis 2021; 72 (09) e265-e271
    CrossrefPubMedGoogle Scholar
  • 30 Curtis CE, Al Bahar F, Marriott JF. The effectiveness of computerised decision support on antibiotic use in hospitals: a systematic review. PLoS One 2017; 12 (08) e0183062
    CrossrefPubMedGoogle Scholar
  • 31 Jenkins JA, Pontefract SK, Cresswell K, Williams R, Sheikh A, Coleman JJ. Antimicrobial stewardship using electronic prescribing systems in hospital settings: a scoping review of interventions and outcome measures. JAC Antimicrob Resist 2022; 4 (03) dlac063
    CrossrefPubMedGoogle Scholar
  • 32 Khadem TM, Ergen HJ, Salata HJ. et al. Impact of clinical decision support system implementation at a community hospital with an existing tele-antimicrobial stewardship program. Open Forum Infect Dis 2022; 9 (07) ofac235
    CrossrefPubMedGoogle Scholar
  • 33 Yuan X, Chen K, Yuan J. et al. Evaluation of the effectiveness and safety of a multi-faceted computerized antimicrobial stewardship intervention in surgical settings: a single-centre cluster-randomized controlled trial. Int J Antimicrob Agents 2023; 61 (05) 106787
    CrossrefPubMedGoogle Scholar