In a recent study published in the Journal of the American Medical Association Internal Medicine, researchers conducted a prospective study to describe the incidence of inappropriate diagnosis of community-acquired pneumonia (CAP) in adults who are hospitalized.

For this study, researchers gathered data from 48 hospitals in Michigan between July 1, 2017, and March 31, 2020. The researchers reviewed data from 17,290 patients hospitalized for CAP. Criteria for eligibility included adults admitted to general care with a discharge diagnostic code of pneumonia who received antibiotics on Day 1 or 2 of hospitalization. The data were assessed between February 2023 and December 2023. The average age of the study cohort was 71.8 years, and 50.3% were female.

With regard to primary outcomes and measures, the authors wrote, “Inappropriate diagnosis of CAP was defined using a National Quality Forum–endorsed metric as CAP-directed antibiotic therapy in patients with fewer than 2 signs or symptoms of CAP or negative chest imaging.”

The secondary outcomes were a composite of 30-day patient outcomes, including 30-day all-cause postdischarge mortality, hospital readmission, emergency department visits, Clostridioides difficile infections, and/or physician-documented, antibiotic-associated adverse events.

To evaluate the correlation between antibiotic treatment and patient outcomes in patients who were inappropriately diagnosed, researchers compared outcomes in patients who received full (>3 days) versus brief (≤3 days) empirical antibiotic treatment.

The results revealed that 2,079 patients (12.0%) met the criteria for inappropriate diagnosis, and 87% of those patients received full courses of antibiotics. The results also revealed that compared with patients with CAP, patients inappropriately diagnosed were older (adjusted odds ratio [AOR], 1.08; 95% CI, 1.05-1.11 per decade) and more likely to have dementia (AOR, 1.79; 95% CI, 1.55-2.08) or altered mental status on presentation (AOR, 1.75; 95% CI, 1.39-2.19).

Furthermore, among those who were inappropriately diagnosed, 30-day composite outcomes for full versus brief treatment did not differ (25.8% vs. 25.6%; AOR, 0.98; 95% CI, 0.79-1.23). Full versus brief duration of antibiotic treatment among patients was related to antibiotic-associated adverse events (31 of 1821 [2.1%] vs. 1 of 258 [0.4%]; P = .03).

Based on their findings, the authors concluded, “This cohort study has important clinical and policy implications. Because hospitalizations for CAP are common, so too are inappropriate diagnoses of CAP. Risks of inappropriate diagnosis are not uniform across populations—already highly vulnerable groups are at highest risk of inappropriate diagnosis. These same vulnerable populations are also most likely to be affected by antibiotic-associated adverse events and resulting morbidity. Thus, balancing harms of underdiagnosis and overdiagnosis of CAP remains essential.”

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