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Clinical Surveillance Decision Support Tools Used to Improve Antimicrobial Stewardship

Antimicrobial resistance has long been identified as a serious threat in healthcare. An increase in the growth of antimicrobial resistant pathogens through the years has resulted in increasing morbidity, mortality and healthcare costs. In their 2007 Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship, the Infectious Disease Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) recognized the need for antimicrobial stewardship programs to improve appropriate use of antibiotics and recommended the use of clinical decision support tools to improve antimicrobial treatment decisions and the use of computer-based surveillance to facilitate good stewardship.(1)  A review of literature was performed to evaluate the effectiveness of these tools for antimicrobial stewardship.

Three electronic databases were searched: MEDLINE, International Pharmaceutical Abstract and Embase. A systematic literature search identified thirty-three publications describing the use of computerized decision support functionality within the electronic health record (EHR), computerized decision support systems (CDSS) or clinical surveillance tools to assist in antimicrobial stewardship program. Of thirty-three publications, sixteen were selected based on inclusion criteria. The inclusion criteria consisted of; evaluative studies, English language only, and published in the last 10 years with inpatient acute care focus. Data extraction was conducted independently by two investigators.

The studies reviewed varied in the types of surveillance and clinical decision support tools used, methods used, and outcomes assessed. There is vast heterogeneity in the definition and use of CDSS, including web-based antibiotic prescribing information support, electronic surveillance alerts, computerized physician order entry (CPOE) order sets embedded with clinical pathways and automated stop orders. Nine of the seventeen studies utilized computerized surveillance detection of sepsis. Three of the sixteen studies evaluated the impact of CPOE clinical pathways and order sets for antimicrobial stewardship. Other studies investigated the effects of web-based antimicrobial therapy knowledge support, automated stop orders or CDSS antibiotic approval platforms. The aggregate results demonstrate the use of CDSS or clinical surveillance tool leads to increased acceptance of pharmacist’s interventions, reduced drug expenditure and improved antibiotic usage. Antimicrobial usage data was measured using normalized defined daily dose (DDD) as surrogate, time to de-escalation of therapy or antimicrobial doses dispensed. Two studies also suggest changes in antimicrobial resistance patterns for multidrug resistant organisms; Staphylococcus aureus, Pseudomonas spp and Extended Spectrum Beta-Lactamase producing organisms (ESBL).

The use of a clinical decision support tool has been demonstrated to be safe and effective to enrich prescriber’s knowledge, improve prescribing behavior, increase antimicrobial drug cost savings by a reduction in antimicrobial usage. Further large randomized controlled trials are needed to determine CDSS impact on clinical outcomes.

Author: Yin Wong, PharmD

1. TH Dellit et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clinical Infectious Diseases 2007; 44:159–77.

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