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Long-term effect of computer-assisted decision support for antibiotic treatment in critically ill patients: a prospective ‘before/after’ cohort study
  1. I Nachtigall1,
  2. S Tafelski1,
  3. M Deja1,
  4. E Halle2,
  5. M C Grebe1,
  6. A Tamarkin1,
  7. A Rothbart1,
  8. A Uhrig3,
  9. E Meyer4,
  10. L Musial-Bright5,
  11. K D Wernecke6,
  12. C Spies1
  1. 1Department of Anaesthesiology and Intensive Care, Charité-Universitaetsmedizin Berlin, Berlin, Germany
  2. 2Charité-Universitaetsmedizin Berlin, Institute for Microbiology and Hygiene, Berlin, Germany
  3. 3Department of Internal Medicine, Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Berlin, Germany
  4. 4Charité Universitaetsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
  5. 5Department of Cardiology, Charité-Universitaetsmedizin Berlin, Berlin, Germany
  6. 6Charité-Universitaetsmedizin Berlin, Institute of Medical Biometrics, and SOSTANA GmbH, Berlin, Germany
  1. Correspondence to Professor C Spies; claudia.spies{at}charite.de

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.

  • Stewardship program
  • Evidence based medicine
  • Antibiotic therapy
  • Computer-assisted decision support systems

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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