ImportanceUrinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed.ObjectiveTo evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI.Design, Setting, and ParticipantsCluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017–September 30, 2018) and 15-month intervention period (April 1, 2019–June 30, 2020).InterventionsCPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education.Main Outcomes and MeasuresThe primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods.ResultsAmong 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively.Conclusions and RelevanceCompared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers.Trial RegistrationClinicalTrials.gov Identifier: NCT03697096

中文翻译：

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管理提示改善尿路感染的抗生素选择

重要性尿路感染 (UTI) 是导致住院的第二常见感染，通常与革兰氏阴性多重耐药菌 (MDRO) 相关。尽管大多数患者感染 MDRO 的风险较低，但临床医生过度使用广谱抗生素。需要采取安全策略来限制经验性抗生素的过度使用。目的评估计算机化提供者订单输入 (CPOE) 提示提供患者和病原体特异性 MDRO 风险评估是否可以减少经验性广谱抗生素在 UTI 治疗中的使用。设计、设置、和参与者在 59 家美国社区医院进行的整群随机试验，比较了 CPOE 管理捆绑包（教育、反馈以及实时和基于风险的 CPOE 提示；29 家医院）与常规管理（n = 30 家医院）对抗生素选择的影响因尿路感染住院的非重症成人（≥18岁）的前3个住院日（经验期），基线为18个月（2017年4月1日至2018年9月30日），干预期为15个月（2019年4月1日至2020 年 6 月 30 日）。干预措施CPOE 提示建议对 MDRO UTI 估计绝对风险较低（<10%）的接受广谱抗生素治疗的患者推荐经验性标准谱抗生素，并结合反馈和教育。主要成果和措施 主要结局是经验性（住院前 3 天）广谱抗生素治疗天数。次要结局包括经验性万古霉素和抗假单胞菌治疗天数。安全结果包括重症监护病房 (ICU) 转移天数和住院时间。使用广义线性混合效应模型评估基线和干预期之间的差异。结果在 59 家医院因 UTI 入院的 127 403 名成年患者（基线 71 991 例，干预期 55 412 例）中，平均 (SD) 年龄为 69.4 岁(17.9) 岁，30.5% 为男性，Elixhauser 合并症指数中位数为 4（IQR，2-5）。与常规管理相比，使用 CPOE 提示的组经验性超广谱治疗天数减少了 17.4%（95% CI，11.2%-23.2%）（比率，0.83 [95% CI，0.77-0.89]；磷< .001）。常规组和干预组之间平均转入 ICU 的天数（6.6 天与 7.0 天）和住院时间（6.3 天与 6.5 天）的安全性结果分别没有显着差异。 结论和相关性与常规管理相比，CPOE 提示提供了真实的结果-针对低 MDRO 风险患者的标准谱抗生素的时间建议，加上反馈和教育，显着减少了因 UTI 入院的非危重症成人中经验性广谱抗生素的使用，而无需改变住院时间或 ICU 转移天数。Trial RegistrationClinicalTrials.gov标识符：NCT03697096