ImportancePneumonia is the most common infection requiring hospitalization and is a major reason for overuse of extended-spectrum antibiotics. Despite low risk of multidrug-resistant organism (MDRO) infection, clinical uncertainty often drives initial antibiotic selection. Strategies to limit empiric antibiotic overuse for patients with pneumonia are needed.ObjectiveTo evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for non–critically ill patients admitted with pneumonia.Design, Setting, and ParticipantsCluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk-based CPOE prompts; n = 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in non–critically ill adults (≥18 years) hospitalized with pneumonia. There was an 18-month baseline period from April 1, 2017, to September 30, 2018, and a 15-month intervention period from April 1, 2019, to June 30, 2020.InterventionCPOE prompts recommending standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics during the empiric period who have low estimated absolute risk (<10%) of MDRO pneumonia, coupled with feedback and education.Main Outcomes and MeasuresThe primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy and safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies.ResultsAmong 59 hospitals with 96 451 (51 671 in the baseline period and 44 780 in the intervention period) adult patients admitted with pneumonia, the mean (SD) age of patients was 68.1 (17.0) years, 48.1% were men, and the median (IQR) Elixhauser comorbidity count was 4 (2-6). Compared with routine stewardship, the group using CPOE prompts had a 28.4% reduction in empiric extended-spectrum days of therapy (rate ratio, 0.72 [95% CI, 0.66-0.78]; P < .001). Safety outcomes of mean days to ICU transfer (6.5 vs 7.1 days) and hospital length of stay (6.8 vs 7.1 days) did not differ significantly between the routine and CPOE intervention groups.Conclusions and RelevanceEmpiric extended-spectrum antibiotic use was significantly lower among adults admitted with pneumonia to non-ICU settings in hospitals using education, feedback, and CPOE prompts recommending standard-spectrum antibiotics for patients at low risk of MDRO infection, compared with routine stewardship practices. Hospital length of stay and days to ICU transfer were unchanged.Trial RegistrationClinicalTrials.gov Identifier: NCT03697070

中文翻译：

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管理工作促使改进肺炎抗生素的选择

重要性肺炎是最常见的需要住院治疗的感染，也是过度使用广谱抗生素的主要原因。尽管多重耐药菌 (MDRO) 感染的风险较低，但临床不确定性往往会推动最初的抗生素选择。需要采取策略来限制肺炎患者的经验性抗生素过度使用。 目的 评估计算机化医疗服务提供者订单输入 (CPOE) 提示提供患者和病原体特异性 MDRO 感染风险评估是否可以减少对肺炎患者入院的非危重患者的经验性广谱抗生素的使用设计、设置和参与者在 59 家美国社区医院进行的整群随机试验，比较 CPOE 管理捆绑包（教育、反馈和基于实时 MDRO 风险的 CPOE 提示；n = 29 家医院）与常规管理（n = 30 家医院）针对因肺炎住院的非危重成人（≥18 岁）在前 3 个住院日（经验期）内选择抗生素。 2017年4月1日至2018年9月30日有18个月的基线期，2019年4月1日至2020年6月30日有15个月的干预期。干预CPOE提示建议患者推荐标准谱抗生素在经验期间接受广谱抗生素治疗的 MDRO 肺炎估计绝对风险较低（<10%）的患者，并给予反馈和教育。主要结果和措施主要结果是经验性（住院前 3 天）延长-频谱抗生素治疗天数。次要结局包括经验性万古霉素和抗假单胞菌治疗天数，安全结局包括重症监护室 (ICU) 转移天数和住院时间。结果比较了不同策略的基线期和干预期之间的差异。结果在 59 家医院收治的 96 451 名（基线期 51 671 名，干预期 44 780 名）成年肺炎患者中，患者的平均 (SD) 年龄为 68.1 岁 (17.0 岁) ) 年，48.1% 为男性，Elixhauser 合并症计数中位数 (IQR) 为 4 (2-6)。与常规管理相比，使用 CPOE 提示的组经验性超广谱治疗天数减少了 28.4%（比率，0.72 [95% CI，0.66-0.78]；磷< .001）。常规干预组和 CPOE 干预组之间，转入 ICU 的平均天数（6.5 天与 7.1 天）和住院时间（6.8 天与 7.1 天）的安全性结果没有显着差异。 结论和相关性成人中经验性广谱抗生素的使用显着较低与常规管理实践相比，通过教育、反馈和 CPOE 提示，为 MDRO 感染风险低的患者推荐标准谱抗生素。住院时间和转入 ICU 的天数没有变化。试验注册ClinicalTrials.gov 标识符：NCT03697070