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Multicenter Study
. 2019 Jun 6;23(1):202.
doi: 10.1186/s13054-019-2475-9.

In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission

Toshikazu Abe  1   2   3 , Yasuharu Tokuda  4 , Atsushi Shiraishi  5 , Seitaro Fujishima  6 , Toshihiko Mayumi  7 , Takehiro Sugiyama  8   9   10   11 , Gautam A Deshpande  12 , Yasukazu Shiino  13 , Toru Hifumi  14 , Yasuhiro Otomo  15 , Kohji Okamoto  16 , Joji Kotani  17 , Yuichiro Sakamoto  18 , Junichi Sasaki  19 , Shin-Ichiro Shiraishi  20 , Kiyotsugu Takuma  21 , Akiyoshi Hagiwara  22 , Kazuma Yamakawa  23 , Naoshi Takeyama  24 , Satoshi Gando  25   26 ; JAAM SPICE Study Group
Collaborators, Affiliations
Multicenter Study

In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission

Toshikazu Abe et al. Crit Care. .

Abstract

Background: Rapid detection, early resuscitation, and appropriate antibiotic use are crucial for sepsis care. Accurate identification of the site of infection may facilitate a timely provision of appropriate care. We aimed to investigate the relationship between misdiagnosis of the site of infection at initial examination and in-hospital mortality.

Methods: This was a secondary-multicenter prospective cohort study involving 37 emergency departments. Consecutive adult patients with infection from December 2017 to February 2018 were included. Misdiagnosis of the site of infection was defined as a discrepancy between the suspected site of infection at initial examination and that at final diagnosis, including those infections remaining unidentified during hospital admission, whereas correct diagnosis was defined as site concordance. In-hospital mortality was compared between those misdiagnosed and those correctly diagnosed.

Results: Of 974 patients included in the analysis, 11.6% were misdiagnosed. Patients diagnosed with lung, intra-abdominal, urinary, soft tissue, and CNS infection at the initial examination, 4.2%, 3.8%, 13.6%, 10.9%, and 58.3% respectively, turned out to have an infection at a different site. In-hospital mortality occurred in 15%. In both generalized estimating equation (GEE) and propensity score-matched models, misdiagnosed patients exhibited higher mortality despite adjustment for patient background, site infection, and severity. The adjusted odds ratios (misdiagnosis vs. correct diagnosis) for in-hospital mortality were 2.66 (95% CI, 1.45-4.89) in the GEE model and 3.03 (95% CI, 1.24-7.38) in the propensity score-matched model. The difference in the absolute risk in the GEE model was 0.11 (0.04-0.18).

Conclusions: Among patients with infection, misdiagnosed site of infection is associated with a > 10% increase in in-hospital mortality.

Keywords: Diagnosis; Infection; Sepsis; Source.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
The relationship between in-hospital mortality and misdiagnosis or unidentified of the site of infection among patients with infection using the generalized estimating equations (GEE) with exchangeable working-correlation matrix models and propensity score-matched (PSM) analysis. The primary analysis described the GEE models for all patients and patients with qSOFA ≥ 2 and the PSM model. The GEE model for all patients adjusted: age, Charlson comorbidity index, clinical frailty scale, qSOFA, site of infection at final diagnosis (lung, intra-abdominal, urinary tract, soft tissue, rare [central nervous system (CNS); osteoarticular; endocardium; wound; catheter-related; and implant device-related], other, or unidentified). The GEE model for patients with qSOFA ≥ 2 adjusted: the same variables of the GEE model for all patients except qSOFA. The PSM model adjusted: age, Charlson comorbidity index, clinical frailty scale, MBP, HR, RR, GCS, site of infection at final diagnosis (lung, intra-abdominal, urinary tract, soft tissue, rare [central nervous system (CNS); osteoarticular; endocardium; wound; catheter-related; and implant device-related], other, or unidentified). The sensitivity analysis described the GEE models for all patients and patients with qSOFA ≥ 2 and PSM model excluding patients with an unidentified site of infection. The GEE model for all patients adjusted: age, Charlson comorbidity index, clinical frailty scale, qSOFA, site of infection at final diagnosis (lung, intra-abdominal, urinary tract, soft tissue, rare [central nervous system (CNS); osteoarticular; endocardium; wound; catheter-related, implant device-related, and other]). The GEE model for patients with qSOFA ≥ 2 adjusted: the same variables of the GEE model for all patients except qSOFA. The PSM adjusted: age, Charlson comorbidity index, clinical frailty scale, MBP, HR, RR, GCS, site of infection at final diagnosis (lung, intra-abdominal, urinary tract, soft tissue, rare [central nervous system (CNS); osteoarticular; endocardium; wound; catheter-related, implant device-related, and other]). qSOFA quick sequential organ failure assessment, PSM propensity score-matched
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