Pharmacy World & Science

, Volume 29, Issue 4, pp 342–349 | Cite as

Clinical decision support systems and antibiotic use

  • Nada Atef SheblEmail author
  • Bryony Dean Franklin
  • Nick Barber
Review Paper



To review and appraise randomised controlled trials (RCT) and ‘before and after' studies published on clinical decision support systems (CDSS) used to support the use of antibiotics.


A literature search was carried out in October 2006 using MEDLINE including Medical Subject Heading (MeSH) terms (1966–2006), EMBASE (Excerpta Medica, 1980–2006) and International Pharmaceutical Abstracts (IPA, 1970–2006) using the combinations of the following terms: (Decision support systems) or (CDSS) AND (antibiotics) or (anti-infectives) or (antibacterials) or (antimicrobials). Only English language papers were selected. Editorials, letters and case reports/series were excluded. The reference sections of all retrieved articles were also searched for any further relevant articles.


Forty articles were identified. Five RCT and six ‘before and after' studies were retrieved. In the RCTs, three studies used computer-based CDSS, one paper-based CDSS and one a combination of both. Two studies were conducted in primary care and three within secondary care. The primary outcomes for each study were different and only three studies were significant in the favour of the use of CDSS. ‘Before and after' studies were used where RCT were not feasible. One ‘before and after' study was excluded because it did not include any control group. The remaining five included historical control groups and evaluated the use of computer-based CDSS within secondary care. Their primary outcomes also varied but all concluded significant benefits of CDSS. Only three of ten studies were conducted outside the USA; one in Switzerland and two in Australia.


CDSS could be a powerful tool to improve clinical care and patient outcomes. It presents a promising future for optimising antibiotic use. However, it is difficult to generalise as most studies were conducted in the United States. Although RCT are the ‘gold standard' in research, they may not be feasible to conduct. Realising that different study designs answer different questions would allow researchers to choose the most appropriate study design to evaluate CDSS in a specified setting.


Antibacterials Antibiotics Anti-infectives Antimicrobials Clinical decision support Decision support system 



Nada Shebl is partly funded by the UK Overseas Research Award Scheme.


