NIHR Signal Computerised decision support can improve antibiotic prescribing in hospitals

Published on 28 November 2017

Using a computerised decision support tool (software used by hospital prescribers) improved the adequacy of antibiotic coverage and adherence to guidelines, and may have reduced the risk of people dying. Only four studies reported on resistance to antibiotics, so no conclusions can be drawn about the impact of this tool on resistance.

Antibiotic stewardship programmes aim to get prescribers to think before they decide to prescribe antibiotics, then consider the type and dose of antibiotic. Computerised decision support aims to support this practice by embedding these principles into everyday practice.

This review suggests that computerised decision support tools may be a useful component of antimicrobial stewardship. The methodological weaknesses of many of the included studies and variations in how they measured outcomes mean that the benefits may be smaller than they appear in this research. However, hospitals could consider measuring these outcomes to improve antibiotic prescribing.

Computerised decision support can improve antibiotic prescribing in hospitals

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Why was this study needed?

The effective and appropriate use of antibiotics is important in an age when bacteria are increasingly resistant to these drugs. Resistance to antibiotics reduces their effectiveness and makes it harder to treat infections. Antibiotic stewardship encourages all healthcare professionals to think before they prescribe and only prescribe antibiotics where necessary.

There are NHS guidance, training and programmes to embed antibiotic stewardship into practice. The NIHR recently published a Signal looking at antibiotic stewardship programmes, which found that these programmes could halve the number of infections and reduce resistance by two-thirds.

This review explored whether using a computerised tool could help to optimise antibiotic prescribing. These tools provide guidance on selecting antibiotics, dosing, adverse reactions and allergies to healthcare professionals as they are prescribing.

What did this study do?

This systematic review included 81 studies that looked at computerised decision support tools that were stand-alone or incorporated into existing computer systems. The tools were compared with usual care, no support, a paper-based decision support system or a different type of computerised decision support. Three studies were from the UK; most were from the US.

The scientific quality of the studies was generally low as they measured outcomes before and after the tool was implemented. This is a simple and inexpensive way to measure outcomes, but it may overestimate the effects, as it does not control for other factors that may affect the outcomes.

For many of the outcomes, there were too many differences between studies to allow the researchers to pool the results. The findings of this research should be viewed with these limitations in mind.

What did it find?

  • Computerised decision support (CDS) improved the adequacy of antibiotic coverage (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.67 to 2.66, 13 studies) – meaning that healthcare professionals were prescribing in line with CDS and guideline recommendations.
  • The risk of mortality was also reduced by 15% when using CDS (OR 0.85, 95% CI 0.75 to 0.96, 20 studies).
  • Most of the studies that examined the volume of antibiotics prescribed reported a reduction in prescribing (14 out of 19 studies). Most studies also reported a reduction in the cost of antibiotics when using a CDS (nine out of 15 studies). Differences in how these studies measured the volume or cost of antibiotics meant it was not possible to combine their results.
  • Antimicrobial resistance was only reported in four studies. The trend was for reduced resistance when using CDS.
  • There were mixed results about uptake and use of CDS from 16 studies.

What does current guidance say on this issue?

NICE 2015 guidelines recommend commissioners implement antimicrobial stewardship programmes that monitor and evaluate prescribing patterns. Monitoring antibiotic prescribing should be integrated into existing quality improvement programmes. NICE recommends following national or local guidelines on the shortest effective course, appropriate dose and the route of administration (injection or oral tablet).

NICE recommends the use of computerised decision support to inform whether to give antibiotics or an alternative approach. It also suggests evaluating systems’ effectiveness.

NICE is also developing a series of specific guidance on antimicrobial prescribing for common conditions, including urinary tract infections and sore throats.

What are the implications?

This review suggests that a computerised decision support tool can help to improve antibiotic prescribing practice.

The studies were generally not of high quality due to using pragmatic methods that are potentially open to bias. Therefore, some uncertainty remains around the effectiveness of these interventions.

Better designed studies using standardised definitions of outcomes would enable healthcare managers and commissioners to make decisions about whether these tools are a useful component of their antimicrobial stewardship programme.

Studies looking at barriers and enablers would also be helpful to support the implementation of such tools.

Citation and Funding

Curtis CE, Al Bahar F, Marriott JF. The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review. PLoS One. 2017;12(8):e0183062.

No relevant funding information was provided for this study.

Bibliography

NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NG15. London: National Institute for Health and Care Excellence; 2015.

NICE. Guidance and advice list. London: National Institute for Health and Care Excellence.

NIHR DC. Carefully managed antibiotic use could halve antibiotic-resistant infections. Southampton: National Institute for Health Research Dissemination Centre; 2017.

Why was this study needed?

The effective and appropriate use of antibiotics is important in an age when bacteria are increasingly resistant to these drugs. Resistance to antibiotics reduces their effectiveness and makes it harder to treat infections. Antibiotic stewardship encourages all healthcare professionals to think before they prescribe and only prescribe antibiotics where necessary.

There are NHS guidance, training and programmes to embed antibiotic stewardship into practice. The NIHR recently published a Signal looking at antibiotic stewardship programmes, which found that these programmes could halve the number of infections and reduce resistance by two-thirds.

This review explored whether using a computerised tool could help to optimise antibiotic prescribing. These tools provide guidance on selecting antibiotics, dosing, adverse reactions and allergies to healthcare professionals as they are prescribing.

What did this study do?

This systematic review included 81 studies that looked at computerised decision support tools that were stand-alone or incorporated into existing computer systems. The tools were compared with usual care, no support, a paper-based decision support system or a different type of computerised decision support. Three studies were from the UK; most were from the US.

