Overdiagnosis of urinary tract infection linked to overdiagnosis of pneumonia: a multihospital cohort study

Abstract

Urinary tract infection (UTI) and community-acquired pneumonia (CAP) are the most common infections treated in hospitals. UTI and CAP are also commonly overdiagnosed, resulting in unnecessary antibiotic use and diagnostic delays. While much is known individually about overdiagnosis of UTI and CAP, it is not known whether hospitals with higher overdiagnosis of one also have higher overdiagnosis of the other. Correlation of overdiagnosis of these two conditions may indicate underlying hospital-level contributors, which in turn may represent targets for intervention. To evaluate the association of overdiagnosis of UTI and CAP, we first determined the proportion of hospitalised patients treated for CAP or UTI at 46 hospitals in Michigan who were overdiagnosed according to national guideline definitions. Then, we used Pearson’s correlation coefficient to compare hospital proportions of overdiagnosis of CAP and UTI. Finally, we assessed for ‘diagnostic momentum’ (ie, accepting a previous diagnosis without sufficient scepticism) by determining how often overdiagnosed patients remained on antibiotics on day 3 of hospitalisation. We included 14 085 patients treated for CAP (11.4% were overdiagnosed) and 10 398 patients treated for UTI (27.8% were overdiagnosed) across 46 hospitals. Within hospitals, the proportion of patients overdiagnosed with UTI was moderately correlated with the proportion of patients overdiagnosed with CAP (r=0.53, p<0.001). Over 80% (81.8% (n=952/1164) of UTI; 89.9% (n=796/885) of CAP) of overdiagnosed patients started on antibiotics by an emergency medicine clinician remained on antibiotics on day 3 of hospitalisation. In conclusion, we found overdiagnosis of UTI and CAP to be correlated at the hospital level. Reducing overdiagnosis of these two common infections may benefit from systematic interventions.

Inappropriate Diagnosis of Pneumonia Among Hospitalized Adults

“…These measures, in place in the 2000s and 2010s, may continue to affect health care professional practice behaviors related to diagnosis. Finally, previously published data show a correlation between inappropriate diagnosis of CAP and inappropriate diagnosis of urinary tract infection at the hospital level, suggesting that local policies, procedures, or culture may affect accurate diagnosis.…”

“…4,5 While some inappropriate diagnosis of CAP is unavoidable due to diagnostic uncertainty when patients are first hospitalized, many patients remain inappropriately diagnosed even on hospital discharge. 6 Inappropriate diagnosis of CAP may harm patients through delayed recognition and treatment of acute (eg, exacerbations of congestive heart failure 7 ), chronic (eg, pulmonary cancer 8 ), or novel diagnoses (eg, pulmonary cancer 8 ) and may lead to unnecessary antibiotic use, 9,10 adverse effects, and antibiotic resistance. [11][12][13] Accurately quantifying the proportion of patients treated for CAP who are inappropriately diagnosed has been challenging due to lack of validated definitions.…”

A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria

“…The association between the primary outcomes and how each could be improved through diagnostic vs antibiotic stewardship is shown in Figure 1. Overall ASB-related antibiotic use was assessed using a metric endorsed by the National Quality Forum for measuring inappropriate diagnosis of UTI: the percentage of patients treated for a UTI who actually have ASB . This metric was used because it measures improvement that happens both due to diagnostic stewardship (ie, more selective urine culturing) and antibiotic stewardship (ie, avoiding antibiotic treatment in patients in whom ASB has been identified).…”

Antibiotic Stewardship Strategies and Their Association With Antibiotic Overuse After Hospital Discharge: An Analysis of the Reducing Overuse of Antibiotics at Discharge (Road) Home Framework

“…Each date could count as a maximum one day of antibiotic overuse (see Supplementary Figure 1 in the Appendix for examples). Unnecessary antibiotic use included any antibiotic use at discharge in patients who had asymptomatic bacteriuria (ASB) or did not meet diagnostic criteria for CAP [ 11 , 15 , 16 ]. Excess duration, determined by disease-specific guidelines, included any antibiotic use at discharge more than 1 day in excess of what was expected [ 5 , 17 ].…”