Kieran Walsh: Antibiotic resistance—a role for clinical decision support?

There have been concerns about antibiotic resistance for decades. But concerns have grown in recent years as the problem continues to get worse. Various strategies have been used to address it—from medical education, to restricted formularies, to directly observed treatment. Strategies have targeted a variety of groups including doctors, students, allied healthcare professionals (such as pharmacists), and patients. There have been campaigns to improve infection control measures, to ensure correct dosing, and even to develop better ways of moving patients between and within institutions. But the situation continues to get worse.

Curtis and colleagues have been the latest to step into the breach to see what they can do to prevent resistance. They have conducted a systematic review to look at the effectiveness of computerised decision support on antibiotic use in hospitals. Their hypothesis is that if we use antibiotics inappropriately, then there will be more antibiotic resistance. Conversely, if we use clinical decision support to ensure careful use of antibiotics, then antibiotic resistance should decrease. So, does clinical decision support help?

The systematic reviewers came up with some interesting results. They found that use of clinical decision support improved antibiotic coverage. Use of clinical decision support was also associated with “marginally lowered mortality,” as well as “lower antibiotic utilisation, increased compliance with antibiotic guidelines, and reductions in antimicrobial resistance.”

There were problems with the trials in the systematic review—some were of poor quality, but all were different and this heterogeneity of both studies and interventions made it difficult to draw firm conclusions. There may also have been publication bias.

The heterogeneity of the studies and interventions is interesting. This is because antibiotic resistance is a multifaceted phenomenon and so there is unlikely to be a single intervention that will fix it. In fact, focusing too much on antibiotics misses many opportunities for earlier intervention. Could clinical decision support help healthcare professionals during diagnosis so that they come to the conclusion that their patient doesn’t have an infection in the first place? Or that they have a viral infection? Or that non-drug management is possible? Or if in the final analysis they do need to prescribe antibiotics, they will prescribe the correct dose for the correct duration? When antibiotic resistance has already occurred, it is likely that interventions will be far too late.

But for clinical decision support to enable early intervention to prevent antibiotic resistance, it will need to fit with the clinical workflow—from assessment, to diagnosis, to differential diagnosis, to non-drug management. Our work with users of BMJ Best Practice has shown us that this fit with the clinical workflow is vital for clinical decision support to work at the point of care. Another important feature is speed. Clinicians have minutes to make decisions—support for such decisions needs to give them answers within seconds. And these seconds are important—they could save years of searching for new antibiotics.

Kieran Walsh is clinical director of BMJ Learning and BMJ Best Practice. He is responsible for the editorial quality of both products. He has worked in the past as a hospital doctor—specialising in care of the elderly medicine and neurology.

Competing interests: Kieran Walsh works for BMJ, which produces resources in clinical decision support and medical education.