{
  "abstract": "Background and Importance Antimicrobial resistance is a leading global health threat driven by inappropriate antimicrobial use, especially in hospitals. Antimicrobial stewardship (AMS) programs aim to optimise therapy, with dosing adjustment based on renal function being critical to prevent treatment failure and toxicity. However, incorrect dosing remains common due to complex manual prescription reviews. To address this, our institution developed a Clinical Decision Support System (CDSS) that integrates clinical data to provide real-time, patient-specific alerts based on pre-defined clinical rules (CRs).Aim and Objectives The present study aimed to design and evaluate the clinical impact of a bundle of CRs within our CDSS to identify patients requiring antimicrobial dose adjustment according to estimated glomerular filtration rate (eGFR), with the goal of optimising antimicrobial therapy, supporting AMS teams in individualised dosing, and preventing adverse drug events (ADEs).Material and Methods A multidisciplinary team of 6 clinical pharmacists specialised in infectious diseases, nephrology, and critical care performed a literature search and designed CRs to identify patients with augmented or impaired renal clearance requiring antimicrobial dose adjustment.Each CR was provided with adjustment recommendations according to the indication. These rules were embedded into the CDSS and piloted over six months. Alerts were reviewed by pharmacists, and clinical interventions were registered. To evaluate the clinical impact, we analysed the positive predictive value (PPV) of each CR (accepted interventions/generated alerts).Results The team defined 57 CRs. During the study period, the CDSS generated 492 alerts (3.94 alerts per working day). Pharmacist-led intervention occurred in 37% of alerts (180/492), with 66% (120/180) resulting in modified antimicrobial therapy to prevent potential ADEs.The overall PPV of the rules was 0.24. The CRs with the highest PPV were ‘Ceftazidime IV/IM and eGFR <50 mL/min’ (PPV=1) and ‘Amoxicillin/Clavulanate IV and eGFR <30 mL/min’ (PPV=0.67).Intervention acceptance rates were highest in medical units (73%), followed by surgical (67%) and critical care units (55%).Conclusion and Relevance The integration of renal function-based CRs into a CDSS significantly enhanced antimicrobial dosing precision and supported AMS efforts. The pharmacist-led review process enabled timely, clinically relevant interventions that reduced the risk of ADEs.Conflict of Interest No conflict of interest",
  "authors": [
    {
      "affiliations": [
        "Hospital General Universitario Gregorio Marañón, Hospital Pharmacy, Madrid, Spain"
      ],
      "name": "A García Souto"
    },
    {
      "affiliations": [
        "Hospital General Universitario Gregorio Marañón, Hospital Pharmacy, Madrid, Spain"
      ],
      "name": "B Torroba Sanz"
    },
    {
      "affiliations": [
        "Hospital General Universitario Gregorio Marañón, Hospital Pharmacy, Madrid, Spain"
      ],
      "name": "S Ibáñez García"
    },
    {
      "affiliations": [
        "University Hospital Clínico San Cecilio, Hospital Pharmacy, Granada, Spain"
      ],
      "name": "M Núñez-Núñez"
    },
    {
      "affiliations": [
        "University of Granada, Statistics and Operations Research, Granada, Spain"
      ],
      "name": "ME Velasco-García"
    },
    {
      "affiliations": [
        "Hospital General Universitario Gregorio Marañón, Hospital Pharmacy, Madrid, Spain"
      ],
      "name": "R Cabrer Barceló"
    },
    {
      "affiliations": [
        "Hospital General Universitario Gregorio Marañón, Hospital Pharmacy, Madrid, Spain"
      ],
      "name": "G Domínguez Chaparro"
    },
    {
      "affiliations": [
        "Ysengineers S.L., Information Systems, Málaga, Spain"
      ],
      "name": "JL De La Rosa Triviño"
    },
    {
      "affiliations": [
        "Hospital General Universitario Gregorio Marañón, Hospital Pharmacy, Madrid, Spain"
      ],
      "name": "A Herranz Alonso"
    },
    {
      "affiliations": [
        "Hospital General Universitario Gregorio Marañón, Hospital Pharmacy, Madrid, Spain"
      ],
      "name": "M Sanjurjo Sáez"
    }
  ],
  "title": "5PSQ-104 Smart alerts, safer doses: revolutionising antimicrobial therapy with renal function-driven clinical rules",
  "uid": "1b2a07fa-11dc-50d3-9128-a903b075e51c"
}