, 2025-04-21 10:26:00
Despite guidelines stating otherwise, clinicians continue to prescribe inappropriate antibiotics to hospitalized patients with skin and soft tissue infections (SSTIs), raising costs and increasing the risk for drug-resistant organisms.
A new study has found that computer-assisted recommendations, coupled with targeted best practices, significantly reduce the use of extended-spectrum antibiotics, all without increasing admissions to intensive care units (ICUs) or prolonging hospital stays.
The INSPIRE 3 study is the third of four trials conducted over the last 2 years by Shruti Gohil, MD, MPH, of the Division of Infectious Diseases at the University of California, Irvine School of Medicine, Irvine, California. Together with her team of researchers, Gohil investigated whether computerized provider order entry (CPOE) prompts, along with patient-specific risk estimates, could safely reduce the empiric use of extended-spectrum antibiotics in patients at low risk for multidrug-resistant infections.
Community-acquired SSTIs account for nearly 900,000 adult hospitalizations annually in the United States. National guidelines support standard-spectrum antibiotics for nonpurulent and nonsurgical SSTIs, but as many as half of hospitalized patients receive extended-spectrum antibiotics.
Failure of clinicians to follow appropriate prescribing results from a lack of data to discern the diagnosis or specific pathogen, as well as delays in hospital throughput leading to the choice of the wrong antibiotic.
Whatever the reason, the use of extended-spectrum antibiotics often falls under the maxim that more is not always better, Gohil said.
“Exposure to extended-spectrum antibiotics kills both the bacteria responsible for an infection but also the bacteria in the body that keeps us healthy,” Gohil said. “This increases patients’ risk of future antibiotic resistance and other infections such as C difficile [Clostridium difficile] colitis.
Broad-spectrum antibiotics also increase the risk for adverse drug effects, such as liver or kidney damage.
The previous INSPIRE trials examined the use of CPOE in treating pneumonia and abdominal and urinary tract infections.
For INSPIRE 3, Gohil and her colleagues examined whether CPOE prompts, along with patient-specific risk estimates for infections, could provide physicians with greater confidence in recommending standard-spectrum antibiotics.
The cluster randomized trial enrolled 118,562 adults at 92 hospitals in the United States and received empiric antibiotics for SSTIs in non-ICU settings. Data were collected from January 2019 to December 2023.
Gohil and her colleagues found the CPOE-guided intervention reduced the use of extended-spectrum antibiotics by 28% without increasing transfers to the ICU or hospital stays. In the usual care arm, 58% of patients received treatment for antibiotic-resistant Gram-negative bacteria, “suggesting that this intervention could be useful for hundreds of thousands of patients hospitalized annually for SSTI” in the United States, the researchers reported.
“The INSPIRE CPOE prompts provide real-time information about a patient’s absolute risk of infection due to antibiotic-resistant bacteria,” Gohil said. “Normally, information about whether extended- or standard-spectrum antibiotics are necessary can take days to return; often clinicians end up choosing extended-spectrum while they await this information.”
“The INSPIRE risk-based prompt gives more information than clinicians currently have to be able to choose standard-spectrum antibiotics at each opportunity, avoiding unnecessary exposure to overly broad-spectrum antibiotics.”
Scott V. Anderson, PharmD, MS, a spokesman for the American Society of Health-System Pharmacists, said refinements in order selection are increasingly important in a healthcare system bogged down by electronic charting and coding.
“This study shows that creating specific alerts, with well-developed criteria and an established goal for use, can be of tremendous value for patient care,” Anderson said. “The alert in this study helps reinforce established guidelines, and the initiative also included an education component, both of which are important steps for improving practice.”
Although the trial was not designed to assess the CPOE-guided effect on the use of vancomycin, a post hoc analysis found a 10% decrease in empiric orders of the drug — which is associated with serious adverse effects and high cost.
“These findings have the potential to improve care for millions of patients hospitalized with infections in the US,” Gohil said. “The success of the INSPIRE trials opens up the possibility for applying a risk-informed approach to antibiotic selection for other infections or settings, such as patients admitted with sepsis, patients with cancer, and even for patients who have viral infections but who get antibiotics anyway.”
Gohil said the approach could be applied to antibiotic selection in other settings such as outpatient clinics, long-term acute care facilities, and nursing homes.
