Hostname: page-component-848d4c4894-v5vhk Total loading time: 0 Render date: 2024-06-18T15:30:24.716Z Has data issue: false hasContentIssue false

Diagnostic Errors that Lead to Inappropriate Antimicrobial Use

Published online by Cambridge University Press:  18 May 2015

Gregory A. Filice*
Affiliation:
Infectious Disease Section, Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota Infectious Disease Section, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
Dimitri M. Drekonja
Affiliation:
Infectious Disease Section, Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota Infectious Disease Section, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
Joseph R. Thurn
Affiliation:
Infectious Disease Section, Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota Infectious Disease Section, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
Galen M. Hamann
Affiliation:
Infectious Disease Section, Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
Bobbie T. Masoud
Affiliation:
Infectious Disease Section, Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
James R. Johnson
Affiliation:
Infectious Disease Section, Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota Infectious Disease Section, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
*
Address correspondence to Gregory A. Filice, MD, Infectious Disease Section (111F), Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Minneapolis, MN 55417 (filic001@umn.edu).

Abstract

OBJECTIVE

We found previously that inappropriate inpatient antimicrobial use was often attributable to erroneous diagnoses. Here, we detail diagnostic errors and their relationship to inappropriate antimicrobial courses.

DESIGN

Retrospective cohort study

SETTING

Veterans Affairs hospital

PATIENTS

A cohort of 500 randomly selected inpatients with an antimicrobial course

METHODS

Blinded reviewers judged the accuracy of the initial provider diagnosis for the condition that led to an antimicrobial course and whether the course was appropriate.

RESULTS

The diagnoses were correct in 291 cases (58%), incorrect in 156 cases (31%), and of indeterminate accuracy in 22 cases (4%). In the remaining 31 cases (6%), the diagnosis was a sign or symptom rather than a syndrome or disease. The odds ratio of a correct diagnosis was 4.3 (95% confidence interval [CI], 2.2–8.5) if the index condition was related to the reason for admission. When the diagnosis was correct, 181 of 292 courses (62%) were appropriate, compared with only 10 of 208 (5%) when the diagnosis was incorrect or indeterminate or when providers were treating a sign or symptom rather than a syndrome or disease (P<.001). Among the 309 cases in which antimicrobial courses were not appropriate, reasons varied by diagnostic accuracy; in 81 of 111 cases (73%) with a correct diagnosis, incorrect antimicrobial(s) were selected; in 166 of 198 other cases (84%), antimicrobial therapy was not indicated.

CONCLUSIONS

Diagnostic accuracy is important for optimal inpatient antimicrobial use. Antimicrobial stewardship strategies should help providers avoid diagnostic errors and know when antimicrobial therapy can be withheld safely.

Infect Control Hosp Epidemiol 2015;36(8):949–956

Type
Original Articles
Copyright
© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

PREVIOUS PRESENTATION. Information presented in this article was previously presented in Program and Abstracts, ID Week, Philadelphia, Pennsylvania, October 8–12, 2014.

