Study identifies method to reduce extended-spectrum antibiotic use for UTI

A team of investigators have identified a way to reduce the use of extended-spectrum antibiotic use among patients with urinary tract infections (UTIs) who have a low estimated risk of gram-negative multidrug-resistant organism (MDRO) infection, according to data from the INSPIRE UTI Trial (NCT03697096) published in JAMA.¹

In total, the study included 127,403 noncritically ill adult patients admitted to the hospital with UTI.

The method involves the use of a computerized provider order entry (CPOE) that provides real-time recommendations to prescribing physicians on the best antibiotic match for each patient. With the program, patients’ risk for an antibiotic-resistant infection is determined using information on patient characteristics from electronic medical records as well as hospital and location-specific data. For the study, physicians treating patients with a low estimated risk (less than 10%) of MDRO UTI were prompted to give standard-spectrum antibiotics.

Concurrently, the INSPIRE Pneumonia Trial was published in JAMA demonstrating the same approach in patients admitted with pneumonia.²

“The right information at the right time can improve physician antibiotic selection. Many different bacteria can cause pneumonia or UTI, and picking the best matched antibiotic can be a challenge. Results from these trials show that giving physicians an alert informing them of their patient’s actual risk for antibiotic resistance can help them choose the best antibiotic and reduce extended-spectrum antibiotic use,” said Shruti Gohil, MD, MPH, in a news release on the findings.³ Gohil is the lead author for both INSPIRE trials, as well as an assistant professor in the Division of Infectious Diseases at the University of California, Irvine School of Medicine.

Overall, 59 US-based hospitals participated in the INSPIRE UTI trial, of which 29 were cluster randomized to the CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts) and 30 were cluster randomized to continued routine antibiotic stewardship strategies in accordance with national standards.

Data showed that the CPOE alerts led to 17.4% significantly lower rate of empiric extended-spectrum days of therapy (rate ratio, 0.83; 95% CI, 0.77-0.89; P < .001) in the CPOE bundle group compared with the routine stewardship group. Specifically, the empiric extended-spectrum days of therapy per 100 days in the routine stewardship group was 431.1 during the baseline period and 446.0 during the intervention period. For the CPOE bundle group, the empiric extended-spectrum days of therapy was 392.2 during the baseline period and 326.0 during the intervention period.

Regarding safety, 4.0% of patients in the routine group and 3.7% of patients in the CPOE bundle group were transferred to the ICU. Further, 10.2% and 10.0% of patients in the routine and CPOE bundle groups, respectively, required antibiotic escalation.

There were no significant differences noted between the intervention and routine groups regarding mean days to ICU transfer (7.0 vs 6.6 days, respectively) or hospital length of stay (6.5 vs 6.3 days, respectively).

In total, the study included 127,403 noncritically ill adult patients admitted to the hospital with UTI, of whom 71,991 participated in the 18-month baseline period and 55,412 participated in the 15-month intervention period. Among all patients, 30.5% were male. The mean age of participants was 69 (SD, 17.9) years.

The primary outcome measure for the study was the extended-spectrum days of therapy in the first 3 days of hospitalization (empiric period). Safety outcome measures included days to antibiotic escalation, days to ICU transfer, and hospital length of stay in days.

Co-author Sujan Reddy, MD, Medical Officer in the Epidemiology, Research and Innovations Branch of CDC’s Division of Healthcare Quality Promotion, concluded in the news release,³ “Pneumonia and urinary tract infections are two of the most common infections requiring hospitalization and a major reason for overuse of broad-spectrum antibiotics. The INSPIRE trials have found a highly effective way to help physicians follow treatment recommendations to optimize antibiotic selection for each patient. These trials show the value of harnessing electronic health data to improve best practice.”

References

1. Gohil SK, Septimus E, Kleinman K, et al. Stewardship Prompts to Improve Antibiotic Selection for Urinary Tract Infection: The INSPIRE Randomized Clinical Trial. JAMA. 2024. doi:10.1001/jama.2024.6259

2. Gohil SK, Septimus E, Kleinman K, et al. Stewardship Prompts to Improve Antibiotic Selection for Pneumonia: The INSPIRE Randomized Clinical Trial. JAMA. 2024. doi:10.1001/jama.2024.6248

3. Two clinical trials identify a better way to target appropriate antibiotics for patients hospitalized with pneumonia or urinary tract infection. News release. April 19, 2024. Accessed May 1, 2024. https://www.businesswire.com/news/home/20240419656742/en/Two-Clinical-Trials-Identify-a-Better-Way-to-Target-Appropriate-Antibiotics-for-Patients-Hospitalized-With-Pneumonia-or-Urinary-Tract-Infection