This article is more than 5 years old. Information may no longer be current.
Inaccurate diagnoses result in unneeded antimicrobials
Click Here to Manage Email Alerts
Inaccurate diagnoses often lead to inappropriate prescribing of antimicrobials, which in turn can lead to negative patient outcomes with increased costs and drug resistance, according to research published in Infection Control and Hospital Epidemiology.
“Antimicrobial therapy is used in approximately 56% of inpatients in U.S. hospitals,” Gregory A. Filice, MD, infectious disease section of Minneapolis Veterans Affairs Health Care System, and colleagues wrote. “Unfortunately, antimicrobial therapy is inappropriate in approximately half of cases. Antimicrobial stewardship programs have been introduced to improve antimicrobial therapy, but in most cases improvements are modest.”
The researchers conducted a retrospective cohort study of 500 randomly selected inpatients (median age, 66 years; 97% men) from the Minneapolis VA Medical Center who had received antimicrobials for treatment between October 2007 and September 2008. Results of the study were first presented at IDWeek 2014.
Gregory A. Filice
Filice and colleagues determined that 58% of provider diagnoses for these patients were accurate and 31% were inaccurate. The remainder were cases where accuracy could not be determined, or where the diagnosis was incomplete.
For all cases, the diagnoses were found to be correct 92% of the time when the providers had strong clinical evidence on which to base their diagnoses, and only 4% (P < .001) in cases where evidence was considered suspect, Filice and colleagues wrote. When diagnoses were correct, antimicrobial courses were appropriate in 62% of cases. That number dropped to 5% (P < .001) in cases where diagnoses were found to be incorrect or indeterminate or when providers treated a symptom rather than a disease.
When the index condition was related to the reason the patient was admitted to the hospital, the health care provider was much more likely to offer a correct diagnosis (71%) than when the index condition was unrelated to the reason for admission (36%; P < .001), according to the researchers. Compared with other diagnoses, the OR for a correct diagnosis was reduced when the diagnosis was pneumonia (0.39; 95% CI, 0.22-0.7) or cystitis, pyelonephritis or urosepsis (0.18; 95% CI, 0.1-0.32), which are the two most common diagnostic groups.
Reasons for misdiagnosis and inappropriate use of antibiotics can include fatigued health care workers, relying on previous patient diagnoses or intuition rather than a more analytical process, and a lack of clinical experience, the researchers wrote.
It may be time to put to rest the notion of antibiotics as a panacea, according to the researchers.
“Antimicrobials have been labeled drugs of fear in that fear of bad outcomes, however unlikely, leads to antimicrobial overuse despite associated risks, including adverse effects in individual patients and relentless increases in antimicrobial resistance generally,” Filice and colleagues wrote. “[Our research suggests] that antimicrobial stewardship programs could increase their impact if they were designed to help providers make accurate initial diagnoses and to help providers know when antimicrobial therapy can be safely withheld.” – by David Jwanier
For more information:
Filice GA, et al. Infect Control Hosp Epidemiol. 2015;doi:10.1017/ice.2015.113.
Filice GA, et al. Abstract 609. Presented at: IDWeek; Oct. 8-12, 2014; Philadelphia.
Disclosure: Filice reports no relevant financial disclosures. Please the full study for a list of all other authors’ relevant financial disclosures.
Perspective
Back to Top
Thomas M. File Jr., MD
The discovery of potent antimicrobial agents was one of the greatest contributions to medicine in the 20th century. When introduced, they had an immediate and dramatic impact on the outcomes of infectious diseases, making once-lethal infections readily curable. Unfortunately, the emergence of antimicrobial-resistant pathogens now threatens these advances. There is no question that antibiotic misuse is the most important modifiable factor that leads to antimicrobial resistance.
The study by Filice and colleagues highlights that approximately half of antimicrobial use in U.S. hospitals is inappropriate — much of this is due to errors in diagnosis. As indicated in their report, antimicrobials are often prescribed as drugs of fear and often used to treat “just in case.” Much of this fear can be related to inexperience or misinterpretation of information. One limitation of the study as mentioned by the authors is the retrospective nature, which precludes direct communication with the prescriber.
We have found during our stewardship rounds that direct discussion with the prescriber during prospective assessment occasionally reveals unknown circumstances, which may be more permissible of antimicrobial use. Nevertheless, there are many instances of inappropriate use of antimicrobials (eg, use of antibacterials for viral RTIs or asymptomatic bacteriuria in nonpregnant women, or unnecessary prolonged duration of therapy).
The good news is that we do have a solution to this problem. As the authors suggest, antimicrobial stewardship programs (ASP) could help providers make more accurate initial diagnoses and help providers know when antimicrobial therapy can be safely withheld. ASPs have proven successful in improving antibiotic use and can improve patient outcomes, reduce adverse events and reduce antibiotic resistance. The proven benefits of ASPs have led to increasing calls for their implementation in all hospitals (including the recent White House release of March, 27, 2015, National Action Plan for Combating Antimicrobic-Resistant Bacteria). Appropriate antimicrobial prescribing with input from an effective ASP is vital to the effective therapy of infections for now and in the future.
Click Here to Manage Email Alerts