Long-term effect of computer-assisted decision support for antibiotic treatment in critically ill patients: a prospective 'before/after' cohort study.

Abstract

OBJECTIVES:

Antibiotic resistance has risen dramatically over the past years. For individual patients, adequate initial antibiotic therapy is essential for clinical outcome. Computer-assisted decision support systems (CDSSs) are advocated to support implementation of rational anti-infective treatment strategies based on guidelines. The aim of this study was to evaluate long-term effects after implementation of a CDSS.

DESIGN:

This prospective 'before/after' cohort study was conducted over four observation periods within 5 years. One preinterventional period (pre) was compared with three postinterventional periods: directly after intensive implementation efforts (post1), 2 years (post2) and 3 years (post3) after implementation.

SETTING:

Five anaesthesiological-managed intensive care units (ICU) (one cardiosurgical, one neurosurgical, two interdisciplinary and one intermediate care) at a university hospital.

PARTICIPANTS:

Adult patients with an ICU stay of >48 h were included in the analysis. 1316 patients were included in the analysis for a total of 12,965 ICU days.

INTERVENTION:

Implementation of a CDSS.

OUTCOME MEASURES:

The primary end point was percentage of days with guideline adherence during ICU treatment. Secondary end points were antibiotic-free days and all-cause mortality compared for patients with low versus high guideline adherence.

MAIN RESULTS:

Adherence to guidelines increased from 61% prior to implementation to 92% in post1, decreased in post2 to 76% and remained significantly higher compared with baseline in post3, with 71% (p=0.178). Additionally, antibiotic-free days increased over study periods. At all time periods, mortality for patients with low guideline adherence was higher with 12.3% versus 8% (p=0.014) and an adjusted OR of 1.56 (95% CI 1.05 to 2.31).

CONCLUSIONS:

Implementation of computerised regional adapted guidelines for antibiotic therapy is paralleled with improved adherence. Even without further measures, adherence stayed high for a longer period and was paralleled by reduced antibiotic exposure. Improved guideline adherence was associated with reduced ICU mortality.

TRIAL REGISTRATION NUMBER:

ISRCTN54598675.

• Authors: I Nachtigall, S Tafelski, M Deja, E Halle, M C Grebe, A Tamarkin, A Rothbart, A Uhrig, E Meyer, L Musial-Bright, K D Wernecke, C Spies
• Journal: BMJ open (BMJ Open) Vol. 4 Issue 12 Pg. e005370 (Dec 22 2014) ISSN: 2044-6055 [Electronic] England
• PMID: 25534209 (Publication Type: Journal Article, Multicenter Study, Observational Study, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)
• Copyright: Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Chemical References

• Anti-Bacterial Agents

Topics

• Aged
• Anti-Bacterial Agents (administration & dosage)
• Bacterial Infections (drug therapy, mortality)
• Critical Illness (mortality, therapy)
• Decision Making, Computer-Assisted
• Female
• Follow-Up Studies
• Germany (epidemiology)
• Guideline Adherence
• Hospital Mortality (trends)
• Humans
• Intensive Care Units
• Male
• Middle Aged
• Prospective Studies
• Survival Rate (trends)
• Time Factors
• Treatment Outcome