Quantifying Clinicians’ Diagnostic Uncertainty When Making Initial Treatment Decisions for Microbial Keratitis

Abstract

There is a need to understand physicians' diagnostic uncertainty in the initial management of microbial keratitis (MK). This study aimed to understand corneal specialists' diagnostic uncertainty by establishing risk thresholds for treatment of MK that could be used to inform a decision curve analysis for prediction modeling.Methods: A cross-sectional survey of corneal specialists with at least 2 years clinical experience was conducted. Clinicians provided the percentage risk at which they would always or never treat MK types (bacterial, fungal, herpetic, and amoebic) based on initial ulcer sizes and locations (,2 mm 2 central, ,2 mm 2 peripheral, and .8 mm 2 central).Results: Seventy-two of 99 ophthalmologists participated who were 50% female with an average of 14.7 (SD = 10.1) years of experience, 60% in academic practices, and 38% outside the United States. Clinicians reported they would "never" and "always" treat a ,2 mm 2 central MK infection if the median risk was 0% and 20% for bacterial (interquartile range, IQR = 0-5 and 5-50), 4.5% and 27.5% for herpetic (IQR = 0-10 and 10-50), 5% and 50% for fungal (IQR = 0-10 and 20-75), and 5% and 50.5% for amoebic (IQR = 0-20 and 32-80), respectively. Mixed-effects models showed lower thresholds to treat larger and central infections (P , 0.001, respectively), and thresholds to always treat differed between MK types for the United States (P , 0.001) but not international clinicians.Conclusions: Risk thresholds to treat differed by practice locations and MK types, location, and size. Researchers can use these thresholds to understand when a clinician is uncertain and to create decision support tools to guide clinicians' treatment decisions.

Herpes simplex keratitis: A brief clinical overview

“…There are lots of anti-viral prescribing patterns currently, Cabrera-Aguas et al [ 164 , 165 ], described the need to standardize the indication and dosage of antiviral therapy in the management of HSK[ 164 , 165 ]. Ultimately, the decision to treat and treatment regimen selection is largely dependent on the individual clinician[ 166 ]. Lázaro-Rodríguez et al [ 167 ] reported isolated primary herpes-simplex virus neuroretinitis in an immunocompetent adult; thus, underpinning the need for starting antiviral therapy for individuals with macular stars who are not immunocompromised but seropositive for HSV IgM after ruling out other infectious causes, ionizing radiation, and arterial hypertension[ 167 ].…”

Rapid Point-of-Care Identification of Aspergillus Species in Microbial Keratitis

“…Timely diagnosis of MK and early prescribing of appropriate antimicrobials are imperative to increase the likelihood of a good patient outcome . However, bacterial and fungal MK cannot be distinguished by clinical presentation alone, and the current diagnostic strategy has several limitations . One limitation is the paucity of diagnostic tests suitable for use within community or primary health care settings .…”

“…6,[8][9][10][11] However, bacterial and fungal MK cannot be distinguished by clinical presentation alone, 12 and the current diagnostic strategy has several limitations. 13,14 One limitation is the paucity of diagnostic tests suitable for use within community or primary health care settings. 10 Lack of diagnostics in these settings is associated with reduced access to and engagement with the health care system, delays in presenting at tertiary care centers, increased economic burden to the patient (who typically has low socioeconomic status), and worse overall outcomes.…”