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Popular Epocrates Bugs & Drugs App used by Physicians is flawed, should be removed from App Store

Iltifat Husain MD (@IltifatMD) contributed to this piece

Infectious disease (ID) is  a difficult topic for many clinicians to handle.

Inevitably, questions arise such as what is the best treatment for a certain infection, how much and how long should I prescribe treatment, and what should I monitor for?

This becomes all the more important as we enter an era where antimicrobial resistance has become all the more apparent, fostering such resistant pathogens as Methicillin-Resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococci (VRE), and Extended spectrum beta-lactamase (ESBL) organisms (1).

Indeed, it is a scary world where multidrug resistant pathogens may kill individuals that would have otherwise responded well to similar treatments in years past.

As a pharmacist, seeing the resistance build-up to our medications is a worrisome problem, and further emphasizes my belief in antibiotic stewardship programs to use antibiotics responsibly in practice (2).

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With that being said, the recent release of Epocrates Bugs + Drugs caught the attention of iMedicalApps as an app that appeared to be a real-time antibiogram. While most hospitals and networks utilize an in-house antibiogram to identify what organisms are susceptible to what antibiotics in that locale, it is reliant on their own in-house testing of isolates and is only updated every so often.

Recently, Epocrates has joined with Athenahealth to tap into their cloud-based EHR to access the pathogen susceptibilities from isolates identified from their large database in real time. In addition, the medication options are then linked to Epocrates drug information to give clinical data on treatment for susceptible infections. Using mobile applications to help providers prescribe the best treatment course for patients facing an infection seems to be a great example of how we can use such mobile references in daily care.

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In theory, this is a great idea. We will say that again: In theory, it is a great idea. The app released is just beautiful, and if we had to make an app that encompasses the functions of an antibiogram, I do not think I could have done it any better; however, while look and functionality are key components of an app, the content of an app is what really matters, and that is where Epocrates has made significant errors in several areas.

First, the initial release of the app was plagued with completely incorrect information. As seen, the app identified several organisms as susceptible to antibiotics that make no sense pharmacologically. For instance, ertapenem should not be used for Pseudomonas aeruginosa.

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After a break out in their comments and reviews on the iTunes App Store and in Twitter by multiple clinicians, it seems that Epocrates has revised several of these errors finally (October 12 update), perhaps after grabbing a copy of the Sanford Antibiotics Guide.

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Next, pulling two hospital anitbiograms, I compared the sensitivities based on those institutions with the data based on the Epocrates app. As seen, there is a great disparity between the data sets. At first, it seems to follow institutional data similarly, but then completely diverges. In addition, the quantity of isolates are paltry in certain situations, which detracts from the value of the information provided. If less than 30 isolates are present, the susceptibility may not be that beneficial for making a clinical decision.

Slide5Slide6Additionally, the Epocrates app did not address certain infections that may be a concern, such as the so called ‘superbugs’ (e.g. MRSA, VRE, ESBL) or other pathogens such as Clostridium difficile. This goes against what Epocrates is advertising with their Superbugs spotted in the wild: Are they lurking in your area?

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Lastly, it can be seen that the app is claiming susceptibilities of “100%” for some pathogens that really make no sense whatsoever. This is especially the case in pathogens where we know that resistance is relatively high and the susceptibilities percentages put forth by the app just seems clinically wrong, as seen in the image below, with Staph. aureus showing sensitivities of 100% to vancomycin.

Does this include isolates of MRSA, MSSA, and just Staph. aureus? It is very hard to determine. There are still other drugs that, while demonstrating no susceptibility in the app, should probably not be included, such as ceftriaxone under Pseudomonas aeruginosa. 

Author:

Timothy Aungst, PharmD

Digital Pharmacist seeking to integrate technology and mHealth into pharmacy practice and patient care. Assistant Professor by day, blogger and writer by night.

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13 Responses to Popular Epocrates Bugs & Drugs App used by Physicians is flawed, should be removed from App Store

  1. Jason Maude November 20, 2013 at 9:39 am #

    A recent study that looked at the value of using CDS to help with appropriate prescribing found that the real problem was the initial diagnosis being wrong. The initial diagnoses were only correct in 55% of cases! http://www.ncbi.nlm.nih.gov/pubmed/23651885

    Clinicians should use an app to help with diagnosis, such as Isabel, before using the new Epocrates app when it’s sorted out.

