本文由小咖机器人翻译整理

期刊来源：JAMA

原文链接：https://doi.org/10.1001/jama.2024.6248

摘要内容如下：

重要性

肺炎是最常见的需要住院治疗的感染，也是过度使用超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，但临床上的不确定性往往会促使最初的抗生素选择。需要制定策略，限制肺炎患者经验性抗生素过度使用。

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感染风险评估是否可以减少非危重肺炎患者经验性使用超广谱抗生素。

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）对非危重成人（≥18岁）肺炎住院患者前3个住院日（经验期）抗生素选择的比较。2017年4月1日至2018年9月30日为18个月的基线期，2019年4月1日至2020年6月30日为15个月的干预期。

干预

CPOE提示建议在经验期内接受超广谱抗生素治疗的MDRO肺炎估计绝对风险较低（<10%）的患者使用标准谱抗生素，并提供反馈和教育。

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。次要结果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。结果比较了不同策略的基线期和干预期的差异。

结果

在59家医院的96451例（基线期51671例，干预期44780例）成人肺炎患者中，患者的平均（SD）年龄为68.1（17.0）岁，48.1%为男性，Elixhauser合并症计数的中位数（IQR）为4（2-6）。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28.4%（比率，0.72[95%CI，0.66-0.78]；P<.001）。平均转入ICU天数（6.5 vs 7.1天）和住院时间（6.8 vs 7.1天）的安全性结果在常规干预组和CPOE干预组之间没有显著差异。

结论和相关性

与常规管理实践相比，通过教育、反馈和CPOE提示，建议对MDRO感染风险较低的患者使用标准谱抗生素，经验性超广谱抗生素的使用在成人肺炎患者中显著降低。住院时间和转入ICU的天数没有变化。

试用注册

ClinicalTrials.gov标识符：NCT03697070。

英文原文如下：

Abstracts

Importance  Pneumonia 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.

Objective  To 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 Participants  Cluster-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.

Intervention  CPOE 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 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 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.

Results  Among 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 Relevance  Empiric 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 Registration  ClinicalTrials.gov Identifier: NCT03697070.

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