2024.05 Ep 5: The GIGO Principle: Inappropriate CAP Diagnosis Results in Unnecessary Antibiotic Exposure in Hospitalized Adults

In this episode, we will discuss a recent study that evaluated the impact of inappropriate diagnosis of CAP and duration of antibiotic use.

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Episode Transcript

(00:03):
Hello and welcome to the first film.
I'm Dan Zlott and I served as a Senior VicePresident of Education and Business
Development and APhA.
As we continue our discussion of medication safetythis month,
let's take a closer look at community acquiredpneumonia.
Inappropriate diagnosis of pneumoniacan result in unnecessary antibiotic treatment
along with downstream sequelae,including antibiotic related events,

(00:26):
increasing levels of antimicrobial resistance
and increased cost to the health care system.
Now, in 2022, new metrics for quantifyinginappropriately diagnosed community
acquired pneumonia or CAP were established andhave been endorsed by the National Quality Forum.
According to this metric, inappropriatediagnosis of CAP is defined as any antibiotic

(00:47):
treatment of cap in a patientwith less than two signs or symptoms of CAP
or who lacks radiographic findingsconsistent with pneumonia.
Using this metric,a retrospective cohort study was conducted
in the Michigan Hospital MedicineSafety Consortium.
This retrospective study assessed datafrom 48 hospitals within the consortium
from the period of July 1st, 2017to March 31st, 2020.

(01:12):
Inclusion criteria for this study includedpatients who were admitted to general care
in the hospital, patients who were diagnosedwith a discharge diagnostic code for pneumonia
and patients who received antibiotics on dayone or two of hospitalization.
Patients were excluded
if they were treated for an additional infectionunrelated to pneumonia,

(01:33):
if they were severely immunocompromised,if they were pregnant,
if they were admitted to the hospitalfor comfort measures,
if they received care in an ICU,if they were placed on a ventilator,
or if they left against medical advice.
Other exclusion criteria included patientswho were admitted to hospitals with fewer than ten
qualifying patients, patients who had unknownor missing antibiotic treatment data,

(01:58):
or patientswho received more than 14 days of antibiotics.
Lastly, patientswho had a history of COPD exacerbation
treated with Zithromaxand or doxycycline alone were also excluded.
Now, over the results of the study, 17,920
patients were treated for pneumonia across48 hospitals in Michigan.

(02:19):
2079 patients, or 12%,
met the criteria for inappropriate diagnosis.
Also, of note, at 30 of 48
hospitals included in the study, 10%or more of patients diagnosed with CAP
were diagnosed incorrectly,according to the metrics I mentioned earlier.
That's a surprisingly high percentageof inappropriate cap diagnoses.

(02:42):
Now, in addition to that, there weresome interesting findings coming out of the study.
Patients who were
inappropriatelydiagnosed with CAP were more likely to be older,
and by olderwe mean greater than or equal to 75 years old.
They were likely to present with alteredmental status, to have decreased mobility
or to have had a prior in-patienthospitalization within the prior 90 days.

(03:05):
So what were the impacts of inappropriateCAPdiagnoses?
First, patients who were inappropriatelydiagnosed with CAP
were more likely to be dischargedto a skilled nursing facility.
Second, patients inappropriatelydiagnosed with CAP received a median of seven days
of antibiotic therapy,four of which occurred as inpatient therapy.

(03:26):
So although the authors don't state this,there were likely some increased costs,
as well as inpatient bed utilization associated
with an inappropriate CAP diagnosis.
Third, 87.6%of inappropriately diagnosed patients.
In other words, 1821 of 2079 patients

(03:47):
received a full course of antibioticsinstead of a brief course.
Not surprisingly,
there was a statistically significant differencein antibiotic associated adverse events
between patients
who received a full course of antibiotic therapyand those who received a brief course.
With 2.1% of patientswho received a full course experiencing
an antibiotic associated adverse event versus

(04:09):
only 0.4% in the brief course group.
The P value for that was 0.03.
Meeting the criteria for statistical significance.
All right.
So what should we take away from this?
What can pharmacists do?
Well,one of the best things is to establish a process
for reviewing antibiotic therapyfor presumptive community acquired pneumonia

(04:29):
48 to 72 hoursafter the initiation of antibiotic therapy.
If there aren't either signs or symptoms of CAP
or radiologic finding consistent with pneumonia,this can be a great time
to contact the prescriberto consider antibiotic cessation.
That will do it for thisepisode of the First Fill.
Thank you as always for listening and subscribing.

(04:52):
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