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Amor-García MÁ, Chamorro-de-Vega E, Rodríguez-González CG, Iglesias-Peinado I, Moreno-Díaz R. Effects of a Pharmacist-Designed Clinical Decision Support System on Antimicrobial Stewardship. Appl Clin Inform 2024; 15:679-688. [PMID: 38857881 PMCID: PMC11324356 DOI: 10.1055/a-2341-8823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 06/06/2024] [Indexed: 06/12/2024] Open
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.
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Affiliation(s)
| | - Esther Chamorro-de-Vega
- Pharmacy Service, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Irene Iglesias-Peinado
- Department of Pharmacology, Pharmacognosy and Botany, Faculty of Pharmacy, Complutense University of Madrid, Madrid, Spain
| | - Raquel Moreno-Díaz
- Pharmacy Service, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain
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Han N, Oh OH, Oh J, Kim Y, Lee Y, Cha WC, Yu YM. The Application of Knowledge-Based Clinical Decision Support Systems to Detect Antibiotic Allergy. Antibiotics (Basel) 2024; 13:244. [PMID: 38534679 DOI: 10.3390/antibiotics13030244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 03/28/2024] Open
Abstract
Prevention of drug allergies is important for patient safety. The objective of this study was to evaluate the outcomes of antibiotic allergy-checking clinical decision support system (CDSS), K-CDSTM. A retrospective chart review study was performed in 29 hospitals and antibiotic allergy alerts data were collected from May to August 2022. A total of 15,535 allergy alert cases from 1586 patients were reviewed. The most frequently prescribed antibiotics were cephalosporins (48.5%), and there were more alerts of potential cross-reactivity between beta-lactam antibiotics than between antibiotics with the same ingredients or of the same class. Regarding allergy symptoms, dermatological disorders were the most common (38.8%), followed by gastrointestinal disorders (28.4%). The 714 cases (4.5%) of immune system disorders included 222 cases of anaphylaxis and 61 cases of severe cutaneous adverse reactions. Alerts for severe symptoms were reported in 6.4% of all cases. This study confirmed that K-CDS can effectively detect antibiotic allergies and prevent the prescription of potentially allergy-causing antibiotics among patients with a history of antibiotic allergies. If K-CDS is expanded to medical institutions nationwide in the future, it can prevent an increase in allergy recurrence related to drug prescriptions through cloud-based allergy detection CDSSs.
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Affiliation(s)
- Nayoung Han
- Jeju Research Institute of Pharmaceutical Sciences, College of Pharmacy, Jeju National University, Jeju 63243, Republic of Korea
| | - Ock Hee Oh
- FirstDIS Ltd., Seoul 07343, Republic of Korea
| | - John Oh
- Kakao Healthcare Corp., Seongnam 13529, Republic of Korea
| | - Yoomi Kim
- Korea Health Information Service, Seoul 04512, Republic of Korea
| | - Younghee Lee
- Department of Pharmacy, Ajou University Hospital, Suwon 16499, Republic of Korea
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul 06355, Republic of Korea
| | - Yun Mi Yu
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon 21983, Republic of Korea
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Chen Z, Liang N, Zhang H, Li H, Yang Y, Zong X, Chen Y, Wang Y, Shi N. Harnessing the power of clinical decision support systems: challenges and opportunities. Open Heart 2023; 10:e002432. [PMID: 38016787 PMCID: PMC10685930 DOI: 10.1136/openhrt-2023-002432] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/31/2023] [Indexed: 11/30/2023] Open
Abstract
Clinical decision support systems (CDSSs) are increasingly integrated into healthcare settings to improve patient outcomes, reduce medical errors and enhance clinical efficiency by providing clinicians with evidence-based recommendations at the point of care. However, the adoption and optimisation of these systems remain a challenge. This review aims to provide an overview of the current state of CDSS, discussing their development, implementation, benefits, limitations and future directions. We also explore the potential for enhancing their effectiveness and provide an outlook for future developments in this field. There are several challenges in CDSS implementation, including data privacy concerns, system integration and clinician acceptance. While CDSS have demonstrated significant potential, their adoption and optimisation remain a challenge.
