December 2, 2022

‘Medical Maximizers’ Distribute Unnecessary Antibiotics for BSA

If you have bacteria in your urine but don’t have symptoms of a urinary tract infection (UTI), such as burning or frequent urination, you probably don’t need antibiotics. Then why did you get this prescription?

The American Society for Infectious Diseases advise against antibiotics in this scenario, with exceptions for patients who are pregnant or undergoing certain urological procedures.

Antibiotics for asymptomatic bacteriuria (ASB) generally do not help; are costly ; and may cause side effects, Clostridioides difficile infection and antibiotic resistance.

Yet antibiotic treatment for asymptomatic bacteriuria remains common, despite guidelines.

And when researchers recently surveyed 551 primary care clinicians to see which ones would prescribe antibiotics inappropriately for a positive result urine culturethe answer was most of them: 71%.

“Regardless of years of practice, training, or professional degree, most clinicians indicated that they would prescribe antibiotics for asymptomatic bacteriuria,” said the the researchers reported in Open JAMA Network.

Certain groups of clinicians seemed particularly likely to prescribe antibiotics unnecessarily.

“Medical maximizers”—clinicians who prefer treatment even when its value is ambiguous—and family medicine clinicians were more likely to prescribe antibiotics in response to a hypothetical case.


On the other hand, resident physicians and clinicians in the US Pacific Northwest were less likely to provide antibiotics inappropriately, the researchers found.

Study author Jonathan D. Baghdadi, MD, PhD, of the Department of Epidemiology and Public Health at the University of Maryland and the Veterans Affairs Maryland Healthcare System in Baltimore, abstract the results on Twitter: “…who prescribes antibiotics for asymptomatic bacteriuria? the answer is most primary care clinicians in all categories, but it’s most common among clinicians who want to ‘do it all’.”

Baghdadi said the shortcomings reflect issues with the medical system rather than individual clinicians.

“I do not believe that individual clinicians knowingly choose to prescribe inappropriate antibiotics in defiance of guidelines,” Baghdadi said. Medscape Medical News. “Clinical decision making is complicated, and the decision to prescribe inappropriate antibiotics depends on patient expectations, clinician’s perception of patient expectations, time pressure in the clinic, regional variation in medical practice , the culture of antibiotic use and probably, in some cases, the feeling that doing more is better.”

Additionally, researchers have used varying definitions of ASB over time and in different contexts, he said.

What to do for Mr. Williams?

To examine clinician attitudes and characteristics associated with prescribing antibiotics for asymptomatic bacteriuria, Baghdadi and colleagues analyzed survey responses from 490 physicians and 61 advanced practice clinicians.

Study participants completed tests that measured numeracy, risk-taking preferences, burnout, and tendencies to maximize care. They were also presented with four hypothetical clinical scenarios, including a case of asymptomatic bacteriuria: “Mr. Williams, a 65-year-old male, comes to the office for follow-up osteoarthritis. He noted foul smelling urine and no pain or difficulty in urinating. A urine dipstick shows traces of blood. He has no particular preference for testing and wants your advice.”

Clinicians who had been in practice for at least 10 years were more likely to prescribe antibiotics (82%) to “Mr. Williams” than those who had been in practice for 3-9 years (73%) or less than 3 years (64%).



Of 120 clinicians with training in family medicine, 85% said they would have prescribed antibiotics, compared with 62% of 207 clinicians with training in internal medicine.

Nurse practitioners and physician assistants were more likely to prescribe antibiotics (90%) than attending physicians (78%) and residents (63%).

In one analysis, a background in family medicine was associated with almost three times the likelihood of prescribing antibiotics. And a high “medical maximizer” score was associated with about twice the odds of prescribing the drugs.

Meanwhile, resident physicians and clinicians in the Pacific Northwest had a lower likelihood of prescribing antibiotics, with odds ratios of 0.57 and 0.49, respectively.

Respondents who prescribed antibiotics estimated a 90% chance of UTI, while those who did not prescribe antibiotics estimated a 15% chance of the condition.

Break a habit

Some prescribers may know that asymptomatic bacteriuria should not be treated, but may mistakenly consider certain findings as symptoms of UTI.

Bradley Langford, PharmD, an expert in antimicrobial stewardship at Public Health Ontario, Canada, said in his experience that most clinicians who say they know that BSA should not be treated properly believe that cloudy urine, impaired cognition and other nonspecific symptoms indicate a UTI.

“The fact that most clinicians would treat BSA suggests there is still a lot of work to be done to improve antimicrobial stewardship, especially outside of the hospital setting,” Langford said. medical landscape.

Avoiding unnecessary antibiotics is important not only because of the lack of benefit, but also because of the potential harm, Langford said. He has created a list rebuttals for common reasons for testing and treating asymptomatic bacteriuria.

“The use of antibiotics for BSA can counterintuitively increase the risk for symptomatic UTIs due to disruption of local protective microflora, allowing the growth of more pathogenic/resistant organisms,” he said.

One approach to solving the problem: do not test urine in the first place if patients are asymptomatic. It has been shown that virtual learning sessions reduce urine culture and prescribing urinary antibiotics in long-term care homes, Langford noted.

Up-to-date training for healthcare professionals from the start can also be essential, and the lower rate of intent to prescribe among medical residents is reassuring, he said.

A role for patients

Patients could also help reduce the inappropriate use of antibiotics.

“Be clear with your doctor about your expectations for healthcare interaction, including whether you expect to receive antibiotics,” Baghdadi said. “Your doctor may assume you contacted them because you wanted a prescription. If you’re not expecting antibiotics, feel free to say so. And if you’re asymptomatic, you may not have need antibiotics, even if the urine culture is positive.”

The study was funded by a grant from the National Institutes of Health, and Baghdadi received a grant from the University of Maryland, Baltimore Institute for Clinical and Translational Research. The co-authors disclosed government grants and ties to Memorial Sloan Kettering Cancer Center, Vedanta Biosciences, Opentrons, and Fimbrion. Langford has reported no relevant financial conflicts of interest.

JAMA Netw Open. Published online May 27, 2022. Complete survey

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