title: A systematic review of clinical decision support systems for antimicrobial management: are we failing to investigate these interventions appropriately?
abstract: OBJECTIVE
  Clinical decision support systems (CDSS) for antimicrobial management can support clinicians to optimize antimicrobial therapy. We reviewed all original literature (qualitative and quantitative) to understand the current scope of CDSS for antimicrobial management and analyse existing methods used to evaluate and report such systems.
  
  
  METHODS
  PRISMA guidelines were followed. Medline, EMBASE, HMIC Health and Management and Global Health databases were searched from 1 January 1980 to 31 October 2015. All primary research studies describing CDSS for antimicrobial management in adults in primary or secondary care were included. For qualitative studies, thematic synthesis was performed. Quality was assessed using Integrated quality Criteria for the Review Of Multiple Study designs (ICROMS) criteria. CDSS reporting was assessed against a reporting framework for behaviour change intervention implementation.
  
  
  RESULTS
  Fifty-eight original articles were included describing 38 independent CDSS. The majority of systems target antimicrobial prescribing (29/38;76%), are platforms integrated with electronic medical records (28/38;74%), and have a rules-based infrastructure providing decision support (29/38;76%). On evaluation against the intervention reporting framework, CDSS studies fail to report consideration of the non-expert, end-user workflow. They have narrow focus, such as antimicrobial selection, and use proxy outcome measures. Engagement with CDSS by clinicians was poor.
  
  
  CONCLUSIONS
  Greater consideration of the factors that drive non-expert decision making must be considered when designing CDSS interventions. Future work must aim to expand CDSS beyond simply selecting appropriate antimicrobials with clear and systematic reporting frameworks for CDSS interventions developed to address current gaps identified in the reporting of evidence.
authors.affiliation: National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK. Electronic address: timothy.rawson07@ic.ac.uk.
authors.forename: T M
authors.initials: TM
authors.lastname: Rawson
authors.affiliation: National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK.
authors.forename: L S P
authors.initials: LSP
authors.lastname: Moore
authors.affiliation: Department of Electrical and Electronic Engineering, Imperial College, London, UK.
authors.forename: B
authors.initials: B
authors.lastname: Hernandez
authors.affiliation: National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK.
authors.forename: E
authors.initials: E
authors.lastname: Charani
authors.affiliation: National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK.
authors.forename: E
authors.initials: E
authors.lastname: Castro-Sanchez
authors.affiliation: Department of Electrical and Electronic Engineering, Imperial College, London, UK.
authors.forename: P
authors.initials: P
authors.lastname: Herrero
authors.affiliation: School of Public Health, Imperial College, London, UK.
authors.forename: B
authors.initials: B
authors.lastname: Hayhoe
authors.affiliation: Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.
authors.forename: W
authors.initials: W
authors.lastname: Hope
authors.affiliation: Department of Electrical and Electronic Engineering, Imperial College, London, UK.
authors.forename: P
authors.initials: P
authors.lastname: Georgiou
authors.affiliation: National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK.
authors.forename: A H
authors.initials: AH
authors.lastname: Holmes
mesh_terms: D000890:Anti-Infective Agents / Q000627:therapeutic use*; D000073602:Antimicrobial Stewardship / Q000458:organization & administration*; D003141:Communicable Diseases / Q000188:drug therapy*; D020000:Decision Support Systems, Clinical; D006302:Health Services Research / Q000379:methods*; D006801:Humans
chemical_list: D000890:Anti-Infective Agents
keywords: Antimicrobial resistance; Antimicrobial stewardship; Decision algorithms; Electronic support