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Reduce Antibiotic Treatment of Questionable Pneumonia
Background, Rationale and Suggested Implementation Strategies
- Educate providers, including hospitalists, internal medicine, family medicine, emergency medicine physicians, residents, advanced practice professionals (APPs), and nursing staff regarding the diagnosis of community acquired pneumonia (CAP) vs. questionable pneumonia (QPNA)
- Educate patients and family members regarding the diagnosis of community acquired pneumonia (CAP) vs. questionable pneumonia (QPNA)
- Review QPNA cases identified by HMS to direct high-yield intervention for recurrent problems.
- Evaluate and understand differences in provider groups (e.g., hospitalists, emergency department physicians). Target interventions to specific provider groups as necessary.
- Identify a hospitalist and ED champion
- Require documentation of dose and indication of antibiotics prescribed in the antibiotic order. Consider adding documentation of respiratory symptom(s) necessitating treatment.
- Encourage documentation of dose, indication, and duration of antibiotics in the progress note.
- Encourage documentation of the total duration of antibiotics in discharge summary, potentially incorporating an area for antibiotic duration to be filled out in an automated discharge process.
- Provide audit and feedback directly to individual providers regarding their rates of treatment for QPNA
Consider implementing a diagnostic stewardship intervention.
Resources and Tools
- Review HMS site reports(hard copy distributed at collaborative wide meetings and live reports available daily via the HMS data entry system) for the following:
- Treatment of Questionable Pneumonia with Antibiotics
- Types of Reports Available via HMS Registry: Hospital Specific, Provider Group Specific(i.e., hospitalist v. emergency room physician), or Provider Specific
- Treatment of Questionable Pneumonia with Antibiotics
- HMS Guideline:
- CAP Pocket Card
- Consider modifying to poster size for posting in workrooms
- HMS Pneumonia Categorization Resource
- Institutional Guideline Examples:
- CAP Guideline Example with signs/symptoms of pneumonia included (Trinity Health Ann Arbor)
- Example Questionable Pneumonia Fallout Letter for sending to providers (adapted from Trinity Health Ann Arbor)
- Information regarding the National Quality Forum/Battelle-endorsed national quality measure surrounding Inappropriate Diagnosis of Community-Acquired Pneumonia
- CDC Poster: Do You Need Antibiotics?
- Diagnostic Error and Antibiotic Use in Patients Hospitalized with Presumed Pneumonia Training Video
- Presentations (For HMS Members – Additional authentication may be required):
- Presentation by Dr. Ashwin Gupta (HMS) and Dr. Anu Malani (Trinity Health Ann Arbor) at the March 12, 2024 Virtual HMS Collaborative Wide Meeting: Antimicrobial Use and Diagnostic Excellence in Questionable Pneumonia – To Treat or Not To Treat?
References
- Atamna A, et al. The Accuracy of a Diagnosis of Pneumonia in the Emergency Department. Int J Infect Dis 2019.
- Interpretation of chest x-rays with the assistance of a radiologist might help in reducing overdiagnosis and minimizing antibiotic overprescription, thus improving the ED diagnostic accuracy of pneumonia.
- Broom JK, et al. Clinical and Social Barriers to Antimicrobial Stewardship in Pulmonary Medicine: A Qualitative Study. Am Journ Infect Cont 2017.
- To facilitate change in antibiotic use, there must be a systematic understanding and interventions to address specific clinical issues. In the case of pulmonary medicine, significant identified issues, such as mistrust in clinical guidelines and diagnostic challenges, need to be addressed.
- Frisbee J, et al. Adverse Outcomes Associated with Potentially Inappropriate Antibiotic Use in Heart Failure Admissions. Open Forum Infect Dis 2019.
- Acute decompensated heart failure (ADHF) patients who received IV antibiotics without evidence of infection had longer lengths of stay, required more diuretics, and were more likely to be readmitted compared with ADHF patients not exposed to IV antibiotics. ADHF patients are a promising target of antibiotic stewardship interventions.
- Gupta A, et al. Inappropriate Diagnosis of Pneumonia Among Hospitalized Adults. JAMA Int Med 2024.
- In this cohort study, inappropriate diagnosis of CAP among hospitalized adults was common, particularly among older adults, those with dementia, and those presenting with altered mental status. Full-course antibiotic treatment of those inappropriately diagnosed with CAP may be harmful.
- Gupta A, et al. Mind the Overlap: How System Problems Contribute to Cognitive Failure and Diagnostic Errors. Diagnosis (Berl) 2018.
- Systems-based factors often facilitate and promote cognitive problems in diagnosis. Linking systems-based contributions to downstream cognitive impacts and intervening on both in tandem may help prevent diagnostic errors.
- Gupta A, et al. Overdiagnosis of Urinary Tract Infection Linked to Overdiagnosis of Pneumonia: A Multi-Hospital Cohort Study. BMJ Qual Saf 2022.
- Overdiagnoses of UTI and CAP are correlated both at the emergency and hospital level. While cognitive contributions to overdiagnosis, including diagnostic momentum, are evident, the hospital correlation between diseases suggests important hospital-level contributors. Identification and targeting of these hospital contributors may help improve diagnosis of multiple infectious diseases.
- Gupta A, et al. The Variability in How Physicians Think: A Case-Based Diagnostic Simulation Exercise. Diagnosis (Berl) 2021.
- Heterogeneity in diagnostic evaluation appears to be common and may indicate faulty data processing. Structured approaches appear helpful in promoting diagnostic accuracy.
- Tsun S, et al. Improving Antimicrobial Use Through Better Diagnosis: The Relationship Between Diagnostic Stewardship and Antimicrobial Stewardship. Inf Cont & Hosp Epi 2023.
- This publication is part of a series who purpose is to provide an overview of diagnostic stewardship. Here, we discuss the distinct and complementary relationship between diagnostic and antimicrobial stewardship and demonstrate how diagnostic stewardship interventions may complement Antimicrobial Stewardship Programs.
- White A, et al. Development of Patient Safety Measures to Identify Inappropriate Diagnosis of Common Infections. Clin Infect Dis 2024.
- This study team developed highly reliable, valid, and usable measures of inappropriate diagnosis of UTI and CAP for hospitalized patients. Hospitals seeking to improve diagnostic safety, antibiotic use, and patient care should consider using these measures to reduce inappropriate diagnosis of CAP and UTI.