    • Satish Misra, MD November 20, 2013 at 1:15 pm #

      Symptom checkers are a very limited, at least in their current state. They are limited first by the input – two patients having the exact same symptom may describe them very differently and those descriptions may be interpreted very differently depending on who is listening. Then the output is more often than not a very long list of potential diagnoses. I generally find them useful tools to make sure I keep my differential broad. But for making a diagnosis, these tools are not there.

      • Jason Maude November 20, 2013 at 1:25 pm #

        We are very clear that making the diagnosis is and will remain the clinician’s job. Tools like Isabel will never be able to do this and are not intended to either. Isabel comes up with a very good list of possibilities (for example, in tests using Medscape cases we have found that in 80% of cases the correct diagnosis is shown as 1 or 2 in the list of 10!) and it is the clinician’s job to work out the probabilities.

  2. Jeff Mason November 20, 2013 at 11:35 am #

    I am wondering if a disclaimer could be added to the beginning of this article stating it is not referring to the respected Canadian resources Bugs & Drugs produced by Alberta Health Services. http://www.bugsanddrugs.ca/.

    • Satish Misra, MD November 20, 2013 at 1:16 pm #

      Thanks for pointing that out – we feel that the specification in the title that this is the Epocrates app and the references to Epocrates in the article should make that clear.

  3. Clinton November 20, 2013 at 12:23 pm #

    I haven’t used this app, but the broad complaint of “hey THIS antibiotic is totally useful” when it it clearly not makes me wonder if a pharmaceutical company played any role in the app development, which could be a deadly source of bias.

  4. Gerry L Tolbert November 20, 2013 at 3:20 pm #

    Not that I disagree that the app could be improved, but as a clinician who tries very hard to practice evidenced based medicine, it’s a handy tool to have in my hand. I don’t have access to the hospital antibiograms in this area, (the three big competing groups could stand to share data a bit better anyway) which makes something like this all the more useful. While your analysis is true for a fraction of clinicians, you seem to be ignoring a large proportion of us who not only think critically, but also understand the difference between IV and PO meds. I agree that playing to the greatest common denominator is important in reviews, but the app does have useful information that a simple amount of analysis can make useful. This isn’t an app for non-physicians, neither is it an app to replace critics thinking. That’s not medicine, it’s an algorithm. Robots and AI aren’t able to replace clinical judgment and critical thinking (yet) and neither will this. Is there room for improvement? Of course. But in the war on antibiotic over/misuse, this app fires a convincing first salvo.

    • Iltifat Husain, MD November 22, 2013 at 10:26 am #

      Good points, but as you can see in the screen shots of the app, it appears the majority of users of this app think the information it provides is all great. This is extremely concerning — as you mentioned, for the “war on antibiotics”, this app has potential for misuse. The IV and PO meds aren’t the main issue. The main issue is the content, at least when initially launched, had some obvious abx mistakes and errors. When an app developer creates an application that has mistakes, it’s a lot easier to understand — and clinicians who use the app will use it with a grain of salt. But when a venerable company such as Epocrates creates a widely used app that has a litany of mistakes — it’s harder to use the excuse of, “they are still working on it”. Unfortunately, many who trust Epoc won’t critically look at the app as they would other apps — this is clear in the comments section of the App in the App Store.

  5. Carter November 20, 2013 at 4:31 pm #

    Take the positive Epocrates app store comments with a grain of salt. For years they have been using a panel of “advocates” to boost their app store rating(s) and provide positive comments.

  6. josh November 25, 2013 at 7:31 am #

    I am very happy with Infectious Disease Compendium. Helpful guidance, pearls, discussions, studded with endless hot-links to the medical literature, and best of all, it is HILARIOUS. Really. You wouldn’t think that ID would be funny. But Dr. Crislip is hilarious. Check out the app.

    I have no financial relationship to Crislip or his app. In fact, I find his podcast boring (probably great for an ID doc, waaaaay too detailed and esoteric for a primary care doc like me). But his ID app is spot on for practicing clinicians. You will LOVE it. If you don’t, bolus with an injection of depo-Prozac and try again later.
    –JSt

  7. Roger Diaz January 7, 2014 at 2:48 pm #

    Our company already has an app that lets hospitals convert antibiogram spreadsheets into a format compatible with the Antibiograms app available for iPhones, iPads, and Android devices. Additionally, we can customize the app to include MIC Breakpoints, oral or IV drugs, and clinical isolates tested. If you download it from the App Store or Google Play you would find that it is much more appropriate for clinicians.

    Thanks and Regards,
    Roger Diaz, MHS, PA-C
    Clinical Consultant
    Portable Databases

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