CPOE Prompts Reduce Use of Empiric Extended-Spectrum Antibiotics for SSTIs Without Increasing ICU Admissions or Hospital LOS
CLINICAL QUESTION: Can computerized provider order entry (CPOE) prompts safely reduce empiric extended-spectrum antibiotic use for noncritically ill, hospitalized patients with skin and soft tissue infection (SSTI) by presenting patient- and pathogen-specific multidrug-resistance-risk factors to ordering physicians?
BACKGROUND: 30 to 50% of hospitalized patients with SSTI receive extended-spectrum antibiotics despite low likelihood of infection with multidrug-resistant organisms (MDROs). Physicians have cited the presence of co-morbidities, insufficient diagnostic data, and concern that the incorrect antibiotic choice will lead to extended hospitalization as reasons for non-adherence to SSTI guidelines. However, extended-spectrum antibiotic overuse can cause harm.
STUDY DESIGN: Cluster-randomized, controlled trial
SETTING: 92 hospitals within the Hospital Corporation of America healthcare system
SYNOPSIS:118,562 hospitalized, noncritically ill adult patients were included. Hospitals were randomly assigned to the routine stewardship group or the CPOE bundle group. The routine stewardship group received educational materials and coaching, including antibiotic selection guidelines and prospective feedback to de-escalate antibiotics. The CPOE bundle group received the same tools as well as CPOE prompts recommending empiric standard-spectrum antibiotics for patients with an absolute risk less than 10% of Pseudomonas or MDRO SSTI, education on risk estimate calculations and local Pseudomonas and MDRO prevalence, investigator site visits and webinars, and clinician SSTI antibiotic prescribing reports. There was a 28% reduction in empiric extended-spectrum antibiotic use without an increase in hospital length of stay or need for early ICU transfer in the CPOE bundle group compared to the routine stewardship group. Study strengths include study size, validated and robust risk estimators, stewardship approach, and the sustainable nature of the intervention. Limitations include the use of skin cultures despite the inability to distinguish colonization from infection. A higher threshold of MDRO risk may have also been equally safe and more effective.
BOTTOM LINE: Unnecessary extended-spectrum antibiotic use for SSTI was safely decreased with the use of electronic medical record prompts, patient risk-stratification, and provider education.
CITATION: Gohil SK, et al. Improving empiric antibiotic selection for patients hospitalized with skin and soft tissue infection: the INSPIRE 3 skin and soft tissue randomized clinical trial. JAMA Intern Med. 2025;185(6):680-691. doi: 10.1001/jamainternmed.2025.0887.
Dr. O’Neill
Dr. O’Neill is a hospitalist at the Nebraska Medical Center and an assistant professor in the department of internal medicine at the University of Nebraska Medical Center, both in Omaha, Neb.