Impact of interactive computerised decision support for hospital antibiotic use (COMPASS): an open-label, cluster- randomised trial in three Swiss hospitals

Background Computerised decision-support systems (CDSSs) for antibiotic stewardship could help to assist physicians in the appropriate prescribing of antibiotics. However, high-quality evidence for their effect on the quantity and quality of antibiotic use remains scarce. The aim of our study was to assess whether a computerised decision support for antimicrobial stewardship combined with feedback on prescribing indicators can reduce antimicrobial prescriptions for adults admitted to hospital. Methods The Computerised Antibiotic Stewardship Study (COMPASS) was a multicentre, cluster-randomised, parallel -group, open-label superiority trial that aimed to assess whether a multimodal computerised antibiotic-stewardship intervention is effective in reducing antibiotic use for adults admitted to hospital. After pairwise matching, 24 wards in three Swiss tertiary-care and secondary-care hospitals were randomised (1:1) to the CDSS intervention or to standard antibiotic stewardship measures using an online random sequence generator. The multimodal intervention consisted of a CDSS providing support for choice, duration, and re-evaluation of antimicrobial therapy, and feedback on antimicrobial prescribing quality. The primary outcome was overall systemic antibiotic use measured in days of therapy per admission, using adjusted-hurdle negative-binomial mixed-effects models. The analysis was done by intention to treat and per protocol. The study was registered with ClinicalTrials.gov (identifier NCT03120975). Findings 24 clusters (16 at Geneva University Hospitals and eight at Ticino Regional Hospitals) were eligible and randomly assigned to control or intervention between Oct 1, 2018, and Dec 31, 2019. Overall, 4578 (40 center dot 2%) of 11384 admissions received antibiotic therapy in the intervention group and 4142 (42 center dot 8%) of 9673 in the control group. The unadjusted overall mean days of therapy per admission was slightly lower in the intervention group than in the control group (3 center dot 2 days of therapy per admission, SD 6 center dot 2, vs 3 center dot 5 days of therapy per admission, SD 6 center dot 8; p<0 center dot 0001), and was similar among patients receiving antibiotics (7 center dot 9 days of therapy per admission, SD 7 center dot 6, vs 8 center dot 1 days of therapy per admission, SD 8 center dot 4; p=0 center dot 50). After adjusting for confounders, there was no statistically significant difference between groups for the odds of an admission receiving antibiotics (odds ratio [OR] for intervention vs control 1 center dot 12, 95% CI 0 center dot 94-1 center dot 33). For admissions with antibiotic exposure, days of therapy per admission were also similar (incidence rate ratio 0 center dot 98, 95% CI 0 center dot 90-1 center dot 07). Overall, the CDSS was used at least once in 3466 (75 center dot 7%) of 4578 admissions with any antibiotic prescription, but from the first day of antibiotic treatment for only 1602 (58 center dot 9%) of 2721 admissions in Geneva. For those for whom the CDSS was not used from the first day, mean time to use of CDSS was 8 center dot 9 days. Based on the manual review of 1195 randomly selected charts, transition from intravenous to oral therapy was significantly more frequent in the intervention group after adjusting for confounders (154 [76 center dot 6%] of 201 vs 187 [87%] of 215, +10 center dot 4%; OR 1 center dot 9, 95% CI 1 center dot 1-3 center dot 3). Consultations by infectious disease specialists were less frequent in the intervention group (388 [13 center dot 4%] of 2889) versus the control group (405 [16 center dot 9%] of 2390; OR 0 center dot 84, 95% CI 0 center dot 59-1 center dot 25). Interpretation An integrated multimodal computerised antibiotic stewardship intervention did not significantly reduce overall antibiotic use, the primary outcome of the study. Contributing factors were probably insufficient uptake, a setting with relatively low antibiotic use at baseline, and delays between ward admission and first CDSS use. Funding Swiss National Science Foundation. Copyright (c) 2022 Elsevier Ltd. All rights reserved.

Automated summary

The study found that an integrated multimodal computerised antibiotic stewardship intervention did not significantly reduce overall antibiotic use, possibly due to factors such as insufficient uptake, a setting with relatively low antibiotic use at baseline, and delays between ward admission and first CDSS use.