A Risk-Based Clinical Decision Support System for Patient-Specific Antimicrobial Therapy (iBiogram): Design and Retrospective Analysis.

BACKGROUND: There is a pressing need for digital tools that can leverage big data to help clinicians select effective antibiotic treatments in the absence of timely susceptibility data. Clinical presentation and local epidemiology can inform therapy selection to balance the risk of antimicrobial resistance and patient risk. However, data and clinical expertise must be appropriately integrated into clinical workflows. OBJECTIVE: The aim of this study is to leverage available data in electronic health records, to develop a data-driven, user-centered, clinical decision support system to navigate patient safety and population health. METHODS: We analyzed 5 years of susceptibility testing (1,078,510 isolates) and patient data (30,761 patients) across a large academic medical center. After curating the data according to the Clinical and Laboratory Standards Institute guidelines, we analyzed and visualized the impact of risk factors on clinical outcomes. On the basis of this data-driven understanding, we developed a probabilistic algorithm that maps these data to individual cases and implemented iBiogram, a prototype digital empiric antimicrobial clinical decision support system, which we evaluated against actual prescribing outcomes. RESULTS: We determined patient-specific factors across syndromes and contexts and identified relevant local patterns of antimicrobial resistance by clinical syndrome. Mortality and length of stay differed significantly depending on these factors and could be used to generate heuristic targets for an acceptable risk of underprescription. Combined with the developed remaining risk algorithm, these factors can be used to inform clinicians' reasoning. A retrospective comparison of the iBiogram-suggested therapies versus the actual prescription by physicians showed similar performance for low-risk diseases such as urinary tract infections, whereas iBiogram recognized risk and recommended more appropriate coverage in high mortality conditions such as sepsis. CONCLUSIONS: The application of such data-driven, patient-centered tools may guide empirical prescription for clinicians to balance morbidity and mortality with antimicrobial stewardship.

The COVID-19 Pandemic and Internal Labour Migration in India: A 'Crisis of Mobility'.

This paper examines the impact of COVID-19 pandemic on migration. The rapid spread of the pandemic caught countries across the world off guard, resulting in widespread lockdowns that clamped down on mobility, commercial activities and social interactions. In India, the pandemic precipitated a severe 'crisis of mobility', with migrant labourers in many major cities seeking to return to their hometowns. Their desperate attempts to return home by any means available rendered the lockdown ineffective in several areas, prompting clashes with authorities, last-minute policy relief and, eventually, the arrangement of transport measures. This paper aims to shed light on the vulnerability of India's internal migrants in terms of their mobility, gender and mental health. In addition, it critically analyses the limitations of public policy in addressing migrants and suggests recommendations for the way ahead.