Accelerating Initiation of Adequate Antimicrobial Therapy Using Real-Time Decision Support and Microarray Testing

Abstract

Introduction: Bloodstream infections (BSI) represent a common cause of sepsis and mortality in children. Early and adequate empirical antimicrobial therapy is a critical component of successful treatment of BSI. Rapid PCR-based diagnostic technologies, such as nucleic acid microarrays, can decrease the time needed to identify pathogens and antimicrobial resistance and have the potential to ensure patients are started on adequate antibiotics as early as possible. However, without appropriate processes to support timely and targeted interpretation of these results, these advantages may not be realized in practice. Methods: Our Antimicrobial Stewardship Program (ASP) implemented a quality improvement initiative using the Institute for Healthcare Improvement’s Model for Improvement to decrease the time between a nucleic acid microarray result for Gram-positive bacteremia and the time a patient was placed on adequate antimicrobial therapy. The primary effective intervention was a near real-time notification system to the managing physicians of inadequate antimicrobial therapy via a call from the ASP team. Results: Following the intervention, the average time to adequate antimicrobial therapy in patients with Gram-positive BSI and inadequate coverage decreased from 38 hours with the nucleic acid microarray result alone to 4.7 hours when results were combined with an ASP clinical decision support intervention, an 87% reduction. Conclusions: The positive effects of rapid-detection technologies to improve patient care are enhanced when combined with clinical decision support tools that can target inadequate antimicrobial treatments in near real time.

Using a Knowledge-Based Clinical Decision Support System to Reduce the Time to Appropriate Antimicrobial Therapy in Hospitalized Patients With Bloodstream Infections: A Single-Center Observational Study

“…RAPID differs from previous CDSSs [ 11 , 12 ] by some of its designs: (1) complete coverage of all hospitalized adult patients, irrespective of services/departments; (2) inclusion of both bacteria and fungus in the database; and (3) working automatically, without the need of or increase in human workload. In addition, there are 2 unique characteristics that may account for the feasibility and effectiveness of RAPID:…”

“…Another large study showed a similar result with an increased mortality rate of 0.3% among patients with community-onset bacteremia with each hour delay of antimicrobial treatment [ 9 ]. Several measures have been developed to reduce TAAT, including using a rapid species identification system [ 10 ], implementing multivariable models to assist empiric antibiotic selection [ 11 ], and setting up a clinical decision support pathway [ 12 ].…”

“…CDSS is also used in antimicrobial prescription, from assisting antimicrobial stewardship programs, to optimizing antimicrobial choice and dosing, to compliance with guidelines [ 14 ]. Until now, only a few reports described the use of CDSS to reduce TAAT, and most of these studies had limitations, such as requiring an extra workforce or the inclusion of only gram-positive or -negative pathogens [ 11 , 12 ].…”

Clinical Decision Support Stewardship: Best Practices and Techniques to Monitor and Improve Interruptive Alerts

“…Consider the following three example projects to (1) reduce in-room monitor-based alarms for patients and families, (2) improve antibiotic prescribing based on culture resistance profiles, and (3) drive proper handhygiene practice. [52][53][54] All three projects target key areas for improvement in patient experience, care delivery, and safety. Quality improvement teams may identify novel and compelling methods to deliver notifications considering their project aims and pay close attention to the burden of these notifications within the scope of their work.…”