  1. 1.
    Bates DW. Using information technology to reduce rates of medication errors in hospitals. Br Med J 2000;320:788–91.CrossRefGoogle Scholar
  2. 2.
    Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. J Am Med Assoc 1998;280:1311–6.CrossRefGoogle Scholar
  3. 3.
    Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma’luf N, et al. The impact of computerised physician order entry on medication error prevention. J Am Med Inform Assoc 1999;6(4):313–21.PubMedGoogle Scholar
  4. 4.
    Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety. Arch Intern Med 2003;163:1409–16.PubMedCrossRefGoogle Scholar
  5. 5.
    Kawamoto K, Houlihan CA, Balas A, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. Br Med J 2005;330: 765–8.CrossRefGoogle Scholar
  6. 6.
    Bates DW, Cohen M, Leape LL, Overhage JM, Shabot MM, Sheridan T. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc 2001;8(4):299–308.PubMedGoogle Scholar
  7. 7.
    Sim I, Gorman P, Greenes RA, Haynes RB, Kaplan B, Lehmann H, et al. Clinical decision support systems for the practice of evidence-based medicine. J Am Med Inform Assoc 2001;8(6):527–34.PubMedGoogle Scholar
  8. 8.
    Hulgan T, Rosenbloom ST, Hargrove F, Talbert DA, Arbogast PG, Bansal P, et al. Oral quinolones in hospitalized patients: an evaluation of a computerized decision support intervention. J Intern Med 2004;256(4):349–57.PubMedCrossRefGoogle Scholar
  9. 9.
    House of Lords Select Committee on Science and Technology-Seventh Report. Resistance to Antibiotics and Other Antimicrobial Agents, 1998. [http://www.parliament.the-stationery-] (January 4th 2006).Google Scholar
  10. 10.
    Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326(5):281–6.PubMedCrossRefGoogle Scholar
  11. 11.
    Lee KR, Leggiadro RJ, Burch KJ. Drug use evaluation of antibiotics in a paediatric teaching hospital. Infect Control Hosp Epidemiol 1994; 15:710–2.PubMedGoogle Scholar
  12. 12.
    Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice guidelines through computer-assisted decision support. Ann Intern Med 1996;124(10):884–90.PubMedGoogle Scholar
  13. 13.
    Mullet CJ, Thomas JG. Database-driven computerized antibiotic decision support: novel use of expert antibiotic susceptibility rules embedded in a pathogen antibiotic logic matrix. In: Musen M, editor. AMIA 2003 Symposium-Biomedical and Health Informatics: From Foundations to Applications [Proceedings]. Washington, DC: American Medical Informatics Association; 2003. p. 480–3.Google Scholar
  14. 14.
    Pestotnik SL, Evans RS, Burke JP, Gardner RM, Classen DC. Therapeutic antibiotic monitoring: surveillance using computerized expert system. Am J Med 1990;88(1):43–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Evans RS, Classen DC, Pestotnik SL, Lundsgaarde HP, Burke JP. Improving empiric antibiotic selection using computer decision support. Arch Intern Med 1994;154:878–84.PubMedCrossRefGoogle Scholar
  16. 16.
    Evans RS, Pestotnik SL, Classen DC, Clemmer TP, Weaver LK, Orme JF Jr, et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998;338(4):232–38.PubMedCrossRefGoogle Scholar
  17. 17.
    Morell R, Wasilauskas B, Winslow R. Personal computer-based expert system for quality assurance of antimicrobial therapy. Am J Hosp Pharm 1993;50:2067–73.Google Scholar
  18. 18.
    Schurink CAM, Lucas PJF, Hoepelman IM, Bonten MJM. Computer-assisted decision support for the diagnosis and treatment of infectious diseases in intensive care units. Lancet Infect Dis 2005; 5:305–12.PubMedCrossRefGoogle Scholar
  19. 19.
    Warner H Jr, Blue SR, Sorenson D, Reimer L, Li L, Nelson M, Barton M, et al. New computer-based tools for empiric antibiotic decision support. In: Masys DR, editor. AMIA 1997 Annual Fall Symposium [Proceedings]. Washington, DC: American Medical Informatics Association; 1997. p. 238–42.Google Scholar
  20. 20.
    Day D, Lubowski TJ, Yamaga CC, Main J, Van Vleet J, Ambegaonkar A. Computer assisted evaluation of antibiotic regimen coverage and cost. Clin Ther 1999;21(8):1418–25.PubMedCrossRefGoogle Scholar
  21. 21.
    Schmidt R., Gierl L. Case-based reasoning for antibiotics therapy advice: an investigation of retrieval algorithms and prototypes. Artif Intell Med 2001;23:171–86.PubMedCrossRefGoogle Scholar
  22. 22.
