Antibiotic computerised decision support systems (CDSSs) are shown to improve antibiotic prescribing, but evidence of beneficial patient outcomes is limited. We conducted a prospective cohort study in a 1500-bed tertiary-care hospital in Singapore, to evaluate the effectiveness of the hospital's antibiotic CDSS on patients' clinical outcomes, and the modification of these effects by patient factors. To account for clustering, we used multilevel logistic regression models. One-quarter of 1886 eligible inpatients received CDSS-recommended antibiotics. Receipt of antibiotics according to CDSS's recommendations seemed to halve mortality risk of patients (OR 0.54, 95% CI 0.26-1.10, P = 0.09). Patients aged ≤65 years had greater mortality benefit (OR 0.45, 95% CI 0.20-1.00, P = 0.05) than patients that were older than 65 (OR 1.28, 95% CI 0.91-1.82, P = 0.16). No effect was observed on incidence of Clostridium difficile (OR 1.02, 95% CI 0.34-3.01), and multidrug-resistant organism (OR 1.06, 95% CI 0.42-2.71) infections. No increase in infection-related readmission (OR 1.16, 95% CI 0.48-2.79) was found in survivors. Receipt of CDSS-recommended antibiotics reduced mortality risk in patients aged 65 years or younger and did not increase the risk in older patients. Physicians should be informed of the benefits to increase their acceptance of CDSS recommendations.

OBJECTIVE:Antibiotic computerized decision support systems (CDSSs) were developed to guide antibiotic decisions, yet prescriptions of CDSS-recommended antibiotics have remained low. Our aim was to identify predictors of patients' receipt of empiric antibiotic therapies recommended by a CDSS when the prescribing physician had an initial preference for using broad-spectrum antibiotics. METHODS:We conducted a prospective cohort study in a 1 500-bed tertiary-care hospital in Singapore. We included all patients admitted from October 1, 2011 through September 30, 2012, who were prescribed piperacillin-tazobactam or carbapenem for empiric therapy and auto-triggered to receive antibiotic recommendations by the in-house antibiotic CDSS. Relevant data on the patient, prescribing and attending physicians were collected via electronic linkages of medical records and administrative databases. To account for clustering, we used multilevel logistic regression models to explore factors associated with receipt of CDSS-recommended antibiotic therapy. RESULTS:One-quarter of the 1 886 patients received CDSS-recommended antibiotics. More patients treated for pneumonia (33.2%) than sepsis (12.1%) and urinary tract infections (7.1%) received CDSS-recommended antibiotic therapies. The prescribing physician - but not the attending physician or clinical specialty - accounted for some (13.3%) of the variation. Prior hospitalization (odds ratio [OR] 1.32, 95% CI, 1.01-1.71), presumed pneumonia (OR 6.77, 95% CI, 3.28-13.99), intensive care unit (ICU) admission (OR 0.38, 95% CI, 0.21-0.66), and renal impairment (OR 0.70, 95% CI, 0.52-0.93) were factors associated with patients' receipt of CDSS-recommended antibiotic therapies. CONCLUSIONS:We observed that ICU admission and renal impairment were negative predictors of patients' receipt of CDSS-recommended antibiotic therapies. Patients admitted to ICU and those with renal impairment might have more complex clinical conditions that require a physician's assessment in addition to antibiotic CDSS.

Methicillin-resistant Staphylococcus aureus (MRSA) has become an increasingly important pathogen in obstetrics. MRSA infections can result in morbidity for both mothers and their infants. Over the past decade, MRSA infection has increased in pregnant women and neonates [1]. Indeed, there is increasing evidence that horizontal transmission from MRSA colonized mothers to their neonates plays a role in increasing neonatal MRSA colonization and, sometimes, infection [2]. Additionally, obstetric patients are frequently exposed to antibiotics, a known risk factor for infection by drug resistant organisms including MRSA.[3] Infection in the postpartum period is still common, even in developed countries [4]. Nonetheless, there is inadequate information in the published literature about the epidemiology of MRSA infections in postpartum women and no consensus on how to reduce the burden and consequences of such infections. This is worrisome given the urgency of the double threat of (multi-)drug resistance and stagnating antibiotic development.

Methicillin-resistant Staphylococcus aureus (MRSA) has become an increasingly important pathogen in obstetrics. MRSA infections can result in morbidity for both mothers and their infants. Over the past decade, MRSA infection has increased in pregnant women and neonates [1]. Indeed, there is increasing evidence that horizontal transmission from MRSA colonized mothers to their neonates plays a role in increasing neonatal MRSA colonization and, sometimes, infection [2]. Additionally, obstetric patients are frequently exposed to antibiotics, a known risk factor for infection by drug resistant organisms including MRSA.[3] Infection in the postpartum period is still common, even in developed countries [4]. Nonetheless, there is inadequate information in the published literature about the epidemiology of MRSA infections in postpartum women and no consensus on how to reduce the burden and consequences of such infections. This is worrisome given the urgency of the double threat of (multi-)drug resistance and stagnating antibiotic development.