In recent years, there has been increased attention on the overprescribing of antimicrobials due to a surge in drug-resistant bacteria and superbugs. Current estimates show that about 2 million Americans are sickened and another 23,000 die from drug-resistant infections each year. These issues persist despite quality improvement efforts and the launching of campaigns to fight the problem.
According to published research, antibiotics are used in approximately 56% of inpatients who are cared for in hospitals in the United States. However, antibiotic use is deemed inappropriate in nearly half of these cases. The inappropriate use of antibiotics can contribute to significant health issues, including antibiotic resistance, clinical failure, adverse drug events, and excessive costs.
In a retrospective study published in Infection Control & Hospital Epidemiology, Gregory A. Filice, MD, and colleagues sought to detail the relationship between diagnostic errors and inappropriate antimicrobial treatment courses. The authors analyzed 500 randomly selected inpatient cases at the Minneapolis VA Medical Center in which an antimicrobial course was prescribed between October 2007 and September 2008. Four reviewers who were board-certified in internal medicine and infectious diseases then assessed the accuracy of the initial provider diagnosis for the condition that led to the antimicrobial course and whether or not the course was appropriate.
Study results showed that initial provider diagnoses were correct in more than half of cases the cases assessed, but many were incorrect or had diagnostic accuracy that was undeterminable. In 6% of cases, the initial provider’s diagnosis was a sign or symptom rather than a syndrome or disease.
“Overall, only 58% of patients received a correct diagnosis,” says Dr. Filice. “This indicates that diagnostic errors were more prevalent in our study than what has been seen in previous studies unrelated to antimicrobial use.” Several common incorrect diagnoses were also identified by the research team (Table).
“When the diagnosis from the initial provider was correct, 62% of antimicrobial courses were deemed appropriate,” says Dr. Filice. However, antimicrobial courses were deemed appropriate in only 5% of cases when the diagnosis was incorrect or indeterminate or when providers were treating a sign or symptom rather than a syndrome or disease.
When the research team further explored cases in which antimicrobial courses were not deemed appropriate, the reasons varied by diagnostic accuracy. For example, incorrect antimicrobials were selected in 73% of cases when the diagnosis was correct. In 84% of other cases, antimicrobial therapy was not indicated. “This incorrect use of antibiotics can cause patient harm, reduce the effectiveness of antibiotics, and increase healthcare costs,” Dr. Filice says.
“Hospitalized patients are a complicated group to manage and often have underlying diseases or comorbidities that make treating them even more challenging,” says Dr. Filice. “This can contribute to incorrect diagnoses and inappropriate use of antibiotics at hospitals.” He adds that healthcare providers are often forced to rely on intuitive processes rather than taking an analytical approach that is safer, more reliable, and more effective.
The investigators also note that many healthcare providers are under considerable pressure due to being overworked and significant time constraints when seeing a high volume of patients. Many physicians also experience fatigue, sleep deprivation, and/or mental overload more often when working in the inpatient setting. “In addition, doctors frequently receive patients with a previous diagnosis from another physician,” Dr. Filice says. Other contributing factors that can lead to an inaccurate diagnosis and inappropriate antibiotic use include a lack of clinical experience and minimal personal experience with adverse drug effects.
Seeing the Big Picture
Throughout the U.S., hospitals are launching antimicrobial stewardship programs to oversee antibiotic use, but Dr. Filice emphasizes that it is important to design these initiatives to help healthcare providers make accurate diagnoses initially and empower them to know when antibiotics can be safely withheld. “There are times when it makes more sense to watch and observe rather than prescribe patients an antibiotic,” he says.
More research is needed to improve diagnostic accuracy because it is integral to the safe use of antibiotics, according to Dr. Filice. “To improve the use of antibiotics in healthcare, we must look for tools and strategies that help clinicians decrease unnecessary and potentially harmful antibiotic use,” he says. “This is a critical step toward improving outcomes, preserving antimicrobial efficacy, and decreasing healthcare costs.”
Readings & Resources (click to view)
Filice GA, Drekonja DM, Thurn HR, et al. Diagnostic errors that lead to inappropriate antimicrobial use. Infect Control Hosp Epidemiol 2015;36:949-956. Available at: http://journals.cambridge.org/action/displayAbstract?aid=9850558&fileId=S0899823X15001130.
Drekonja DM, Filice GA, Greer N, et al. Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol. 2015;36:142-152.
Filice GA, Drekonja DM, Thurn JR, et al. Use of a computer decision support system and antimicrobial therapy appropriateness. Infect Control Hosp Epidemiol. 2013;34:558-565.
Linkin DR, Fishman NO, Landis JR, et al. Effect of communication errors during calls to an antimicrobial stewardship program. Infect Control Hosp Epidemiol. 2007;28:1374-1381.