A Compass for Antibiotic Stewardship: Using a Digital Tool to Improve Guideline Adherence for Appendicitis Treatment in the Emergency Department

From the 2023 HVPA National Conference

Mai Vu BS (UC San Francisco, School of Medicine), Hope Shwartz BA, Steven Straube MD, Neha Pondicherry BA, David Emanuels BS, Jaskirat Dhanoa MD, Jaskaran Bains MD, Malini Singh MD, MPH, MBA, Nicholas Stark MD, MBA, Christopher Peabody MD, MBA

Background:
The Emergency Department (ED) is an important setting for antibiotic stewardship to combat the increasing prevalence of multidrug-resistant organisms associated with a longer duration of illness and increased mortality rates. Clinical decision support systems (CDSS) can be utilized to assist healthcare workers with clinical decision-making and appropriate antibiotic selection. Our ED developed E*Drive, a web-based open-access platform for redesigning and disseminating clinical guidelines built using human-centered design. At baseline in our ED, 75% of patients with appendicitis received broader-spectrum ertapenem for pre-surgical treatment rather than our institution’s recommended narrower-spectrum ceftriaxone/metronidazole combination.

Objective:
We aimed to inform clinician prescribing behavior and improve antibiotic stewardship by redesigning the information-dense appendicitis treatment guideline and disseminating it via E*Drive, a web-based, open-access CDSS platform developed by our institution.

Methods:
We conducted a retrospective study of antibiotic prescribing in our ED before and after the implementation of our redesigned CDSS guideline. The adult appendicitis treatment guideline was standardized on Google Slides using a systematic process to maximize readability and accessibility (Figure 1). The updated guideline was posted on E*Drive on October 18, 2021. We performed a chart review 180 days pre- (day -179 to 0) and 180 days post-intervention (day 1-180, intervention on day 1) from April 21, 2021 through April 15, 2022. Our primary outcome was guideline compliance defined by receiving Ceftriaxone 1g or 2g and Metronidazole 500mg. Our secondary outcomes included subdividing Ceftriaxone doses into 1g or 2g and any antibiotics compliant with Infectious Diseases Society of America (IDSA) guidelines. While our guideline recommends Ceftriaxone 2g with Metronidazole 500mg, we considered the administration of Ceftriaxone at 1g or 2g as compliant because both doses are IDSA compliant. Univariate, logistic regression was performed with guideline adherence as the dependent variable and time period (pre or post-intervention) as the independent variable.

Results:
20.0% of patients treated for appendicitis in the pre-intervention group received antibiotics concordant with our institutional guideline compared to 69.4% in the post-intervention group. (OR=9.07, 95% CI [3.84, 21.41]). The administration of any IDSA-compliant antibiotic was 86.2% pre-intervention and 81.6% post-intervention (OR=0.71, 95% CI [0.26, 1.96]). Breaking down Ceftriaxone IDSA compliant dosages, Ceftriaxone 1g administration increased pre- and post-intervention from 15.4% to 44.9% (OR=6.07, 95% CI [1.77, 25.32]) and Ceftriaxone 2g increased from 4.6% pre-intervention to 24.5% post-intervention (OR=4.48, 95% CI [1.86, 10.78]). Adherence to the guideline persisted during the study period. Ceftriaxone at any IDSA-compliant dose (1g or 2g) and Metronidazole 500mg were used in 61.1% of cases in days 1-90 (OR=6.29, 95% CI [2.04, 19.38]) and 74.2% in days 90-180 (OR=11.50, 95% CI [4.20, 31.52]) (Table 1).

Conclusion:
Although our ED was compliant with IDSA guidelines during the entire study period, our intervention increased the usage of a narrower spectrum regimen.

Clinical Implications:
Our results suggest that antibiotic stewardship can be increased by ensuring clinicians have access to convenient, standardized, and up-to-date guidelines through clinical decision support systems. While we studied one clinical guideline, our low-cost and replicable process may be scalable to multiple areas of clinician behavior, including diagnostic decision-making, disposition planning, and intra-hospital communication. Simplifying guidelines and increasing access is a potentially powerful tool to influence clinician behavior.

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