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| Name | Class |
|---|---|
| Centers for Disease Control and Prevention | FED |
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The goal of this prospective randomized study is to improve antibiotic use among hospitalized patients with suspected pneumonia. An alert was built into the electronic health record to guide use of diagnostic testing based on probability of bacterial pneumonia. Patients with test results suggesting viral infection will be randomized to either: (1) receive a structured communication from the antimicrobial stewardship team to de-escalate antibiotics or (2) usual care.
Low-risk patients with viral pneumonia do not benefit from and may be harmed by antibiotic therapy. In this study, an alert will appear in the electronic health record of patients undergoing molecular diagnostic testing for respiratory symptoms that provides options for diagnostic testing based on pre-test probability of bacterial infection. Patients with test results suggesting possible viral infection will be randomized to either usual care or to receive test results along with structured guidance from antimicrobial stewardship to consider discontinuing or de-escalating antibiotics. This guidance, which will include an explicit calculation of the post-test probability of bacterial infection based on considering risk factors, vital signs, symptoms, and available imaging, will be communicated to the primary care team via direct electronic message and a summary note in the patient's chart. The final decision on whether to continue antibiotic therapy will be up to the primary team. The primary outcome of interest will be in-hospital antibiotic use. Safety outcomes will include length of stay, readmissions, hospital-free days, and mortality.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Electronic alert plus structured communication of test results | Experimental | An electronic health record alert will guide diagnostic testing for pneumonia. For patients with low or moderate probability of bacterial pneumonia, test results will be communicated to the primary team with guidance to consider discontinuing or de-escalating antibiotics. |
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| Electronic alert without structured communication of test results | Active Comparator | An electronic health record alert will guide diagnostic testing for pneumonia. The primary care team will access and interpret test results and decide upon composition and duration of antimicrobial without external guidance. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Electronic alert | Behavioral | An alert will appear in the electronic health record that provides options for diagnostic testing based on low, medium, or high probability of bacterial pneumonia. |
| Measure | Description | Time Frame |
|---|---|---|
| Hospital antibiotic days of therapy | The aggregate sum of days for which any amount of a specific antimicrobial agent was administered during the hospital encounter, from arrival in the emergency department or on the hospital ward until discharge. | Up to 90 days after randomization |
| Measure | Description | Time Frame |
|---|---|---|
| Hospital length of stay | Duration of hospitalization from admission to discharge | Up to 90 days after randomization |
| In-hospital mortality | Death or discharge to hospice during initial hospitalization for any cause |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Daniel J. Morgan, MD, MS | University of Maryland, Baltimore | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| University of Maryland Medical Center - Midtown Campus | Baltimore | Maryland | 21201 | United States | ||
| University of Maryland Medical Center |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 41823187 | Result | Baghdadi JD, Harris AD, Pineles L, Al-Shanqeeti S, Palacio D, Charles DW, Heil E, Claeys KC, Bork JT, Sommerkamp S, Wilkerson RG, Godwin G, Sutherland ME, Johnson JK, Morgan DJ. Using Probability of Community-Acquired Pneumonia to Tailor Antimicrobials Among Inpatients: A Pragmatic, Randomized Trial. Clin Infect Dis. 2026 Jul 8;82(6):954-961. doi: 10.1093/cid/ciag126. |
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| ID | Term |
|---|---|
| D011014 | Pneumonia |
| D011024 | Pneumonia, Viral |
| D018410 | Pneumonia, Bacterial |
| ID | Term |
|---|---|
| D012141 | Respiratory Tract Infections |
| D007239 | Infections |
| D008171 | Lung Diseases |
| D012140 | Respiratory Tract Diseases |
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This study involves a randomized trial embedded within a quasi-experiment. During the 1-year study period, we anticipate that 1,500 patients will be exposed to the electronic health record modification performed as part of the quasi-experiment. Regarding the randomized trial, if 100 patients are enrolled during the 1-year study period, including 50 in intervention patients and 50 controls, we anticipate that we will have sufficient precision to estimate the difference in binary outcomes (e.g., antibiotic discontinuation within 5 days) between the two groups with a margin of error of approximately 15% based on a 95% confidence interval.
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| Structured communication of test results | Behavioral | A clinical research team member will send an electronic message to the primary care team on behalf of the antimicrobial stewardship program with structured guidance to stop or de-escalate antibiotics and document these recommendations in the patient's chart. |
|
| Up to 90 days after randomization |
| Readmissions within 30-days of randomization | Readmissions for any cause within 30-days of randomization | Within 30 days after randomization |
| C. difficile infections in the 30-days post-randomization | Positive test for C. difficile associated with initiation of antibiotics targeting C. difficile. | Within 30 days after randomization |
| Acute kidney injury | Defined by an elevation in creatinine of > 0.5mg/dl or 2x baseline in a patient without previous end-stage renal disease. | Within 14 days of randomization |
| Ventilator-free days in the 30-days post-randomization | Days without a requirement for mechanical ventilation in the 30 days after randomization. | 30 days after randomization. |
| Hospital-free days in the 30-days post-randomization | Days without hospitalization in the 30 days after randomization. | 30 days after randomization. |
| Antibiotic de-escalations within 72 hours after initiation | Including narrowing, discontinuing, or converting the route of administration from intravenous to oral. | 3 days after randomization. |
| Baltimore |
| Maryland |
| 21201 |
| United States |
| D014777 |
| Virus Diseases |
| D001424 | Bacterial Infections |
| D001423 | Bacterial Infections and Mycoses |