Two large multi-state clinical trials have demonstrated a highly effective method to improve antibiotic selection for hospitalized patients with common infections, potentially addressing the growing global threat of antibiotic resistance. The findings were published in JAMA Surgery and JAMA Internal Medicine and highlighted at the Congress of the European Society of Clinical Microbiology and Infectious Diseases.
The INSPIRE Abdominal and Skin & Soft Tissue Trials, funded by the National Institutes of Health and led by researchers from the University of California, Irvine, Harvard Pilgrim Health Care Institute, and HCA Healthcare, involved more than 316,000 patients across 92 hospitals in 15 states.
Significant Improvements in Antibiotic Selection
In hospitals where the intervention was implemented, clinicians received computerized alerts providing information about the optimal antibiotic match for individual patients at the moment of prescription. This real-time guidance resulted in a 35% improvement in appropriate antibiotic selection for patients with abdominal infections and a 28% improvement for those with skin and soft tissue infections compared to control groups.
The alerts were powered by patient-specific data from electronic medical records combined with hospital-specific information to determine each patient's risk for antibiotic-resistant infection. Risk assessments were based on pre-trial data from more than 420,000 HCA Healthcare patients with similar infections.
Dr. Shruti Gohil, Associate Professor in the Division of Infectious Diseases at the University of California, Irvine School of Medicine, explained: "Many different bacteria can cause abdominal or skin/soft tissue infections, and picking the best matched antibiotic can be a challenge. Results from these trials show that giving physicians an alert informing them of their patient's actual risk for antibiotic resistance can help them choose the best antibiotic and reduce extended-spectrum antibiotic use."
Addressing a Major Public Health Threat
Antibiotic resistance represents one of the most pressing public health challenges globally. According to the Centers for Disease Control & Prevention, more than 2.8 million infections with antibiotic-resistant bacteria occur annually in the United States alone. The World Health Organization attributed 1.27 million deaths to antibacterial resistance in 2019.
Physicians often default to prescribing extended-spectrum antibiotics that target a broad range of bacteria out of concern that patients might have resistant infections. However, this practice contributes to the development of antibiotic resistance and increases the risk of adverse events such as kidney/liver toxicity and Clostridioides difficile infections.
The INSPIRE trials specifically identified patients at low risk for antibiotic-resistant infections and prompted physicians to consider switching to standard-spectrum antibiotics when broad-spectrum drugs were unnecessarily selected. This approach aligned antibiotic prescribing more closely with current Infectious Diseases Society of America treatment recommendations.
Building on Previous Success
These latest findings build upon earlier work by the same research team, which previously published results from two trials that improved antibiotic selection in patients with pneumonia and urinary tract infections. Together, these INSPIRE studies address the four most common infections requiring hospitalization that drive overuse of broad-spectrum antibiotics.
"The ability to identify patients at low-risk for antibiotic resistance to limit the overall use of wide-spectrum antibiotics can help hospitals everywhere improve antibiotic stewardship efforts and curb resistance," said Dr. Kenneth Sands, chief epidemiologist at HCA Healthcare.
Widespread Implementation Potential
The scale and diversity of the participating hospitals support the likelihood that these results are applicable to healthcare facilities nationwide. HCA Healthcare has already implemented alerts based on the first two INSPIRE studies across its system and is in the process of extending the new protocols to all 190 of its hospitals.
The findings have significant implications for improving care for millions of patients hospitalized with infections in the United States. By harnessing electronic health data to deliver the right information at the right time, healthcare systems can make substantial progress in combating antibiotic resistance while improving patient outcomes.
Clinical Impact and Future Directions
By tailoring antibiotic prescriptions to individual patients, the approach demonstrated in these trials can preserve healthy bacteria in the body while reducing the risk of future antibiotic resistance and serious adverse events. The computerized alert system represents a scalable intervention that could be implemented across diverse healthcare settings.
The success of these trials highlights the value of collaborative research between academic institutions and healthcare systems. The longstanding scientific partnership between HCA Healthcare, Harvard Pilgrim Health Care Institute, and the University of California, Irvine, demonstrates how combining clinical expertise with large-scale patient data can address critical healthcare challenges.
As antibiotic resistance continues to threaten global public health, evidence-based interventions like those validated in the INSPIRE trials offer promising strategies to preserve the effectiveness of existing antibiotics while improving patient care.
