Two clinical trials identify a better way to target appropriate antibiotics for patients hospitalized with pneumonia or urinary tract infection

Algorithm-driven alerts help identify best antibiotic for patients with common infections in two 59-hospital trials, with implications to reduce antibiotic resistance

NASHVILLE, Tenn., ORANGE, Calif., ATLANTA and BOSTON — Two large, multi-state studies uncovered a highly effective way to improve antibiotic selection for patients hospitalized with pneumonia or urinary tract infections (UTI), enabling better antibiotic stewardship in hospitals. The research was published today in the Journal of the American Medical Association (JAMA).

Stewardship Prompts to Improve Antibiotic Selection for Pneumonia

Stewardship Prompts to Improve Antibiotic Selection for Urinary Tract Infection

The studies, led by Harvard Pilgrim Health Care Institute, HCA Healthcare and the University of California, Irvine, were funded by the Centers for Disease Control and Prevention (CDC).

Antibiotic resistance, which occurs when germs like bacteria and fungi mutate to defeat the drugs designed to kill them, is a major public health threat. Helping clinicians tailor antibiotic prescriptions to individual patients can improve patient outcomes by preserving healthy bacteria in the body and reducing the risk of future antibiotic resistance. The two newly published studies, the INSPIRE Pneumonia and UTI Trials, involved more than 220,000 patients with pneumonia or UTI in 59 HCA Healthcare hospitals.

In half of the hospitals, clinicians were given algorithm-driven computerized alerts with information about the best antibiotic match for an individual patient at the moment antibiotics were being prescribed. This resulted in a better match for 28% of pneumonia patients and 17% of patients with UTI when compared to hospitals where physicians were not provided with alerts according to the trials.

The alerts used patient characteristics from the electronic medical record as well as hospital and location-specific data to determine the patient’s risk for an antibiotic-resistant infection. Assessment of risk was based on pre-trial data from more than 200,000 HCA Healthcare patients with pneumonia and UTI. Physicians treating patients with a low risk for antibiotic-resistant bacteria were prompted to give standard-spectrum antibiotics.

“Pneumonia and urinary tract infections are two of the most common infections requiring hospitalization and a major reason for overuse of broad-spectrum antibiotics,” said Sujan Reddy, MD, medical officer in the Epidemiology, Research and Innovations Branch of CDC’s Division of Healthcare Quality Promotion. “The INSPIRE trials have found a highly effective way to help physicians follow treatment recommendations to optimize antibiotic selection for each patient. These trials show the value of harnessing electronic health data to improve best practice.”

Physicians often choose extended-spectrum antibiotics that cover a very broad range of bacteria out of concern that their patients could be sick with antibiotic-resistant bacteria. The INSPIRE trials identified patients with low risk for antibiotic resistance and prompted physicians to order standard-spectrum antibiotics if extended-spectrum antibiotics were being ordered. The trials found that giving physicians real-time information about their patients’ risk for antibiotic resistance worked significantly better to align antibiotic prescribing with current Infectious Diseases Society of America treatment recommendations.

“The right information at the right time can improve physician antibiotic selection,” said Shruti Gohil, MD, MPH, senior investigator and assistant professor in the Division of Infectious Diseases at the University of California, Irvine School of Medicine. “Many different bacteria can cause pneumonia or UTI, and picking the best matched antibiotic can be a challenge. Results from these trials show that giving physicians an alert informing them of their patient’s actual risk for antibiotic resistance can help them choose the best antibiotic and reduce extended-spectrum antibiotic use.”

The INSPIRE trials were ongoing when the COVID-19 pandemic began. The trials showed continued beneficial effects in antibiotic selection when other hospitals in the nation were reporting large increases in use of extended-spectrum antibiotics. Part of this benefit is attributed to having an automated prompt that continues to work when hospital resources and staff attention are diverted.

The 59 participating community hospitals spanned 12 states and are part of HCA Healthcare, the largest private inpatient healthcare system in the U.S. The size of the studies involving a wide breadth of community hospitals supports the likelihood that results are applicable to hospitals across the country.

“HCA Healthcare is committed to excellence and innovation in delivering high-quality healthcare, and we are honored to continue our longstanding collaboration with the CDC, Harvard and UCI to leverage our health system’s scale to answer clinical questions for the benefit of patients,” said Kenneth Sands, MD, MPH, chief epidemiologist at HCA Healthcare. “We began using this groundbreaking technology and workflow in the hospitals where we tested it, and have since implemented it across our entire system to improve care for individual patients while also contributing to our growing body of work supporting appropriate antibiotic use everywhere.”

The studies were conducted through a scientific consortium including HCA Healthcare, Harvard Medical School’s Department of Population Medicine at the Harvard Pilgrim Health Care Institute, the University of California, Irvine and the Centers for Disease Control and Prevention.

Additional information about the INSPIRE Pneumonia and UTI Trials can be found in the following JAMA author interview podcast.

Editorial: Harnessing the Electronic Health Record to Improve Empiric Antibiotic Prescribing

About Centers for Disease Control and Prevention

Whether diseases start at home or abroad, are curable or preventable, chronic or acute, or from human activity or deliberate attack, CDC’s world-leading experts protect lives and livelihoods, national security and the U.S. economy by providing timely, commonsense information, and rapidly identifying and responding to diseases, including outbreaks and illnesses. CDC drives science, public health research, and data innovation in communities across the country by investing in local initiatives to protect everyone’s health.

About Harvard Pilgrim Health Care Institute’s Department of Population Medicine

The Harvard Pilgrim Health Care Institute's Department of Population Medicine is a unique collaboration between Harvard Pilgrim Health Care and Harvard Medical School. Created in 1992, it is the first appointing medical school department in the United States based in a health plan. The Institute focuses on improving health care delivery and population health through innovative research and education, in partnership with health plans, delivery systems, and public health agencies. Point32Health is the parent company of Harvard Pilgrim Health Care and Tufts Health Plan. Follow us on Twitter and LinkedIn.

About HCA Healthcare

Nashville-based HCA Healthcare is one of the nation’s leading providers of healthcare services comprising 186 hospitals and approximately 2,400 ambulatory sites of care, including surgery centers, freestanding ERs, urgent care centers, and physician clinics, in 20 states and the United Kingdom. With its founding in 1968, HCA Healthcare created a new model for hospital care in the United States, using combined resources to strengthen hospitals, deliver patient-focused care and improve the practice of medicine. With a robust system for analyzing clinical data across large and diverse patient populations, HCA Healthcare is a leader in pragmatic research like the Swap Out, ABATE and REDUCE MRSA trials that can help identify new standards of care. HCA Healthcare is a learning health system that uses its more than 43 million annual patient encounters to advance science, improve patient care and save lives. 

About UCI Health

UCI Health is the clinical enterprise of the University of California, Irvine, and the only academic health system based in Orange County. UCI Health is comprised of its main campus, UCI Medical Center, a 459-bed, acute care hospital in in Orange, Calif., four hospitals and affiliated physicians of the UCI Health Community Network in Orange and Los Angeles counties and ambulatory care centers across the region. Listed among America’s Best Hospitals by U.S. News & World Report for 23 consecutive years, UCI Medical Center provides tertiary and quaternary care and is home to Orange County’s only National Cancer Institute-designated comprehensive cancer center, high-risk perinatal/neonatal program and American College of Surgeons-verified Level I adult and Level II pediatric trauma center, gold level 1 geriatric emergency department and regional burn center. UCI Health serves a region of nearly 4 million people in Orange County, western Riverside County and southeast Los Angeles County. Follow us on Facebook, Instagram, LinkedIn and Twitter.