title: Long-term effect of computer-assisted decision support for antibiotic treatment in critically ill patients: a prospective 'before/after' cohort study.
abstract: OBJECTIVE
  Antibiotic resistance has risen dramatically over the past years. For individual patients, adequate initial antibiotic therapy is essential for clinical outcome. Computer-assisted decision support systems (CDSSs) are advocated to support implementation of rational anti-infective treatment strategies based on guidelines. The aim of this study was to evaluate long-term effects after implementation of a CDSS.
  
  
  METHODS
  This prospective 'before/after' cohort study was conducted over four observation periods within 5 years. One preinterventional period (pre) was compared with three postinterventional periods: directly after intensive implementation efforts (post1), 2 years (post2) and 3 years (post3) after implementation.
  
  
  METHODS
  Five anaesthesiological-managed intensive care units (ICU) (one cardiosurgical, one neurosurgical, two interdisciplinary and one intermediate care) at a university hospital.
  
  
  METHODS
  Adult patients with an ICU stay of >48 h were included in the analysis. 1316 patients were included in the analysis for a total of 12,965 ICU days.
  
  
  METHODS
  Implementation of a CDSS.
  
  
  METHODS
  The primary end point was percentage of days with guideline adherence during ICU treatment. Secondary end points were antibiotic-free days and all-cause mortality compared for patients with low versus high guideline adherence.
  
  
  RESULTS
  Adherence to guidelines increased from 61% prior to implementation to 92% in post1, decreased in post2 to 76% and remained significantly higher compared with baseline in post3, with 71% (p=0.178). Additionally, antibiotic-free days increased over study periods. At all time periods, mortality for patients with low guideline adherence was higher with 12.3% versus 8% (p=0.014) and an adjusted OR of 1.56 (95% CI 1.05 to 2.31).
  
  
  CONCLUSIONS
  Implementation of computerised regional adapted guidelines for antibiotic therapy is paralleled with improved adherence. Even without further measures, adherence stayed high for a longer period and was paralleled by reduced antibiotic exposure. Improved guideline adherence was associated with reduced ICU mortality.
  
  
  BACKGROUND
  ISRCTN54598675.
authors.affiliation: Department of Anaesthesiology and Intensive Care, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
authors.forename: I
authors.initials: I
authors.lastname: Nachtigall
authors.affiliation: Department of Anaesthesiology and Intensive Care, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Tafelski
authors.affiliation: Department of Anaesthesiology and Intensive Care, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Deja
authors.affiliation: Charité-Universitaetsmedizin Berlin, Institute for Microbiology and Hygiene, Berlin, Germany.
authors.forename: E
authors.initials: E
authors.lastname: Halle
authors.affiliation: Department of Anaesthesiology and Intensive Care, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
authors.forename: M C
authors.initials: MC
authors.lastname: Grebe
authors.affiliation: Department of Anaesthesiology and Intensive Care, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Tamarkin
authors.affiliation: Department of Anaesthesiology and Intensive Care, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Rothbart
authors.affiliation: Department of Internal Medicine, Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Uhrig
authors.affiliation: Charité Universitaetsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.
authors.forename: E
authors.initials: E
authors.lastname: Meyer
authors.affiliation: Department of Cardiology, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
authors.forename: L
authors.initials: L
authors.lastname: Musial-Bright
authors.affiliation: Charité-Universitaetsmedizin Berlin, Institute of Medical Biometrics, and SOSTANA GmbH, Berlin, Germany.
authors.forename: K D
authors.initials: KD
authors.lastname: Wernecke
authors.affiliation: Department of Anaesthesiology and Intensive Care, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
authors.forename: C
authors.initials: C
authors.lastname: Spies
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D001424:Bacterial Infections / Q000188:drug therapy / Q000401:mortality; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D003658:Decision Making, Computer-Assisted; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D019983:Guideline Adherence; D017052:Hospital Mortality / Q000639:trends; D007362:Intensive Care Units; D011446:Prospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents
keywords: Antibiotic therapy; Computer-assisted decision support systems; Evidence based medicine; Stewardship program