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Affiliation(s)
- Zhao Chen
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ning Liang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Haili Zhang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Huizhen Li
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yijiu Yang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xingyu Zong
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yaxin Chen
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yanping Wang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Nannan Shi
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
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Whitney L, Armstrong‐James D, Lyster HS, Reed AK, Dunning J, Nwankwo L, Cheong J. Antifungal stewardship in solid‐organ transplantation: What is needed? Transpl Infect Dis 2022; 24:e13894. [DOI: 10.1111/tid.13894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/15/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Haifa S. Lyster
- Department of Heart and Lung Transplantation The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital Harefield Middlesex UK
| | - Anna K. Reed
- Department of Lung Transplantation Royal Brompton and Harefield National Health Service (NHS) Foundation Trust London UK
| | - John Dunning
- Department of Lung Transplantation Royal Brompton and Harefield National Health Service (NHS) Foundation Trust London UK
| | - Lisa Nwankwo
- Department of Pharmacy Royal Brompton & Harefield NHS Foundation Trust London UK
| | - Jamie Cheong
- Department of Pharmacy Royal Brompton & Harefield NHS Foundation Trust London UK
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O'Connell N, Gasior S, Slevin B, Power L, Barrett S, Bhutta S, Minihan B, Powell J, Dunne C. Microbial epidemiology and clinical risk factors of carbapenemase-producing Enterobacterales amongst Irish patients from first detection in 2009 until 2020. Infect Prev Pract 2022; 4:100230. [PMID: 35935263 PMCID: PMC9352914 DOI: 10.1016/j.infpip.2022.100230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background Carbapenemase producing Enterobacterales (CPE) are major public health threats. Aim To review microbial epidemiology of CPE, as well as clinical risk factors and infections, amongst CPE positive patients over 12 years in an Irish tertiary hospital. Methods Retrospective observational study of data extracted from a laboratory CPE database, electronic healthcare records and manual review of patient charts. Common risk factors, treatment regimens for all CPE related infections, and clinical outcomes were ascertained. Findings Among CPE strains isolated from 460 patients, Klebsiella pneumoniae carbapenemase (KPC) was the carbapenemase most frequently detected, accounting for 87.4% (459) of all CPE enzymes. Citrobacter species 177 (33.7%) were the most common species harbouring this enzyme. 428 CPE positive patients (93%) were identified in the acute hospital setting; the most common risk factor for CPE acquisition was history of hospitalisation, observed in 305 (66%) cases. Thirty patients (6.5%) had confirmed infections post-acquisition, of which four were bloodstream infections. There were 19 subsequent episodes of non CPE-related bacteraemia in this cohort. All causal mortality at 30 days was 41 patients (8.9%). However, clinical review determined that CPE was an indirect associative factor in 8 patient deaths. Conclusions In this tertiary hospital setting, microbial epidemiology is changing; with both OXA-48 enzymes and KPC-producing Citrobacter species becoming more prevalent. Whilst the burden of CPE related infections, especially bacteraemia, was low over the study period, it remains critical that basic infection prevention and control practices are adhered to lest the observed changes in epidemiology result in an increase in clinical manifestations.
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Affiliation(s)
- N.H. O'Connell
- Department of Clinical Microbiology University Limerick Hospital Group (ULHG), Limerick, Ireland
- Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
| | - S. Gasior
- School of Medicine, University of Limerick, Limerick, Ireland
| | - B. Slevin
- Department of Infection Prevention and Control, ULHG, Limerick, Ireland
| | - L. Power
- Department of Clinical Microbiology University Limerick Hospital Group (ULHG), Limerick, Ireland
| | - S. Barrett
- Department of Pharmacy, ULHG, Limerick, Ireland
| | - S.I. Bhutta
- Department of Gastroenterology, ULHG, Limerick, Ireland
| | - B. Minihan
- Department of Clinical Microbiology University Limerick Hospital Group (ULHG), Limerick, Ireland
| | - J. Powell
- Department of Clinical Microbiology University Limerick Hospital Group (ULHG), Limerick, Ireland
- Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - C.P. Dunne
- Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
- Corresponding author. Address: Foundation Chair and Director of Research, School of Medicine, University of Limerick, Ireland. Tel.: +35361234703.
