INSPIRE 4
Trial question
What is the role of computerized provider order entry stewardship bundle in noncritically ill patients hospitalized with abdominal infection?
Study design
Multi-center
Open label
RCT
Population
Characteristics of study participants
59.0% female
41.0% male
N = 105004
105004 patients (62101 female, 42903 male).
Inclusion criteria: noncritically ill patients hospitalized with abdominal infection.
Key exclusion criteria: age < 18 years; ordered to receive extended-spectrum antibiotics for abdominal infection.
Interventions
N=50620 CPOE stewardship bundle (computerized patient order entry prompts recommending standard-spectrum antibiotics coupled with clinician education and feedback).
N=54384 routine stewardship (educational materials and quarterly coaching calls to maintain stewardship activities per national guidelines).
Primary outcome
Reduction in extended-spectrum days of therapy
169.3
19.8
169.3 days p...
127.0 days p...
84.7 days p...
42.3 days p...
0.0 days p...
CPOE stewardship
bundle
Routine
stewardship
Significant
increase ▲
Significantly greater reduction in extended-spectrum days of therapy (169.3 days per 1,000 empiric days vs. 19.8 days per 1000 empiric days; RR 1.54, 95% CI 1.4 to 1.66).
Secondary outcomes
Significantly greater reduction in vancomycin days of therapy (29.7 days per 1,000 empiric days vs. 11.8 days per 1000 empiric days; RR 1.25, 95% CI 1.15 to 1.37).
Significantly greater reduction in antipseudomonal days of therapy (131.8 days per 1,000 empiric days vs. 5.6 days per 1000 empiric days; RR 1.64, 95% CI 1.49 to 1.78).
Safety outcomes
No significant differences in length of stay, days to ICU transfers.
Conclusion
In noncritically ill patients hospitalized with abdominal infection, CPOE stewardship bundle was superior to routine stewardship with respect to reduction in extended-spectrum days of therapy.
Reference
Shruti K Gohil, Edward Septimus, Ken Kleinman et al. Improving Empiric Antibiotic Selection for Patients Hospitalized With Abdominal Infection: The INSPIRE 4 Cluster Randomized Clinical Trial. JAMA Surg. 2025 Apr 10:e251108. Online ahead of print.
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