    Christakis DA, Zimmerman FJ, Wright JA, Garrison MM, Rivara FP, Davis RL. A randomized controlled trial of point-of-care evidence to improve the antibiotic prescribing practices for otitis media in children. Pediatrics 2001;107(2):1–4.CrossRefGoogle Scholar
  23. 23.
    Randolph AG, Haynes B, Jeremy C, Wyatt MD, Cook DJ, Guyatt GH. How to use an article evaluating the clinical impact of a computer-based clinical decision support system. J Am Med Assoc 1999;282:67–74.CrossRefGoogle Scholar
  24. 24.
    Smith F. Research methods in pharmacy practice. London: Pharmaceutical Press; 2002.Google Scholar
  25. 25.
    Bowling A. Research methods in health-Investigating health and health services. 2nd ed. Buckingham: Open University Press; 2002.Google Scholar
  26. 26.
    Christakis DA, Zimmerman FJ, Wright JA, Garrison MM, Rivara FP, Davis RL. A randomized controlled trial of point-of-care evidence to improve the antibiotic prescribing practices for otitis media in children. Pediatrics 2001;107(2):1–4.CrossRefGoogle Scholar
  27. 27.
    Shojania KG, Yokoe D, Platt R, Fiskio J, Ma’luf N, Bates DW. Reducing vancomycin use utilizing a computer guideline. J Am Med Inform Assoc 1998;5:554–62.PubMedGoogle Scholar
  28. 28.
    Samore MH, Bateman K, Alder SC, Hannah E, Donnelly S, Stoddard GJ, et al. Clinical decision support and appropriateness of antimicrobial prescribing. J Am Med Assoc 2005;294:2305–14.CrossRefGoogle Scholar
  29. 29.
    Senn L, Burnand B, Francioli P, Zanetti G. Improving appropriateness of antibiotic therapy: randomized trial of an intervention to foster reassessment of prescription after 3 days. J Antimicrob Chemother 2004;53(6):1062–7.PubMedCrossRefGoogle Scholar
  30. 30.
    McGregor JC, Weekes E, Forrest GN, Standiford HC, Perencevich EN, Furuno JP, Harris AD. Impact of a computerized clinical decision support system on reducing inappropriate antimicrobial use: a randomized controlled trial. J Am Med Inform Assoc. 2006;13(4):378–84.PubMedCrossRefGoogle Scholar
  31. 31.
    Larsen RA, Evans RS, Burke JP, Pestotnik SL, Gardner RM, Classen DC. Improved perioperative antibiotic use and reduced surgical wound infections through use of computer decision analysis. Infect Control Hosp Epidemiol 1989;10(7):316–20.PubMedCrossRefGoogle Scholar
  32. 32.
    Mullett CJ, et al. Development and impact of a computerized pediatric antiinfective decision support program. Pediatrics 2001;108(4):E75-E.CrossRefGoogle Scholar
  33. 33.
    Sintchenko V, Iredell JR, Gilbert GL, Coiera E. Handheld computer-based decision support reduces patient length of stay and antibiotic prescribing in critical care. J Am Med Inform Assoc 2005;12(4):398–402.PubMedCrossRefGoogle Scholar
  34. 34.
    Thursky KA, Buising KL, Bak N, Macgregor L, Street AC, Macintyre CR, Presneill JJ, Cade JF, Brown GV. Reduction of broad-spectrum antibiotic use with computerized decision support in an intensive care unit. Int J Qual Health Care 2006;18(3):224–31.PubMedCrossRefGoogle Scholar
  35. 35.
    Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes. JAMA 1998;280:1339–46.PubMedCrossRefGoogle Scholar
  36. 36.
    Johnston ME, Langton KB, Haynes RB Mathieu A. Effects of computer-based clinical decision support systems on clinician performance and patient outcome. Ann Intern Med 1994;120(2):135–42.PubMedGoogle Scholar
  37. 37.
    Kaplan B. Evaluating informatics applications-clinical decision support systems literature review. Int J Med Inform 2001;64:15–37.PubMedCrossRefGoogle Scholar
  38. 38.
    Walton RT, Harvery E, Dovey S, Freemantle N. Computerised advice on drug dosage to improve prescribing practice. The Cochrane Library 2006;1:1–22.Google Scholar
  39. 39.
    Bowling A, Ebrahim S. Handbook of health research methods: investigation, measurement and analysis. England: Open University Press; 2006.Google Scholar
  40. 40.
    Ruland CM, Bakken S. Developing, implementing and evaluating decision support systems for shared decision making in patient care: a conceptual model and case illustration. J Biomed Inform 2002;35:313–21.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Nada Atef Shebl
    • 1
    Email author
  • Bryony Dean Franklin
    • 2
  • Nick Barber
    • 1
  1. 1.Department of Practice and Policy, The School of PharmacyUniversity of LondonLondonUK
  2. 2.Center for Medication Safety and Service Quality, Hammersmith Hospitals NHS Trust and The School of PharmacyUniversity of LondonLondonUK

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