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Hughes S, Heard K, Mughal N, Moore LSP. Burden of enteral supplement interactions with common antimicrobial agents: a single-centre observational analysis. Eur J Hosp Pharm 2022; 29:280-283. [PMID: 33414257 PMCID: PMC9660598 DOI: 10.1136/ejhpharm-2020-002445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 12/01/2020] [Accepted: 12/08/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Oral antimicrobials, including ciprofloxacin, levofloxacin and doxycycline, are susceptible to binding with enteral therapies such as calcium and iron therapies. Administered together, the bioavailability of these antimicrobials is expected to be reduced. METHODS A retrospective case series of patients receiving oral antimicrobials (ciprofloxacin, levofloxacin and doxycycline) was analysed at a single-centre NHS acute hospital (April 2016-September 2019). Patient demographics, including concurrent enteral therapies, were recorded using medical records. Clinically important interactions were defined as doses administered within 2 hours of antimicrobial therapy. RESULTS A total of 4067 prescriptions for the study antimicrobials (ciprofloxacin, n=1905; levofloxacin, n=538; and doxycycline, n=1624) were prescribed for 3584 patients. 1918/3583 (53.5%) of the patients were female, and the median age was 67 years (range 0.5-105.0 years). 810/4067 (19.3%) prescriptions reviewed had an interacting enteral therapy (calcium or iron salt) administered within 2 hours of the study medication. CONCLUSION The concomitant administration of enteral calcium and iron with oral antimicrobials is common within the acute care hospital setting. Approximately one in five patients has a clinically important interaction which may impair oral bioavailability and limit treatment efficacy. As antimicrobial stewardship teams strive for increased intravenous-to-oral de-escalation, it is important that optimum dosing administration is followed to optimise patient outcomes.
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Affiliation(s)
- Stephen Hughes
- Pharmacy, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Katie Heard
- Pharmacy, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nabeela Mughal
- Microbiology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Kistler CE, Wretman CJ, Zimmerman S, Enyioha C, Ward K, Farel CE, Sloane PD, Boynton MH, Beeber AS, Preisser JS. Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline. J Am Geriatr Soc 2022; 70:1070-1081. [PMID: 35014024 DOI: 10.1111/jgs.17638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification. METHODS We conducted a cross-sectional web-based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted. RESULTS One thousand seven hundred forty-eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios. Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively). CONCLUSIONS Clinicians tend to over-diagnose urinary tract infections, necessitating systems-based interventions to augment clinical decision-making. Clinician type, UTI knowledge, and personality traits may also influence behavior and deserve further study.
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Affiliation(s)
- Christine E Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.,The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA.,School of Social Work, University of North Carolina, Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA.,School of Social Work, University of North Carolina, Chapel Hill, NC, USA.,Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Chineme Enyioha
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kimberly Ward
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Claire E Farel
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.,The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Marcella H Boynton
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Anna S Beeber
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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Quintens C, Peetermans WE, Lagrou K, Declercq P, Schuermans A, Debaveye Y, Van den Bosch B, Spriet I. The effectiveness of Check of Medication Appropriateness for antimicrobial stewardship: an interrupted time series analysis. J Antimicrob Chemother 2021; 77:259-267. [PMID: 34618025 DOI: 10.1093/jac/dkab364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/01/2021] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Inappropriate prescribing of antimicrobials in hospitals contributes to the emergence of resistance and adverse drug events. To support antimicrobial stewardship (AMS), clinical decision rules focusing on antimicrobial therapy were implemented in the 'Check of Medication Appropriateness' (CMA). The CMA is a hospital-wide pharmacist-led medication review service consisting of a clinical rule-based screening for potentially inappropriate prescriptions (PIPs). We aimed to investigate the impact of the CMA on antimicrobial prescribing. METHODS An interrupted time series study was performed at the University Hospitals Leuven. The pre-implementation cohort was exposed to standard-of-care AMS. Afterwards, an AMS-focused CMA comprising 41 specific clinical rules, targeting six AMS objectives, was implemented in the post-implementation period. A regression model was used to assess the impact of the intervention on the number of AMS-related residual PIPs between both periods. The total number of recommendations and acceptance rate was recorded for the 2 year post-implementation period. RESULTS Pre-implementation, a median proportion of 75% (range: 33%-100%) residual PIPs per day was observed. After the CMA intervention, the proportion was reduced to 8% (range: 0%-33%) per day. Use of clinical rules resulted in an immediate relative reduction of 86.70% (P < 0.0001) in AMS-related residual PIPs. No significant underlying time trends were observed during the study period. Post-implementation, 2790 recommendations were provided of which 81.32% were accepted. CONCLUSIONS We proved that the CMA approach reduced the number of AMS-related residual PIPs in a highly significant and sustained manner, with the potential to further expand the service to other AMS objectives.
