Skip to main content Accessibility help

Lost in Translation? Reliability of Assessing Inpatient Antimicrobial Appropriateness With Use of Computerized Case Vignettes

  • David N. Schwartz (a1) (a2), Ulysses S. Wu (a1) (a2), Rosie D. Lyles (a1), Yingxu Xiang (a1), Piotr Kieszkowski (a1), Bala Hota (a1) (a2) and Robert A. Weinstein (a1) (a2)...



To describe and measure reliability of a computer-assisted method of case vignette assembly and expert review to assess the appropriateness of antimicrobial therapy for hospitalized adults.


Feasibility and reliability analysis of computer-assisted tool used to compare the effects of antimicrobial stewardship interventions.


Public teaching hospital.


Randomly selected adult antimicrobial recipients admitted to inpatient medicine services.


Clinical data abstracted from 504 paper medical records were merged with computerized laboratory and pharmacy data to assemble case vignettes that underwent expert review for appropriateness. We performed 3 validations, as follows: data for 35 vignettes abstracted independently by 2 research assistants were assessed for interrater agreement, expert review of 24 vignettes was compared with review of the corresponding paper medical records, and interrater reliability of antimicrobial appropriateness assessments by 2 experts was determined for 70 case vignettes.


Vignette assembly and expert review each required 10–12 minutes per case. Potentially important discrepancies occurred in 0%–32% of clinical findings abstracted independently by 2 research assistants. Expert review of 24 vignettes and the corresponding full paper medical records yielded fair agreement (kappa, 0.30). The 2 experts identified inappropriate initial antimicrobial therapy in 67% and 61% of case vignettes reviewed independently; interrater agreement was improved after sequential case discussion and stringent application of appropriateness criteria (kappa, 0.72).


Our case vignette assembly and expert review method is efficient, but improvements in both technical and human performance are needed to be able to yield valid estimates of the prevalence of inappropriate antimicrobial use. Assessments of antimicrobial appropriateness require validation.


Corresponding author

Division of Infectious Diseases, Stroger Hospital of Cook County, 1901 W. Harrison St., Chicago, IL 60612 (


Hide All
1.Schwartz, DN, Abiad, H, DeMarais, PL, et al.An educational intervention to improve antimicrobial use in a hospital-based long-term care facility. ; Am Geriatr Soc 2007;55:12361242.
2.Gyssens, IC, Blok, WL, van den Broek, PJ, Hekster, YA, van der Meer, JWM. Implementation of an educational program and an antibiotic order form to optimize quality of antimicrobial drug use in a department of internal medicine. Eur J Clin Microbiol Infect Dis 1997;16:904912.
3.Spinewine, A, Schmader, KE, Barber, N, et al.Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 2007;370:173184.
4.Henriksen, K, Kaplan, H. Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care 2003;12(Suppl 2):4650.
5.Hanlon, JT, Schmader, KE, Samsa, GP, et al.A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992;45:10451051.
6.Glowacki, RC, Itokazu, GS, Schwartz, DN, et al. Computer-assisted antimicrobial review to optimize therapy (CAROT): results of pharmacists' interventions. In: Proceedings of the 16th Annual Meeting of the Society for Healthcare Epidemiology of America; March 16-21, 2006; Chicago, IL. Abstract 27.
7.Hota, B, Schwartz, DN, Glowacki, RC, et al. Computer-assisted antimicrobial review to optimize therapy (CAROT): a randomized trial of antimicrobial stewardship programs. In: Proceedings of the 16th Annual Meeting of the Society for Healthcare Epidemiology of America; March 16-21, 2006; Chicago, IL. Abstract 317.
8.Schwartz, DN, Lyles, RD, Wu, US, et al. Computer-assisted antimicrobial recommendations for optimal therapy (CAROT): analysis of prescribing errors in a randomized trial of antimicrobial stewardship programs. In: Proceedings of the 17th Annual Meeting of the Society for Healthcare Epidemiology of America; April 14-17, 2007; Baltimore, MD. Abstract 298.
9.Wisniewski, MF, Kieszkowski, P, Zagorski, BM, et al.Development of a clinical data warehouse for hospital infection control. J Am Med Inform Assoc 2003;10:454462.
10.Warren, JW, Abrutyn, E, Hebel, JR, Johnson, JR, Schaeffer, AJ, Stamm, WE. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis 1999;29:745758.
11.Mandell, LA, Bartlett, JG, Dowell, SF, File, TM, Musher, DM, Whitney, C. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis 2003;37:14051433.
12.Mills, GD, Oehley, MR, Arrol, B. Effectiveness of β lactam antibiotics compared with antibiotics active against atypical pathogens in non-severe community acquired pneumonia: meta-analysis. BMJ 2005;330:456.
13.Shefet, D, Robenshtok, E, Paul, M, Leibovici, L. Empirical atypical coverage for inpatients with community-acquired pneumonia: systematic review of randomized controlled trials. Arch Intern Med 2005;165:19922000.
14.Gyssens, IC, van den Broek, PJ, Kullberg, B-J, Hekster, YA, van der Meer, JWM. Optimizing antimicrobial therapy: a method for antimicrobial drug use evaluation. J Antimicrob Chemother 1992;30:724727.
15.Mol, PGM, Gans, ROB, Nannan Panday, PV, Degener, JE, Laseur, M, Haaijer-Ruskamp, FM. Reliability of assessment of adherence to an antimicrobial treatment guideline. J Hosp Infect 2005;60:321328.
16.Taylor, CT, Stewart, LM, Byrd, DC, Church, CO. Reliability of an instrument for evaluating antimicrobial appropriateness in hospitalized patients. Am J Health Syst Pharm 2001;58:242246.
17.Linkin, DR, Fishman, NO, Landis, JR, et al.The effect of communication errors during calls to an antimicrobial stewardship program. Infect Control Hosp Epidemiol 2007;28:13741381.
18.Schouten, JA, Hulscher, MEJL, Wollersheim, H, et al.Quality of antibiotic use for lower respiratory tract infections at hospitals: (how) can we measure it? Clin Infect Dis 2005;41:450460.
19.Chen, LM, Martin, CM, Morrison, TL, Sibbald, WJ. Interobserver variability in data collection of the APACHE II score in teaching and community hospitals. Crit Care Med 1999;27:19992004.
20.Itokazu, GS, Glowacki, RC, Schwartz, DN, Wisniewski, MF, Rydman, RJ, Weinstein, RA. Antimicrobial consumption data from pharmacy and nursing records: how good are they? Infect Control Hosp Epidemiol 2005;26:395400.


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed