CME: Analyzing Inappropriate Antibiotic Use

CME: Analyzing Inappropriate Antibiotic Use
Author Information (click to view)

Gregory A. Filice, MD

Chief, VA Infectious Disease Section
Minneapolis Veterans Affairs Health Care System
Professor of Medicine
Adjunct Professor of Epidemiology & Community Health
University of Minnesota School of Public Health

Gregory A. Filice, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

Figure 1 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

 

  • Explain the impact of inappropriate antibiotic use on patient outcomes in the United States.
  • Discuss the findings of a study that sought to detail the relationship between diagnostic errors and inappropriate antimicrobial treatment courses.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwMar6.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

FACULTY DISCLOSURES

Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Gregory A. Filice, MD
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Gregory A. Filice, MD (click to view)

Gregory A. Filice, MD

Chief, VA Infectious Disease Section
Minneapolis Veterans Affairs Health Care System
Professor of Medicine
Adjunct Professor of Epidemiology & Community Health
University of Minnesota School of Public Health

Gregory A. Filice, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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Misdiagnosis often leads to improper antibiotic use in hospitals, according to published research. Efforts are needed to develop tools and strategies to help clinicians decrease unnecessary and potentially harmful antibiotic use.
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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.

 

Misdiagnoses Common

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).

 

Inappropriate Use

“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.

 

Important Implications

“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.

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