References

1. Fridkin, S, Baggs, J, Fagan, R, et al. Vital signs: improving antibiotic use among hospitalized patients. MMWR Morb Mortal Wkly Rep 2014;63:194200.Google Scholar
2. Dellit, TH, Owens, RC, McGowan, JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159177.Google Scholar
3. Ohl, CA, Luther, VP. Antimicrobial stewardship for inpatient facilities. J Hosp Med 2011;6(Suppl 1):S4S15.Google Scholar
4. Hecker, MT, Aron, DC, Patel, NP, Lehmann, MK, Donskey, CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med 2003;163:972978.Google Scholar
5. Micek, ST, Welch, EC, Khan, J, et al. Empiric combination antibiotic therapy is associated with improved outcome against sepsis due to Gram-negative bacteria: a retrospective analysis. Antimicrob Agents Chemother 2010;54:17421748.Google Scholar
6. Kollef, MH, Sherman, G, Ward, S, Fraser, VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 1999;115:462474.CrossRefGoogle ScholarPubMed
7. Classen, DC, Pestotnik, SL, Evans, RS, Burke, JP. Computerized surveillance of adverse drug events in hospital patients. JAMA 1991;266:28472851.CrossRefGoogle ScholarPubMed
8. Smolinski, M, Hamburg, M, Lederberg, J. Microbial Threats to Health. Emergence, Detection, and Response. Washington, DC: The National Academies Press, 2003.Google Scholar
9. Bartlett, JG. A call to arms: the imperative for antimicrobial stewardship. Clin Infect Dis 2011;53(Suppl 1):S4S7.Google Scholar
10. European Centre for Disease Prevention and Control and European Medicines Agency. ECDC/EMEA JOINT TECHNICAL REPORT. The bacterial challenge: time to react. Stockholm, Sweden: European Centre for Disease Prevention and Control and European Medicines Agency. http://www.ecdc.europa.eu/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf. Published 2009. Accessed December 29, 2011.Google Scholar
11. Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol 2012;33:322327.Google Scholar
12. Filice, GA, Drekonja, DM, Thurn, JR, et al. Use of a computer decision support system and antimicrobial therapy appropriateness. Infect Control Hosp Epidemiol 2013;34:558565.Google Scholar
13. Graber, ML, Franklin, N, Gordon, R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:14931499.CrossRefGoogle ScholarPubMed
14. Schwartz, DN, Wu, US, Lyles, RD, et al. Lost in translation? Reliability of assessing inpatient antimicrobial appropriateness with use of computerized case vignettes. Infect Control Hosp Epidemiol 2009;30:163171.Google Scholar
15. Linkin, DR, Fishman, NO, Landis, JR, et al. Effect of communication errors during calls to an antimicrobial stewardship program. Infect Control Hosp Epidemiol 2007;28:13741381.Google Scholar
16. Braykov, NP, Morgan, DJ, Schweizer, ML, et al. Assessment of empirical antibiotic therapy optimisation in six hospitals: an observational cohort study. Lancet Infect Dis 2014;14:12201227.Google Scholar
17. Berner, ES, Graber, ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121:S2S23.Google Scholar
18. Croskerry, P, Singhal, G, Mamede, S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf 2013;22(Suppl 2):ii58ii64.Google Scholar
19. Mamede, S, van Gog, T, van den Berge, K, et al. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA 2010;304:11981203.Google Scholar
20. Kahneman, D. Thinking Fast and Slow. New York: Farrar, Straus and Giroux, 2011.Google Scholar
21. Croskerry, P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78:775780.CrossRefGoogle Scholar
22. Chinburapa, V, Larson, LN, Brucks, M, Draugalis, J, Bootman, JL, Puto, CP. Physician prescribing decisions: the effects of situational involvement and task complexity on information acquisition and decision making. Soc Sci Med 1993;36:14731482.Google Scholar
23. Barlow, G, Nathwani, D, Myers, E, et al. Identifying barriers to the rapid administration of appropriate antibiotics in community-acquired pneumonia. J Antimicrob Chemother 2008;61:442451.Google Scholar
24. Avorn, J, Solomon, DH. Cultural and economic factors that (mis)shape antibiotic use: the nonpharmacologic basis of therapeutics. Ann Intern Med 2000;133:128135.Google Scholar
25. Hulscher, ME, Grol, RP, van der Meer, JW. Antibiotic prescribing in hospitals: a social and behavioural scientific approach. Lancet Infect Dis 2010;10:167175.Google Scholar
26. Steinman, MA, Landefeld, CS, Gonzales, R. Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care. JAMA 2003;289:719725.Google Scholar
27. Kunin, CM, Tupasi, T, Craig, WA. Use of antibiotics. A brief exposition of the problem and some tentative solutions. Ann Intern Med 1973;79:555560.Google Scholar
28. Cadieux, G, Tamblyn, R, Dauphinee, D, Libman, M. Predictors of inappropriate antibiotic prescribing among primary care physicians. CMAJ 2007;177:877883.Google Scholar
29. Arnold, SR. Revenge of the killer microbe. CMAJ 2007;177:895896.CrossRefGoogle ScholarPubMed
30. Drekonja, DM, Amundson, WH, Decarolis, DD, Kuskowski, MA, Lederle, FA, Johnson, JR. Antimicrobial use and risk for recurrent Clostridium difficile infection. Am J Med 2011;124:1081.e11081.e7.CrossRefGoogle ScholarPubMed
31. Drekonja, DM, Okoye, NC, Kuskowski, MA, Johnson, JR. Appropriateness of urinary tract infection diagnosis and treatment duration. Arch Intern Med 2010;170:489490.Google Scholar
32. Croskerry, P, Singhal, G, Mamede, S. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf 2013;22(Suppl 2):ii65ii72.Google Scholar
33. Croskerry, P, Nimmo, GR. Better clinical decision making and reducing diagnostic error. J R Coll Physicians Edinb 2011;41:155162.Google Scholar
34. Trowbridge, RL, Dhaliwal, G, Cosby, KS. Educational agenda for diagnostic error reduction. BMJ Qual Saf 2013;22(Suppl 2):ii28ii32.CrossRefGoogle ScholarPubMed
35. Pelaccia, T, Tardif, J, Triby, E, Charlin, B. An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Med Educ Online 2011;16:5890.CrossRefGoogle ScholarPubMed
36. McDonald, KM, Matesic, B, Contopoulos-Ioannidis, DG, et al. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Med 2013;158:381389.Google Scholar