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A Lesson From Taiwan

Yung-Ching Liu, MD; Wen-Kuei Huang, MT; Tsi-Shu Huang, MS; Calvin M. Kunin, MD

Arch Intern Med. 2001;161:2366-2370.

Background  Antibiotic resistance is a serious problem worldwide. It is particularly alarming in Taiwan and other countries of the Pacific Rim, where antimicrobial drugs are used excessively.

Objective  To determine whether use of antimicrobial drugs before coming to an emergency department was associated with delayed admission or masked or missed diagnoses at a large general hospital in Taiwan.

Methods  Antimicrobial activity in urine (AAU) was determined in all patients seen in the emergency department during a 3-month study. A physician, unaware of the results of the urine tests, reviewed the medical charts of patients who were admitted to the hospital to determine whether admission was delayed for at least 7 days or the diagnosis was masked or missed.

Results  Of the 1182 patients, 444 were admitted to the hospital. In 220 patients (49.5%), AAU was detected. There was no significant difference in AAU between patients with or without an infectious disease (53.0% vs 46.3%, respectively; P = .41). For patients with infection, 34.8% of those with AAU had a delayed admission, compared with only 21.6% without AAU (relative risk [RR], 1.61; 95% confidence interval [CI], 1.03-2.52; P = .03). For patients without infection, 36.2% of those with AAU had a delayed admission compared with 31.1% without AAU (RR, 1.16; 95% CI, 0.81-1.68; P = .64). For patients with infection, 48.7% of those with AAU had a masked or missed diagnosis, compared with 25.5% without AAU (RR, 1.91; 95% CI, 1.30-2.80; P<.001). For patients without infection, 27.6% of those with AAU had a masked or missed diagnosis compared with 14.8% without AAU (RR, 1.87; 95% CI, 1.11-3.17; P = .02).

Conclusion  Use of antimicrobial drugs before coming to an emergency department was associated with a significantly increased risk for delayed and masked or missed diagnoses of infectious diseases and missed diagnosis of noninfectious diseases.

From the Sections of Infectious Diseases and Microbiology, Veterans General Hospital, Kaohsiung, and National Yang-Ming University, Taipei, Taiwan (Dr Liu, Mr Huang, and Ms Huang); and the Department of Internal Medicine, Ohio State University, Columbus (Dr Kunin).

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