How common is inappropriate diagnosis of community-acquired pneumonia?

Shortness of breath, coughing, heavy sputum. Pneumonia symptoms are clear-cut and well-known.In the U.S., 25 out of 10,000 people are diagnosed with community-acquired pneumonia (CAP) annually. CAP is also responsible for 3-million deaths each year. While disease can be severe and indeed common, a new study finds that inappropriate diagnosis of CAP is common, too. In this new cohort study published in JAMA of 17,290 hospitalized adults treated for pneumonia, 2,079 (12%) were misdiagnosed. “Older patients, those with dementia, and those presenting with altered mental status had the highest risk of being inappropriately diagnosed,” wrote Dr. Ashwin Bharat Gupta, an internal medicine doctor at the University of Michigan, with his coauthors. “Of the 2,079 patients inappropriately diagnosed with CAP, 73.6% lacked radiographic criteria, 24.4% had fewer than two signs or symptoms of pneumonia and 2% met neither criterion.”Published in March, the study authors suggest inappropriate diagnosis of CAP can harm patients through: delayed recognition and treatment of acute diagnoses (like exacerbating congestive heart failure), chronic or novel diagnoses (like a pulmonary cancer) and may lead to unnecessary antibiotic use, adverse effects and antibiotic resistance. Older adults, those with dementia and those with altered mental status were most at-risk for an misdiagnosis, found the researchers. “In these populations, guidelines recommend reconsideration, de-escalation, and cessation of antibiotics within 48- to 72-hours once infection has been ruled out,” wrote the authors. “In the present study, we found little evidence of antibiotic cessation. Rather, patients empirically receiving antibiotic therapy for presumed CAP typically received a full antibiotic course.” Indeed, the researchers found that 87.6% of the patients who were misdiagnosed received a full course of antibiotics—noting that longer durations of antibiotics are associated with increased morbidity and delayed diagnosis of underlying conditions. The researchers highlights a number of factors that can lead physicians to misdiagnose CAP: t’s common, so physicians are at high risk for cognitive biases such as availability bias; historical quality metrics like the Joint Commission (requiring antibiotics within six hours of presentation) which could unintentionally lead to more diagnoses of the disease; and the nonspecific symptoms of CAP, which can overlap with other cardiopulmonary diseases, such as congestive heart failure. “Given poor outcomes associated with CAP, in the setting of uncertainty, healthcare professionals may favour overtreatment rather than potentially missing a CAP diagnosis,” wrote the authors.

How common is inappropriate diagnosis of community-acquired pneumonia?

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