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Affiliation(s)
- Charlotte Quintens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Willy E Peetermans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Peter Declercq
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Annette Schuermans
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Department of Infection Control and Epidemiology, University Hospitals Leuven, Leuven, Belgium
| | - Yves Debaveye
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Bart Van den Bosch
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Department of Information Technology, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
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Nadeau E, Mercier A, Perron J, Gilbert M, Nault V, Beaudoin M, Abou Chakra C, Valiquette L, Carignan A. Clinical impact of accepting or rejecting a recommendation from a clinical decision support system-assisted antibiotic stewardship program. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:85-93. [PMID: 36341037 PMCID: PMC9608694 DOI: 10.3138/jammi-2020-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/04/2020] [Indexed: 06/16/2023]
Abstract
BACKGROUND Outcomes associated with physician responses to recommendations from an antimicrobial stewardship program (ASP) at an individual patient level have not yet been assessed. We aimed to compare clinical characteristics and mortality risk among patients for whom recommendations from an ASP were accepted or refused. METHODS A prospective cohort study was performed with hospitalized adults who received intravenous or oral antimicrobials at a 677-bed academic centre in Canada in 2014-2017. We included patients with an alert produced by a clinical decision support system (CDSS) for whom a recommendation was made by the pharmacist to the attending physician. The outcome was 90-day in-hospital all-cause mortality. RESULTS We identified 3,197 recommendations throughout the study period, of which 2,885 (90.2%) were accepted. The median length of antimicrobial treatment was significantly shorter when a recommendation was accepted (0.26 versus 1.78 d; p < 0.001). Refusal of a recommendation was not associated with mortality (odds ratio 1.32; 95% confidence interval, 0.93 to 1.89; p = 0.12). The independent risk factors associated with in-hospital mortality were age, Charlson Comorbidity Index score, admission to a critical care unit, duration between admission and recommendation, and issuance of a recommendation on a carbapenem. CONCLUSIONS The duration of antimicrobial treatment was significantly shorter when a recommendation originating from a CDSS-assisted ASP program was accepted. Future prospective studies including potential residual confounding variables, such as the source of infection or physiological derangement, might help in understanding whether CDSS-assisted ASP will have a direct impact on patient mortality.
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Affiliation(s)
- Esther Nadeau
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Adam Mercier
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Julie Perron
- Department of Pharmacy, Centre Intégré Universitaire de Santé et des Services Sociaux de l’Estrie, Sherbrooke, Quebec, Canada
| | - Mélanie Gilbert
- Department of Pharmacy, Centre Intégré Universitaire de Santé et des Services Sociaux de l’Estrie, Sherbrooke, Quebec, Canada
| | - Vincent Nault
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mathieu Beaudoin
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Claire Nour Abou Chakra
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Louis Valiquette
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alex Carignan
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Kistler CE, Zimmerman S, Khairat S. Health Information Technology Challenges and Innovations in Long-Term Care. J Am Med Dir Assoc 2021; 22:981-983. [PMID: 33896713 DOI: 10.1016/j.jamda.2021.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Christine E Kistler
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Saif Khairat
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Heard KL, Killington K, Mughal N, Moore LSP, Hughes S. Clinical outcomes of temocillin use for invasive Enterobacterales infections: a single-centre retrospective analysis. JAC Antimicrob Resist 2021; 3:dlab005. [PMID: 34223083 PMCID: PMC8210019 DOI: 10.1093/jacamr/dlab005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/05/2021] [Indexed: 01/13/2023] Open
Abstract
Background With increasing frequency of resistant Gram-negative bacteria, temocillin has potential utility in reducing carbapenem use. The 2020 EUCAST guideline changes temocillin breakpoints and reclassifies isolates with an MIC of 0.001–16 mg/L as ‘susceptible, increased exposure’ necessitating 6 g/day rather than the previous 4 g/day, associated with significant cost implications. Objectives We explore the clinical utility and treatment failure rate of temocillin at 4 g/day dosing. Methods All adult inpatient electronic prescriptions of temocillin (3 days or greater) from March 2016 to October 2019 were retrieved using a clinical decision support system (ICNET®). Treatment success was defined as survival, no switch to broad-spectrum agent for the same indication and no subsequent recrudescence of infection, occurring within 30 days. Results Temocillin was used in 205 eligible patient-episodes, median age 79 years (IQR : 71–87 years), 42.4% female. Median temocillin course length was 5.9 days (IQR : 4.6–7.8 days). Indications for use: urinary tract infection (UTI) (n = 141), pneumonia (n = 53), other (n = 11). In total, 144 (70.2%) patients had targeted treatment; 74 (36.1%) against Escherichia coli, 70 (34.4%) other Enterobacterales. A total of 130 (63%) patients received 4 g/day; the remaining patients had reduced renal function with dosing in accordance with guidance. Overall temocillin treatment success was 79.5%; highest when used to treat UTI 85.8% (versus 67.9% in respiratory infections, P = 0.008). Empirical treatment demonstrated 82.0% (50/61) success [versus 78.5% (113/144) among targeted treatment, P = 0. 71]. Conclusions Temocillin at 4 g/day is an effective and safe alternative in treating patients with Gram-negative infections, but should be considered in the context of patient age and comorbidities. Increased dosing or alternate strategies may be indicated when the infection is not of a urinary source.
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Affiliation(s)
- Katie L Heard
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK
| | - Kieran Killington
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK
| | - Nabeela Mughal
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK.,North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road. London W6 8RF, UK.,National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, UK
| | - Luke S P Moore
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK.,North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road. London W6 8RF, UK.,National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, UK
| | - Stephen Hughes
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK
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Schaaf J, Prokosch HU, Boeker M, Schaefer J, Vasseur J, Storf H, Sedlmayr M. Interviews with experts in rare diseases for the development of clinical decision support system software - a qualitative study. BMC Med Inform Decis Mak 2020; 20:230. [PMID: 32938448 PMCID: PMC7493382 DOI: 10.1186/s12911-020-01254-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 09/09/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Patients with rare diseases (RDs) are often diagnosed too late or not at all. Clinical decision support systems (CDSSs) could support the diagnosis in RDs. The MIRACUM (Medical Informatics in Research and Medicine) consortium, which is one of four funded consortia in the German Medical Informatics Initiative, will develop a CDSS for RDs based on distributed clinical data from ten university hospitals. This qualitative study aims to investigate (1) the relevant organizational conditions for the operation of a CDSS for RDs when diagnose patients (e.g. the diagnosis workflow), (2) which data is necessary for decision support, and (3) the appropriate user group for such a CDSS. METHODS Interviews were carried out with RDs experts. Participants were recruited from staff physicians at the Rare Disease Centers (RDCs) at the MIRACUM locations, which offer diagnosis and treatment of RDs. An interview guide was developed with a category-guided deductive approach. The interviews were recorded on an audio device and then transcribed into written form. We continued data collection until all interviews were completed. Afterwards, data analysis was performed using Mayring's qualitative content analysis approach. RESULTS A total of seven experts were included in the study. The results show that medical center guides and physicians from RDC B-centers (with a focus on different RDs) are involved in the diagnostic process. Furthermore, interdisciplinary case discussions between physicians are conducted. The experts explained that RDs exist which cannot be fully differentiated, but rather described only by their overall symptoms or findings: diagnosis is dependent on the disease or disease group. At the end of the diagnostic process, most centers prepare a summary of the patient case. Furthermore, the experts considered both physicians and experts from the B-centers to be potential users of a CDSS. The experts also have different experiences with CDSS for RDs. CONCLUSIONS This qualitative study is a first step towards establishing the requirements for the development of a CDSS for RDs. Further research is necessary to create solutions by also including the experts on RDs.
