A clinical decision support system algorithm for intravenous to oral antibiotic switch therapy: validity, clinical relevance and usefulness in a three-step evaluation study

Akhloufi, H.; Hulscher, Marlies; Hoeven, Conrad P. van der; Prins, Jan M.; Sijs, Heleen van der; Melles∗, Damian C.; Verbon, Annelies

doi:10.1093/jac/dky141

Cited by 16 publications

(20 citation statements)

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“…An early switch from intravenous to oral administration has been advocated for a long time and decision support tools are effective in shortening intravenous therapies without a negative impact on morbidity or mortality [21,30]. In our institution, a simple algorithm led to a 19% reduction in the number of days on intravenous antibiotics with no increase in the number of complications [21].…”

Section: Discussionmentioning

confidence: 85%

Appropriateness of antimicrobial prescribing in a Swiss tertiary care hospital: a repeated point prevalence survey

et al. 2019

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AIMS OF THE STUDY: Inappropriate use of antimicrobials is associated with the emergence of antimicrobial resistance and adverse events. Antimicrobial stewardship programmes may both optimise treatment of infections and reduce antimicrobial resistance but are implemented in only a minority of Swiss hospitals. In addition, data on prescribing patterns and quality are scarce. We conducted a repeated point prevalence survey to evaluate the quality of antimicrobial prescribing in a single tertiary care centre. METHODS: Antimicrobial use was audited twice (summer 2017 and winter 2018) among all patients admitted to the University Hospital Basel, Switzerland. Data were collected from the electronic health record. Appropriateness of antimicrobial use was evaluated according to previously published rules and local national guidelines. RESULTS: We evaluated 1112 patients of whom 378 (34%) received 548 prescriptions in total (30% for prophylaxis). Penicillins with β-lactamase inhibitors were most commonly used (30%), followed by cotrimoxazole (12%) and ceftriaxone (7%). Intravenous administration was chosen in 56% of patients. Prior to antimicrobial therapy, blood cultures were collected in 69% of patients. Overall, 182 (33%) prescriptions were not appropriate; reasons included lack of indication (11%), incorrect dosing (7%), delay in intravenous to oral switch (9%) or non-adherence to local guidelines (15%). A minority of patients received antimicrobials despite documented allergies (2%). Almost 38% of empirical prescriptions were inappropriate, compared with only 19% of prophylactic and 20% of targeted prescriptions. Penicillins with β-lactamase inhibitors and cephalosporins were most commonly involved in inappropriate prescribing (>50%) followed by carbapenems (30%), narrow-spectrum penicillins (17%) and cotrimoxazole (6%), with oral administration being involved less frequently than intravenous administration (15 vs 37%). Infectious diseases consultation and presence of immunosuppression were associated with reduced odds (odds ra-tio [OR] 0.38, 95% confidence interval [CI] 0.21-0.70 and OR 0.31, 95% CI 0.17-0.54, respectively) of inappropriate prescription in the per-patient multivariable analysis, whereas being admitted to a surgical or intensive care unit was associated with increased odds (OR 1.83 and 5.67) compared with a medical unit. CONCLUSION: Almost one third of prescriptions were inappropriate in our tertiary care centre despite local guidelines and an on-demand infectious diseases consultation service. Our results underscore the need for expanding current antimicrobial stewardship efforts, including national initiatives such as stewardship and prescribing guidelines, repeated surveys and identification of areas for improvement including timely intravenous to oral switches in order to reduce the consequences of inappropriate prescribing and of multidrug resistant organisms.

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Section: Discussionmentioning

confidence: 85%

Appropriateness of antimicrobial prescribing in a Swiss tertiary care hospital: a repeated point prevalence survey

et al. 2019

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“…Computerized decision support was often applied as an optimization strategy to aid the management of clinical conditions with standardized treatment algorithms amenable to decision support. 17 , 19 – 21 Computerized decision support was also used for broader clinical goals, such as to promote switching of antibiotics from the intravenous to oral route to support antimicrobial stewardship, 24 and for anemia management in dialysis patients. 23 …”

