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期刊来源：JAMA

原文链接：https://doi.org/10.1001/jama.2024.6259

摘要内容如下：

重要性

尿路感染（UTI）是导致住院的第二大常见感染，通常与革兰氏阴性多重耐药菌（MDRO）有关。临床医生过度使用超广谱抗生素，尽管大多数患者MDRO感染的风险较低。需要限制过度使用经验性抗生素的安全策略。

目的

评估计算机化医嘱输入（CPOE）提示提供患者和病原体特异性MDRO风险评估是否可以减少经验性超广谱抗生素在UTI治疗中的使用。

设计、设置和参与者

在59家美国社区医院进行的集群随机试验，比较了CPOE管理组合（教育、反馈、实时和基于风险的CPOE提示；29家医院）与常规管理（n=30家医院）在18个月基线（2017年4月1日-2018年9月30日）和15个月干预期（2018年4月1日，2019年-2020年6月30日）。

干预措施

CPOE提示建议接受超广谱抗生素的患者使用经验性标准谱抗生素，这些患者的MDRO/UTI估计绝对风险较低（<10%），同时提供反馈和教育。

主要成果和措施

主要结果是经验性（住院前3天）超广谱抗生素治疗天数。次要转归包括经验性万古霉素和抗假单胞菌治疗天数。安全性结果包括转入重症监护室（ICU）的天数和住院时间。使用广义线性混合效应模型评估结果，以评估基线和干预期之间的差异。

结果

在59家医院收治的127403例UTI成年患者（基线为719991例，干预期为55412例）中，平均（SD）年龄为69.4（17.9）岁，30.5%为男性，中位Elixhauser合并症指数计数为4（IQR，2-5）。与常规管理相比，使用CPOE提示组的经验性扩谱治疗天数减少了17.4%（95%CI，11.2%-23.2%）（比率，0.83[95%CI，0.77-0.89]；P<.001）。在常规组和干预组之间，转入ICU的平均天数（6.6天vs 7.0天）和住院时间（6.3天vs 6.5天）的安全性结果分别没有显著差异。

结论和相关性

与常规管理相比，CPOE提示为MDRO风险低的患者提供标准谱抗生素的实时建议，并结合反馈和教育，在不改变住院时间或转至ICU的天数的情况下，显著减少了患有UTI的非危重成人中经验性超广谱抗生素的使用。

试用注册

ClinicalTrials.gov标识符：NCT03697096。

英文原文如下：

Abstracts

Importance  Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed.

Objective  To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI.

Design, Setting, and Participants  Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020).

Interventions  CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education.

Main Outcomes and Measures  The 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. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods.

Results  Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively.

Conclusions and Relevance  Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers.

Trial Registration  ClinicalTrials.gov Identifier: NCT03697096.

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