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Randomized Controlled Trial
. 2023 Jun;18(6):491-501.
doi: 10.1002/jhm.13101. Epub 2023 Apr 12.

Antibiotic clinical decision support for pneumonia in the ED: A randomized trial

Derek J Williams  1 , Judith M Martin  2 , Hui Nian  1 , Asli O Weitkamp  1 , Jason Slagle  1 , Robert W Turer  3 , Srinivasan Suresh  2 , Jakobi Johnson  1 , Justine Stassun  1 , Shari L Just  1 , Carrie Reale  1 , Russ Beebe  1 , Donald H Arnold  1 , James W Antoon  1 , Nancy S Rixe  2 , Laura F Sartori  4 , Robert E Freundlich  1 , Krow Ampofo  5 , Andrew T Pavia  5 , Joshua C Smith  1 , Matthew B Weinger  1 , Yuwei Zhu  1 , Carlos G Grijalva  1
Affiliations
Randomized Controlled Trial

Antibiotic clinical decision support for pneumonia in the ED: A randomized trial

Derek J Williams et al. J Hosp Med. 2023 Jun.

Abstract

Background: Electronic health record-based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED).

Objective: To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline-concordant antibiotic prescribing for pneumonia in the pediatric ED.

Design: Pragmatic randomized clinical trial.

Setting and participants: Encounters for children (6 months-18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States.

Intervention: CDS or usual care was randomly assigned during 4-week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines.

Main outcome and measures: The primary outcome was exclusive guideline-concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3- and 7-day revisits.

Results: 1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline-concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre-specified stratified analyses, CDS was associated with guideline-concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p = .024). There were no differences in safety outcomes.

Conclusions: Effectiveness of ED-based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.

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Conflict of interest statement

Derek Williams reports in-kind research support from Biomerieux for unrelated work; Judith Martin receives funding from Merck, Sharp and Dome for unrelated work; Carlos Grijalva reports consultancy fees from Pfizer, Merck, and Sanofi-Pasteur; and grants from Campbell Alliance/Syneos Health and Sanofi for unrelated work. Robert Freundlich reports stock in 3M and consulting from Oak Hill Clinical Informatics for unrelated work.

Figures

Figure 1.
Figure 1.
Consort Diagram
Figure 2.
Figure 2.. Antibiotic Selection, 1st 24 Hours of Care
Antibiotic selection was categorized into mutually exclusive groups based on oral or parental antibiotics received during the 31st 24 hours of care. Macrolide antibiotics were allowed to be grouped with any other combination of antibiotics and are represented with lighter shading. Those not receiving antibiotics, represented as a proportion of all encounters included in the study population, are presented to the left of the vertical double line. Antibiotic groupings, represented as a proportion of all encounters in which antibiotics were received, are presented to the right of the vertical double line
Figure 3.
Figure 3.. Adjusted Odds Ratios for Exclusive and Any Guideline-Concordant Antibiotic Prescribing During First 24 Hours of Care and for Entire Episode
Forest plots demonstrating adjusted odds ratios with 95% confidence intervals for exclusive (3A) and any (3B) guideline-concordant antibiotic prescribing during first 24 hours of care and for entire episode, overall and for analyses stratified by enrollment site, initial disposition from emergency department, and age, and an analysis restricted to those receiving antibiotics. Odds ratios estimated using logistic regression models adjusted for pneumonia severity score (linear predictor) incorporating age, sex, race/ethnicity, SpO2:FiO2, HR, RR, SBP.
Figure 3.
Figure 3.. Adjusted Odds Ratios for Exclusive and Any Guideline-Concordant Antibiotic Prescribing During First 24 Hours of Care and for Entire Episode
Forest plots demonstrating adjusted odds ratios with 95% confidence intervals for exclusive (3A) and any (3B) guideline-concordant antibiotic prescribing during first 24 hours of care and for entire episode, overall and for analyses stratified by enrollment site, initial disposition from emergency department, and age, and an analysis restricted to those receiving antibiotics. Odds ratios estimated using logistic regression models adjusted for pneumonia severity score (linear predictor) incorporating age, sex, race/ethnicity, SpO2:FiO2, HR, RR, SBP.
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References

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