228. Decision Support Improves Antimicrobial Appropriateness
Session: Poster Abstract Session: Antimicrobial Stewardship in Clinical Practice
Friday, October 21, 2011
Room: Poster Hall B1
Background:  Decision support is proposed as one component of antimicrobial stewardship, but there is limited evidence that it improves antimicrobial prescribing comprehensively. We studied the impact of an antimicrobial computerized decision support system (CDSS) on adherence to recommendations and guidelines at the Minneapolis Veterans Affairs Medical Center.

Methods:  We reviewed 1010 randomly chosen inpatient antimicrobial courses given to 1010 different patients from fiscal year 2008. Courses given for prophylaxis, started before admission, or given only in the ER were excluded. Clinical data for 500 evaluable cases were presented to two randomly selected infectious disease (ID) physician reviewers out of a pool of four. Courses were assessed for appropriateness, defined as customary and reasonable use of antimicrobials based upon guidelines and clinical judgment. Reviewers were blinded to potential confounders. Differences were reconciled by a third reviewer. 

Results:  Of 500 courses, 295 (59%) were ordered with CDSS. Prescribing was appropriate in 128 of 295 (43%) CDSS cases compared with 63 of 205 (31%) non-CDSS cases (p = 0.005, Fisher exact). In 273 (55%) cases, reviewers judged that the initial prescriber diagnosis for the syndrome leading to antimicrobial therapy was correct. Antimicrobial prescribing was appropriate in 167 (61%) of these 273 cases compared with 24 (11%) of 227 of cases in which the initial prescriber diagnosis was incorrect (p < 0.001, Chi Square). In multivariate analysis, appropriateness was associated with both correct initial prescriber diagnosis (OR 7.90, 95% CI 4.77 to 13.09, p < 0.001) and CDSS use (OR 1.58, 95% CI 1.21 to 2.04, p = 0.001). Other variables associated with appropriateness included cases in which syndrome leading to antimicrobial therapy was related to reason for admission, and patient location in ICU or on observation status. 

Conclusion:  CDSS use was strongly associated with appropriate antimicrobial use. For further improvements, providers also need help making the best initial diagnosis. Decision support should be part of a multifaceted antimicrobial stewardship program.

Subject Category: J. Clinical practice issues

Anne-Marie Leuck, MD1,2, Galen M. Hamann, BSN1, Bobbie T. Masoud, PharmD1, Curtis L. Nordgaard, MS2, Meredith K. Eilertson, PharmD1, Thomas S. Rector, PhD1,2, Dimitri M. Drekonja, MD, MS1,2, James R. Johnson, MD1,2, Joseph R. Thurn, MD, MPH1,2 and Gregory A. Filice, MD1,2, (1)Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, (2)University of Minnesota, Minneapolis, MN


A. M. Leuck, None

G. M. Hamann, None

B. T. Masoud, None

C. L. Nordgaard, None

M. K. Eilertson, None

T. S. Rector, None

D. M. Drekonja, None

J. R. Johnson, None

J. R. Thurn, None

G. A. Filice, None

Findings in the abstracts are embargoed until 12:01 a.m. EST Thursday, Oct. 20 with the exception of research findings presented at IDSA press conferences.