Section: Resultsmentioning

confidence: 99%

Optimizing Hospital Electronic Prescribing Systems: A Systematic Scoping Review

et al. 2022

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Objective: Considerable international investment in hospital electronic prescribing (ePrescribing) systems has been made, but despite this, it is proving difficult for most organizations to realize safety, quality, and efficiency gains in prescribing. The objective of this work was to develop policy-relevant insights into the optimization of hospital ePrescribing systems to maximize the benefits and minimize the risks of these expensive digital health infrastructures.Methods: We undertook a systematic scoping review of the literature by searching MEDLINE, Embase, and CINAHL databases. We searched for primary studies reporting on ePrescribing optimization strategies and independently screened and abstracted data until saturation was achieved. Findings were theoretically and thematically synthesized taking a medicine life-cycle perspective, incorporating consultative phases with domain experts.Results: We identified 23,609 potentially eligible studies from which 1367 satisfied our inclusion criteria. Thematic synthesis was conducted on a data set of 76 studies, of which 48 were based in the United States. Key approaches to optimization included the following: stakeholder engagement, system or process redesign, technological innovations, and education and training packages. Single-component interventions (n = 26) described technological optimization strategies focusing on a single, specific step in the prescribing process. Multicomponent interventions (n = 50) used a combination of optimization strategies, typically targeting multiple steps in the medicines management process.Discussion: We identified numerous optimization strategies for enhancing the performance of ePrescribing systems. Key considerations for ePrescribing optimization include meaningful stakeholder engagement to reconceptualize the service delivery model and implementing technological innovations with supporting training packages to simultaneously impact on different facets of the medicines management process.

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“…An e-questionnaire, followed by a face-to-face meeting, was conducted to reach consensus among the experts on the identified criteria. A final set of 13 switch criteria, grouped into two categories (ie, ability of oral absorption and type of infection), was obtained 2 5 11 13–15 25 27 34–40. Of all switch criteria, seven were translated into measurable elements based on structured data available on the EHR.…”

Section: Methodsmentioning

confidence: 99%

“…However, these strategies are time-consuming and costly 24 25. Also technology-based interventions have been investigated, including computer-generated reminders as part of a computerised physician order entry (CPOE) or clinical decision support system (CDSS) 24–27…”

Section: Introductionmentioning

confidence: 99%

From basic to advanced computerised intravenous to oral switch for paracetamol and antibiotics: an interrupted time series analysis

et al. 2022

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ObjectivesEarly switch from intravenous to oral therapy of bioequivalent drugs has major advantages but remains challenging. At our hospital, a basic clinical rule was designed to automatically alert the physician to review potential intravenous to oral switch (IVOS). A rather low acceptance rate was observed. In this study, we aimed to develop, validate and investigate the effect of more advanced clinical rules for IVOS, as part of a centralised pharmacist-led medication review service.Design and settingA quasi-experimental study was performed in a large teaching hospital in Belgium using an interrupted time series design.InterventionA definite set of 13 criteria for IVOS, focusing on the ability of oral absorption and type of infection, was obtained by literature search and validated by a multidisciplinary expert panel. Based on these criteria, we developed a clinical rule for paracetamol and one for ten bioequivalent antibiotics to identify patients with potentially inappropriate intravenous prescriptions (PIVs). Postintervention, the clinical rule alerts were reviewed by pharmacists, who provided recommendations to switch in case of eligibility.Primary and secondary outcome measuresA regression model was used to assess the impact of the intervention on the number of persistent PIVs between the preintervention and the postintervention period. The total number of recommendations, acceptance rate and financial impact were recorded for the 8-month postintervention period.ResultsAt baseline, a median number of 11 (range: 7–16) persistent PIVs per day was observed. After the intervention, the number reduced to 3 (range: 1–7) per day. The advanced IVOS clinical rules showed an immediate relative reduction of 79% (incidence rate ratio=0.21, 95% CI 0.13 to 0.32; p<0.01) in the proportion of persistent PIVs. No significant underlying time trends were observed during the study. Postintervention, 1091 recommendations were provided, of which 74.1% were accepted, resulting in a total 1-day cost saving of €4648.35.ConclusionsWe showed the efficacy of advanced clinical rules combined with a pharmacist-led medication review for IVOS of bioequivalent drugs.

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A clinical decision support system algorithm for intravenous to oral antibiotic switch therapy: validity, clinical relevance and usefulness in a three-step evaluation study

Abstract: This prospective cohort study shows that the alerts were clinically relevant in >50% (n = 449) and useful in 10% (n = 85). The CDSS needs to be evaluated in hospitals with varying activity of infectious disease consultancy services as this probably influences usefulness.

Cited by 16 publications

References 20 publications

Appropriateness of antimicrobial prescribing in a Swiss tertiary care hospital: a repeated point prevalence survey

Appropriateness of antimicrobial prescribing in a Swiss tertiary care hospital: a repeated point prevalence survey

Optimizing Hospital Electronic Prescribing Systems: A Systematic Scoping Review

From basic to advanced computerised intravenous to oral switch for paracetamol and antibiotics: an interrupted time series analysis

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