Infection, Bacterial Clinical Trial
Official title:
Effective Antimicrobial StewaRdship StrategIES (ARIES): Cluster-randomized Trial of a Computerized Decision Support System Versus Antibiotic Prospective Review and Feedback in Antimicrobial Stewardship
Background Prospective review and feedback (PRF) of antibiotic prescriptions is a
labor-intensive core strategy of antimicrobial stewardship (AMS). The investigators
hypothesized that a computerized decision support system (CDSS) providing recommendations for
antibiotics, investigations and referrals would reduce the requirement for PRF without
causing harm.
Methods A parallel-group, 1:1 block-cluster randomized, cross-over study was conducted in 32
medical and surgical wards from March to August 2017. The intervention arm comprised
voluntary use of CDSS at first prescription of piperacillin-tazobactam or a carbapenem, while
the control arm was compulsory CDSS. PRF was continued for both arms. Primary outcome was
30-day mortality.
Increasing antimicrobial resistance due to inappropriate antimicrobial use is a global
concern. Multi-disciplinary antimicrobial stewardship teams have become an integral part of
the response to this issue. Through prospective review of antibiotic prescriptions and
feedback (PRF) to healthcare providers, antimicrobial stewardship has been shown to improve
clinical response, reduce adverse effects and mortality. However, this strategy is
labor-intensive to implement and skilled healthcare workers are an expensive and scarce
resource. Antibiotic computerized decision support systems (CDSS) have been used to
facilitate these processes and may circumvent the limitations of lack of manpower. In
previous studies, CDSS led to increased susceptibility of Pseudomonas aeruginosa to imipenem
and Enterobacteriaceae to gentamicin and ciprofloxacin, and an overall reduction in
broad-spectrum antibiotic use. CDSS could improve clinical outcomes. Currently, there are
limited studies comparing the combined effects of these two strategies.
At Tan Tock Seng Hospital, a university teaching hospital in Singapore, antimicrobial
stewardship has focused on PRF by a multi-disciplinary team since 2009. This team reviews
piperacillin-tazobactam and carbapenem orders against hospital antibiotic guidelines from day
two of antibiotic prescription. In March 2010, we implemented CDSS triggered at the point of
antibiotic ordering and compulsory for the prescriber to review. Prescribers are free to
accept or reject the CDSS recommendations. While PRF and CDSS are performed following the
same institutional guidelines, there may be differences in physicians' acceptance of
recommendations and the accessibility to recommendations between these two interventions. In
previous studies, PRF recommendations had an acceptance of 60-70% while compulsory CDSS was
40%. The investigators hypothesized that compulsory CDSS and PRF would improve clinical
outcomes compared with voluntary CDSS and PRF, and compulsory CDSS would improve appropriate
antibiotic practice and reduce the requirement for subsequent PRF.
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