title: Reducing co-administration of proton pump inhibitors and antibiotics using a computerized order entry alert and prospective audit and feedback.
abstract: Antibiotics and proton pump inhibitors (PPIs) are associated with Clostridium difficile infection (CDI). Both a computer order entry alert to highlight this association as well as antimicrobial stewardship directed prospective audit and feedback represent novel interventions to reduce the co-administration of antibiotics and PPIs among hospitalized patients.
  
  
  
  Consecutive patients admitted to two General Internal Medicine wards from October 1, 2010 until March 31, 2013 at a teaching hospital in Toronto, Ontario, Canada were evaluated. The baseline observation period was followed by the first phase, which involved the creation of a computerized order entry alert that was triggered when either a PPI or an antibiotic was ordered in the presence of the other. The second phase consisted of the introduction of an antibiotic stewardship-initiated prospective audit and feedback strategy. The primary outcome was the co-administration of antibiotics and PPIs during each phase.
  
  
  
  This alert led to a significant reduction in the co-administration of antibiotics and PPIs adjusted for month and secular trends, expressed as days of therapy per 100 patient days (4.99 vs. 3.14, p < 0.001) The subsequent introduction of the antibiotic stewardship program further reduced the co-administration (3.14 vs. 1.80, p <0.001). No change was observed in adjusted monthly CDI rates per 100 patient care days between the baseline and alert cohorts (0.12 vs. 0.12, p = 0.99) or the baseline and antibiotic stewardship phases (0.12 vs. 0.13, p = 0.97).
  
  
  
  Decreasing the co-administration of PPIs and antibiotics can be achieved using a simple automatic alert followed by prospective audit and feedback.
authors.affiliation: Department of Medicine, University of Toronto, Toronto, M5S 1A8, Canada.
authors.forename: Christopher E
authors.initials: CE
authors.lastname: Kandel
authors.affiliation: Pharmacy Department, Toronto East General Hospital, Toronto, M4C 3E7, Canada.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Gill
authors.affiliation: Division of Infectious Diseases, Toronto East General Hospital, 825 Coxwell Avenue, Toronto, ON, M4C 3E7, Canada.
authors.forename: Janine
authors.initials: J
authors.lastname: McCready
authors.affiliation: Department of General Internal Medicine, Toronto General Hospital, Toronto, M5G 2C4, Canada.
authors.forename: John
authors.initials: J
authors.lastname: Matelski
authors.affiliation: Division of Infectious Diseases, Toronto East General Hospital, 825 Coxwell Avenue, Toronto, ON, M4C 3E7, Canada. jpowi@tegh.on.ca.
authors.forename: Jeff E
authors.initials: JE
authors.lastname: Powis
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D002170:Canada; D054869:Clinical Audit; D020000:Decision Support Systems, Clinical; D005260:Female; D006760:Hospitalization; D006784:Hospitals, Teaching; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control* / Q000706:statistics & numerical data; D008297:Male; D050316:Medical Order Entry Systems; D008875:Middle Aged; D009864:Ontario; D011446:Prospective Studies; D054328:Proton Pump Inhibitors / Q000008:administration & dosage*
chemical_list: D000900:Anti-Bacterial Agents; D054328:Proton Pump Inhibitors
keywords: Antibiotic stewardship; Clostridium difficile infection; Computerized alerts; Prospective audit and feedback; Proton pump inhibitors