Lost in Translation? Reliability of Assessing Inpatient Antimicrobial Appropriateness With Use of Computerized Case Vignettes

Schwartz, David N.; Wu, Ulysses; Lyles, Rosie D.; Xiang, Yingxu; Kieszkowski, Piotr; Hota, Bala; Weinstein, Robert A.

doi:10.1086/593970

Cited by 25 publications

(23 citation statements)

References 17 publications

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“…14,15 The inter-rater agreement in this study was similar to that reported previously in studies of antimicrobial appropriateness. 14,15 Second, our cases were diverse, and judgments were complex, involving diagnostic accuracy and appropriateness of initial and subsequent antimicrobial choices, dose, route, and duration.…”

Section: Discussionsupporting

confidence: 88%

“…Criteria for appropriateness, in order of priority, were the following: (1) whether treatment followed CDSS recommendations, (2) alternatives consistent with published guidelines, high-quality evidence, and antimicrobial susceptibility patterns, and (3) reasonable alternatives, given specific circumstances. 14,15 Adjustments to antimicrobial therapy based on clinical response and test results were considered. 16 Reviewers ignored trivial errors (eg, 1-2-day deviations from recommended treatment durations) that were otherwise clinically appropriate.…”

Section: Accuracy Of Provider Diagnoses Of Index Conditionsmentioning

confidence: 99%

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Diagnostic Errors that Lead to Inappropriate Antimicrobial Use

Filice

Drekonja

Thurn

et al. 2015

Infect. Control Hosp. Epidemiol.

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Background. We have reported that diagnostic errors factor into 89% of inappropriate inpatient antimicrobial (AM) courses. Here we describe in detail the diagnostic errors that led to inappropriate courses.Methods. We studied AM courses given to 500 randomly selected VA hospital inpatients between 2007 and 2008. We recorded information about the syndrome or disease that led to AM use (index condition), the initial provider diagnosis of the index condition ( provider diagnosis), and AM drug(s), dose, route, and duration. Each case summary was assigned randomly to 2 of 4 blinded reviewers. Based on data available to providers in real time, reviewers classified the provider diagnosis as correct, uncertain, not correct, or a sign or symptom of a potential infection rather than a syndrome or disease (sign or symptom) and the index AM course as appropriate or not, considering drug selection, route, dose, and duration.Results. Overall, provider diagnoses were correct in 292/500 (58%) of cases, but accuracy varied by diagnosis. For the 6 most common diagnostic groups (376 [75%] of all cases), accuracy ranged from 90% for bacteremia or sepsis to 27% for cystitis, pyelonephritis, or urosepsis (P < .001). Provider AM courses were considered appropriate in 191/500 (38%) of cases overall, but appropriateness varied in relation to diagnostic accuracy. When provider diagnoses were correct, 181/292 (62%) of courses were appropriate compared with only 10/208 (5%) when diagnoses were incorrect, uncertain, or signs or symptoms (P < .001). Considering the 111 cases in which provider diagnoses were correct and AM courses were inappropriate, reasons included wrong AM drug(s) (81, 73%), wrong duration (43, 39%), wrong dose (5, 5%), another type of drug error (1, 1%), and AM therapy not indicated (11, 4%). In contrast, of the 198 cases in which provider diagnoses were incorrect or uncertain or were signs or symptoms and AM courses were inappropriate, AM therapy was not indicated in 171 (86%) cases. Other reasons included wrong AM drugs (31, 16%), incorrect duration (13, 7%), wrong dose (2, 1%), and another type of drug error (1, 0.5%).Conclusion. Efforts to improve AM courses should include strategies to help providers make accurate diagnoses of syndromes that might be due to infection.

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Section: Discussionsupporting

confidence: 88%

Section: Accuracy Of Provider Diagnoses Of Index Conditionsmentioning

confidence: 99%

Diagnostic Errors that Lead to Inappropriate Antimicrobial Use

Filice

Drekonja

Thurn

et al. 2015

Infect. Control Hosp. Epidemiol.

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“…Although it seems likely that administration of inappropriate therapy could lead to higher mortality in MRSA patients (18,39), a recent systematic review (26) argues that this has never been adequately assessed, since detailed analyses that take into account timeliness and drug levels of empirical therapy are still lacking. Moreover, poor interrater agreement on the multiple factors that influence judgments about appropriateness make it difficult to measure (34). A priori, one would also assume that inappropriate empirical therapy should have had a different impact in each participating center due to distinct local prescribing practices.…”

Section: Discussionmentioning

confidence: 99%

Clinical Impact of Antimicrobial Resistance in European Hospitals: Excess Mortality and Length of Hospital Stay Related to Methicillin-Resistant Staphylococcus aureus Bloodstream Infections