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Affiliation(s)
- Jannik Schaaf
- Medical Informatics Group (MIG), University Hospital Frankfurt, Frankfurt, Germany.
| | - Hans-Ulrich Prokosch
- Chair of Medical Informatics, Department of Medical Informatics, Biometrics and Epidemiology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Martin Boeker
- Institute of Medical Biometry and Statistics, Medical Faculty and Medical Centre - University of Freiburg, Freiburg, Germany
| | - Johanna Schaefer
- Medical Informatics Group (MIG), University Hospital Frankfurt, Frankfurt, Germany
| | - Jessica Vasseur
- Medical Informatics Group (MIG), University Hospital Frankfurt, Frankfurt, Germany
| | - Holger Storf
- Medical Informatics Group (MIG), University Hospital Frankfurt, Frankfurt, Germany
| | - Martin Sedlmayr
- Institute for Medical Informatics and Biometry, Carl Gustav Carus Faculty of Medicine Technical University of Dresden, Dresden, Germany
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Dramburg S, Marchante Fernández M, Potapova E, Matricardi PM. The Potential of Clinical Decision Support Systems for Prevention, Diagnosis, and Monitoring of Allergic Diseases. Front Immunol 2020; 11:2116. [PMID: 33013892 PMCID: PMC7511544 DOI: 10.3389/fimmu.2020.02116] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/05/2020] [Indexed: 12/11/2022] Open
Abstract
Clinical decision support systems (CDSS) aid health care professionals (HCP) in evaluating large sets of information and taking informed decisions during their clinical routine. CDSS are becoming particularly important in the perspective of precision medicine, when HCP need to consider growing amounts of data to create precise patient profiles for personalized diagnosis, treatment and outcome monitoring. In allergy care, several CDSS are being developed and investigated, mainly for respiratory allergic diseases. Although the proposed solutions address different stakeholders, the majority aims at facilitating evidence-based and shared decision-making, incorporating guidelines, and real-time clinical data. We offer here an overview on existing tools, new developments and novel concepts and discuss the potential of digital CDSS in improving prevention, diagnosis and monitoring of allergic diseases.
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Affiliation(s)
- Stephanie Dramburg
- Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - María Marchante Fernández
- Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ekaterina Potapova
- Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Paolo Maria Matricardi
- Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Hughes S, Troise O, Donaldson H, Mughal N, Moore LSP. Bacterial and fungal coinfection among hospitalized patients with COVID-19: a retrospective cohort study in a UK secondary-care setting. Clin Microbiol Infect 2020; 26:1395-1399. [PMID: 32603803 PMCID: PMC7320692 DOI: 10.1016/j.cmi.2020.06.025] [Citation(s) in RCA: 409] [Impact Index Per Article: 102.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/15/2020] [Accepted: 06/24/2020] [Indexed: 12/16/2022]
Abstract
Objectives To investigate the incidence of bacterial and fungal coinfection of hospitalized patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in this retrospective observational study across two London hospitals during the first UK wave of coronavirus disease 2019 (COVID-19). Methods A retrospective case series of hospitalized patients with confirmed SARS-CoV-2 by PCR was analysed across two acute NHS hospitals (20 February–20 April 2020; each isolate reviewed independently in parallel). This was contrasted to a control group of influenza-positive patients admitted during the 2019–2020 flu season. Patient demographics, microbiology and clinical outcomes were analysed. Results A total of 836 patients with confirmed SARS-CoV-2 were included; 27 (3.2%) of 836 had early confirmed bacterial isolates identified (0–5 days after admission), rising to 51 (6.1%) of 836 throughout admission. Blood cultures, respiratory samples, pneumococcal or Legionella urinary antigens and respiratory viral PCR panels were obtained from 643 (77%), 110 (13%), 249 (30%), 246 (29%) and 250 (30%) COVID-19 patients, respectively. A positive blood culture was identified in 60 patients (7.1%), of which 39 were classified as contaminants. Bacteraemia resulting from respiratory infection was confirmed in two cases (one each community-acquired Klebsiella pneumoniae and ventilator-associated Enterobacter cloacae). Line-related bacteraemia was identified in six patients (three Candida, two Enterococcus spp. and one Pseudomonas aeruginosa). All other community-acquired bacteraemias (n = 16) were attributed to nonrespiratory infection. Zero concomitant pneumococcal, Legionella or influenza infection was detected. A low yield of positive respiratory cultures was identified; Staphylococcus aureus was the most common respiratory pathogen isolated in community-acquired coinfection (4/24; 16.7%), with pseudomonas and yeast identified in late-onset infection. Invasive fungal infections (n = 3) were attributed to line-related infections. Comparable rates of positive coinfection were identified in the control group of confirmed influenza infection; clinically relevant bacteraemias (2/141; 1.4%), respiratory cultures (10/38; 26.3%) and pneumococcal-positive antigens (1/19; 5.3%) were low. Conclusions We found a low frequency of bacterial coinfection in early COVID-19 hospital presentation, and no evidence of concomitant fungal infection, at least in the early phase of COVID-19.
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Affiliation(s)
- S Hughes
- Chelsea and Westminster NHS Foundation Trust, Hammersmith Campus, London, UK.
| | - O Troise
- Chelsea and Westminster NHS Foundation Trust, Hammersmith Campus, London, UK
| | - H Donaldson
- Chelsea and Westminster NHS Foundation Trust, Hammersmith Campus, London, UK; North West London Pathology, Imperial College Healthcare NHS Trust, Hammersmith Campus, London, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | - N Mughal
- Chelsea and Westminster NHS Foundation Trust, Hammersmith Campus, London, UK; North West London Pathology, Imperial College Healthcare NHS Trust, Hammersmith Campus, London, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | - L S P Moore
- Chelsea and Westminster NHS Foundation Trust, Hammersmith Campus, London, UK; North West London Pathology, Imperial College Healthcare NHS Trust, Hammersmith Campus, London, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
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Rittmann B, Stevens MP. Clinical Decision Support Systems and Their Role in Antibiotic Stewardship: a Systematic Review. Curr Infect Dis Rep 2019; 21:29. [PMID: 31342180 DOI: 10.1007/s11908-019-0683-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW The purpose of this article is to perform a systematic review over the past 5 years on the role and effectiveness of clinical decision support systems (CDSSs) on antibiotic stewardship. RECENT FINDINGS CDDS interventions found a significant impact on multiple outcomes relevant to antibiotic stewardship. There are various types of CDSS implementations, both active and passive (provider initiated). Passive interventions were associated with more significant outcomes; however, both interventions appeared effective. In the reviewed literature, CDSSs were consistently associated with decreasing antibiotic consumption and narrowing the spectrum of antibiotic usage. Generally, guideline adherence was improved with CDSS, although this was not universal. The effect on other outcomes, such as mortality, Clostridiodes difficile infections, length of stay, and cost, inconsistently showed a significant difference. Overall, CDDS implementation has effectively decreased antibiotic consumption and improved guideline adherence across the various types of CDSS. Other positive outcomes were noted in certain settings, but were not universal. When creating a new intervention, it is important to identify the optimal structure and deployment of a CDSS for a specific setting.
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Affiliation(s)
- Barry Rittmann
- Virginia Commonwealth University Health Systems, Richmond, USA. .,, 825 Fairfax Avenue, 4th Floor, Norfolk, VA, 23507, USA.
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