Long-term effect of computer-assisted decision support for antibiotic treatment in critically ill patients: a prospective 'before/after' cohort study

BMJ Open. 2014 Dec 22;4(12):e005370. doi: 10.1136/bmjopen-2014-005370.


Objectives: Antibiotic resistance has risen dramatically over the past years. For individual patients, adequate initial antibiotic therapy is essential for clinical outcome. Computer-assisted decision support systems (CDSSs) are advocated to support implementation of rational anti-infective treatment strategies based on guidelines. The aim of this study was to evaluate long-term effects after implementation of a CDSS.

Design: This prospective 'before/after' cohort study was conducted over four observation periods within 5 years. One preinterventional period (pre) was compared with three postinterventional periods: directly after intensive implementation efforts (post1), 2 years (post2) and 3 years (post3) after implementation.

Setting: Five anaesthesiological-managed intensive care units (ICU) (one cardiosurgical, one neurosurgical, two interdisciplinary and one intermediate care) at a university hospital.

Participants: Adult patients with an ICU stay of >48 h were included in the analysis. 1316 patients were included in the analysis for a total of 12,965 ICU days.

Intervention: Implementation of a CDSS.

Outcome measures: The primary end point was percentage of days with guideline adherence during ICU treatment. Secondary end points were antibiotic-free days and all-cause mortality compared for patients with low versus high guideline adherence.

Main results: Adherence to guidelines increased from 61% prior to implementation to 92% in post1, decreased in post2 to 76% and remained significantly higher compared with baseline in post3, with 71% (p=0.178). Additionally, antibiotic-free days increased over study periods. At all time periods, mortality for patients with low guideline adherence was higher with 12.3% versus 8% (p=0.014) and an adjusted OR of 1.56 (95% CI 1.05 to 2.31).

Conclusions: Implementation of computerised regional adapted guidelines for antibiotic therapy is paralleled with improved adherence. Even without further measures, adherence stayed high for a longer period and was paralleled by reduced antibiotic exposure. Improved guideline adherence was associated with reduced ICU mortality.

Trial registration number: ISRCTN54598675.

Keywords: Antibiotic therapy; Computer-assisted decision support systems; Evidence based medicine; Stewardship program.

Publication types

  • Multicenter Study
  • Observational Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anti-Bacterial Agents / administration & dosage*
  • Bacterial Infections / drug therapy*
  • Bacterial Infections / mortality
  • Critical Illness / mortality
  • Critical Illness / therapy*
  • Decision Making, Computer-Assisted*
  • Female
  • Follow-Up Studies
  • Germany / epidemiology
  • Guideline Adherence*
  • Hospital Mortality / trends
  • Humans
  • Intensive Care Units
  • Male
  • Middle Aged
  • Prospective Studies
  • Survival Rate / trends
  • Time Factors
  • Treatment Outcome


  • Anti-Bacterial Agents

Associated data

  • ISRCTN/ISRCTN54598675