The scientific quality of the studies was generally low as they measured outcomes before and after the tool was implemented. This is a simple and inexpensive way to measure outcomes, but it may overestimate the effects, as it does not control for other factors that may affect the outcomes.

For many of the outcomes, there were too many differences between studies to allow the researchers to pool the results. The findings of this research should be viewed with these limitations in mind.

What did it find?

  • Computerised decision support (CDS) improved the adequacy of antibiotic coverage (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.67 to 2.66, 13 studies) – meaning that healthcare professionals were prescribing in line with CDS and guideline recommendations.
  • The risk of mortality was also reduced by 15% when using CDS (OR 0.85, 95% CI 0.75 to 0.96, 20 studies).
  • Most of the studies that examined the volume of antibiotics prescribed reported a reduction in prescribing (14 out of 19 studies). Most studies also reported a reduction in the cost of antibiotics when using a CDS (nine out of 15 studies). Differences in how these studies measured the volume or cost of antibiotics meant it was not possible to combine their results.
  • Antimicrobial resistance was only reported in four studies. The trend was for reduced resistance when using CDS.
  • There were mixed results about uptake and use of CDS from 16 studies.

What does current guidance say on this issue?

NICE 2015 guidelines recommend commissioners implement antimicrobial stewardship programmes that monitor and evaluate prescribing patterns. Monitoring antibiotic prescribing should be integrated into existing quality improvement programmes. NICE recommends following national or local guidelines on the shortest effective course, appropriate dose and the route of administration (injection or oral tablet).

NICE recommends the use of computerised decision support to inform whether to give antibiotics or an alternative approach. It also suggests evaluating systems’ effectiveness.

NICE is also developing a series of specific guidance on antimicrobial prescribing for common conditions, including urinary tract infections and sore throats.

What are the implications?

This review suggests that a computerised decision support tool can help to improve antibiotic prescribing practice.

The studies were generally not of high quality due to using pragmatic methods that are potentially open to bias. Therefore, some uncertainty remains around the effectiveness of these interventions.

Better designed studies using standardised definitions of outcomes would enable healthcare managers and commissioners to make decisions about whether these tools are a useful component of their antimicrobial stewardship programme.

Studies looking at barriers and enablers would also be helpful to support the implementation of such tools.

Citation and Funding

Curtis CE, Al Bahar F, Marriott JF. The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review. PLoS One. 2017;12(8):e0183062.

No relevant funding information was provided for this study.

Bibliography

NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NG15. London: National Institute for Health and Care Excellence; 2015.

NICE. Guidance and advice list. London: National Institute for Health and Care Excellence.

NIHR DC. Carefully managed antibiotic use could halve antibiotic-resistant infections. Southampton: National Institute for Health Research Dissemination Centre; 2017.

The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review

Published on 25 August 2017

Curtis, C. E.,Al Bahar, F.,Marriott, J. F.

PLoS One Volume 12 Issue 8 , 2017

BACKGROUND: Inappropriate antimicrobial use has been shown to be an important determinant of the emergence of antimicrobial resistance (AMR). Health information technology (HIT) in the form of Computerised Decision Support (CDS) represents an option for improving antimicrobial prescribing and containing AMR. OBJECTIVES: To evaluate the evidence for CDS in improving quantitative and qualitative measures of antibiotic prescribing in inpatient hospital settings. METHODS: A systematic literature search was conducted of articles published from inception to 20th December 2014 using eight electronic databases: MEDLINE, EMBASE, PUBMED, Web of Science, CINAHL, Cochrane Library, HMIC and PsychINFo. An updated systematic literature search was conducted from January 1st 2015 to October 1st 2016 using PUBMED. The search strategy used combinations of the following terms: (electronic prescribing) OR (clinical decision support) AND (antibiotic or antibacterial or antimicrobial) AND (hospital or secondary care or inpatient). Studies were evaluated for quality using a 10-point rating scale. RESULTS: Eighty-one studies were identified matching the inclusion criteria. Seven outcome measures were evaluated: adequacy of antibiotic coverage, mortality, volume of antibiotic usage, length of stay, antibiotic cost, compliance with guidelines, antimicrobial resistance, and CDS implementation and uptake. Meta-analysis of pooled outcomes showed CDS significantly improved the adequacy of antibiotic coverage (n = 13; odds ratio [OR], 2.11 [95% CI, 1.67 to 2.66, p </= 0.00001]). Also, CDS was associated with marginally lowered mortality (n = 20; OR, 0.85 [CI, 0.75 to 0.96, p = 0.01]). CDS was associated with lower antibiotic utilisation, increased compliance with antibiotic guidelines and reductions in antimicrobial resistance. Conflicting effects of CDS on length of stay, antibiotic costs and system uptake were also noted. CONCLUSIONS: CDS has the potential to improve the adequacy of antibiotic coverage and marginally decrease mortality in hospital-related settings.

Expert commentary

More and more hospitals are introducing computerised prescribing systems, including varying degrees of decision support. One of the anticipated benefits of such technology is being able to guide prescribers towards safer, more effective or more cost-effective choices.

In the case of antibacterials, this also includes prescribing choices that reduce the risk of antimicrobial resistance. Given the costs of such systems, it is important to find out if these potential benefits are being realised.

This analysis suggests there are indeed some benefits. Perhaps we should be making greater use of decision support in optimising antibacterial prescribing in the hospital setting.

Bryony Dean Franklin, Professor of Medication Safety, UCL School of Pharmacy, & Theme Lead, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College