Kraker

Wolkewitz

Davey

et al. 2011

Antimicrob Agents Chemother

222

105

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. Their excess LOS was 9.2 days. MSSA patients also had higher 30-day (aOR ‫؍‬ 2.4) and hospital (aHR ‫؍‬ 3.1) mortality and an excess LOS of 8.6 days. When the outcomes from the two cohorts were compared, an effect attributable to methicillin resistance was found for 30-day mortality (OR ‫؍‬ 1.8; P ‫؍‬ 0.04), but not for hospital mortality (HR ‫؍‬ 1.1; P ‫؍‬ 0.63) or LOS (difference ‫؍‬ 0.6 days; P ‫؍‬ 0.96). Irrespective of methicillin susceptibility, S. aureus BSI has a significant impact on morbidity and mortality. In addition, MRSA BSI leads to a fatal outcome more frequently than MSSA BSI. Infection control efforts in hospitals should aim to contain infections caused by both resistant and susceptible S. aureus.The emergence of resistant bacteria is a natural consequence of antibiotic use and complicates the treatment of infected patients. Staphylococcus aureus resistant to isoxazolyl penicillins (methicillin-resistant S. aureus [MRSA]) is one of the most frequent pathogens causing resistant infections in hospitals worldwide (14,21,33). The questions are whether and to what extent resistance affects survival and the duration of hospital admission in patients with bacterial infections. Previous studies compared patients with MRSA infections to those infected by methicillin-susceptible S. aureus (MSSA), using mortality as one of the main endpoints. New insights challenge this approach for a number of reasons.Several studies have shown that patients with MRSA bloodstream infection (BSI) differ in many ways from those with MSSA BSI; they are older, have more comorbidities, and experience longer hospital admissions before the onset of infection (6,22,37). If these two groups of patients are compared directly, bias is introduced, compromising the validity of the results. Of all hospitalized patients at risk of acquiring MRSA BSI, the younger, relatively more healthy MSSA patients are selected as the control group, magnifying the possible impact of resistance (20). Moreover, time-dependent distortions are introduced, as patients staying in the hospital for a shorter period, like MSSA patients, have a smaller chance of acquiring MRSA BSI than patients hospitalized for longer periods, who for many reasons are more likely to die, thus leading to overestimation of the clinical impact of resistance (36).

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“…Inter-rater reliability was not assessed; however, published criteria for use were stringently applied, and antimicrobials of uncertain appropriateness were reviewed by a second expert. 32 …”

Section: Discussionmentioning

confidence: 99%

Factors associated with the receipt of antimicrobials among chronic hemodialysis patients

Patel

Kallen

Strom

et al. 2016

American Journal of Infection Control

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Background Antimicrobial use is common among patients receiving chronic hemodialysis (CHD) and may represent an important antimicrobial stewardship opportunity. The objective of this study is to characterize CHD patients at increased risk of receiving antimicrobials, including not indicated antimicrobials. Methods We conducted a prospective cohort study over a 12-month period among patients receiving CHD in 2 outpatient dialysis units. Each parenteral antimicrobial dose administered was characterized as indicated or not indicated based on national guidelines. Patient factors associated with receipt of antimicrobials and receipt of ≥1 inappropriate antimicrobial dose were analyzed. Results A total of 89 of 278 CHD patients (32%) received ≥1 antimicrobial doses and 52 (58%) received ≥1 inappropriately indicated dose. Patients with tunneled catheter access, a history of colonization or infection with a multidrug-resistant organism, and receiving CHD sessions during daytime shifts were more likely to receive antimicrobials (odds ratio [OR], 5.16; 95% confidence interval [CI], 2.72–9.80; OR, 5.43; 95% CI, 1.84–16.06; OR, 4.59; 95% CI, 1.20–17.52, respectively). Patients with tunneled catheter access, receiving CHD at dialysis unit B, and with a longer duration of CHD prior to enrollment were at higher risk of receiving an inappropriately indicated antimicrobial dose (incidence rate ratio, 2.23; 95% CI, 1.16–4.29; incidence rate ratio, 2.67; 95% CI, 1.34–5.35; incidence rate ratio, 1.11; 95% CI, 1.01–1.23, respectively). Conclusions This study of all types of antimicrobials administered in 2 outpatient dialysis units identified several important factors to consider when developing antimicrobial stewardship programs in this health care setting.

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Lost in Translation? Reliability of Assessing Inpatient Antimicrobial Appropriateness With Use of Computerized Case Vignettes

Abstract: Our case vignette assembly and expert review method is efficient, but improvements in both technical and human performance are needed to be able to yield valid estimates of the prevalence of inappropriate antimicrobial use. Assessments of antimicrobial appropriateness require validation.

Cited by 25 publications

References 17 publications

Diagnostic Errors that Lead to Inappropriate Antimicrobial Use

Diagnostic Errors that Lead to Inappropriate Antimicrobial Use

Clinical Impact of Antimicrobial Resistance in European Hospitals: Excess Mortality and Length of Hospital Stay Related to Methicillin-Resistant Staphylococcus aureus Bloodstream Infections

Factors associated with the receipt of antimicrobials among chronic hemodialysis patients

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