Diagnostic Errors Are Key Source of Inappropriate Antibiotic Use

Inaccurate diagnosis is an important contributor to inappropriate antimicrobial prescribing for hospitalized patients, according to a report in Infection Control and Hospital Epidemiology.

The retrospective analysis included a random sample of 500 patients receiving systemic antimicrobial drug treatment during a stay at a Veterans Affairs hospital. In blinded fashion, a panel of infectious disease physicians rated the accuracy of the initial diagnosis and the appropriateness of treatment.

The initial diagnosis was rated correct in 58 percent of cases, incorrect in 31 percent, and of indeterminate accuracy in 4 percent. In the remaining 6 percent of cases, the “diagnosis” was actually a sign or symptom rather than a disease or syndrome. Cystitis, pyelonephritis, and urosepsis were the diagnoses with the lowest rate of agreement between providers and reviewers—just 27 percent. The agreement rate for pneumonia was 48 percent.

Antimicrobial treatment was considered appropriate for 62 percent of cases when the diagnosis was correct but only 5 percent when the diagnosis was incorrect, indeterminate, or a sign or symptom. On analysis of 309 instances of inappropriate treatment, an incorrect antimicrobial was chosen for 73 percent of patients with a correct diagnosis. In cases of diagnostic error, antimicrobial treatment was not indicated in 84 percent of cases.

The study builds on previous results showing that inappropriate antimicrobial prescribing for hospitalized patients is often related to diagnostic error. Factors that may contribute to inaccurate diagnosis and inappropriate antibiotic use include reliance on intuitive processes, fatigue, previous diagnoses from other providers, and lack of experience [Filice GA, et al. Diagnostic errors that lead to inappropriate antimicrobial use. Infect Control Hosp Epidemiol 2015; doi:10.1017/ice.2015.113].