October 2, 2022

Most clinicians prescribe antibiotics inappropriately for asymptomatic bacteriuria

A new study has found that nearly three quarters of primary care clinicians would prescribe antibiotics for bacteria in urine against established guidelines.

In a survey of primary care clinicians, the majority of respondents said they would prescribe antibiotics for asymptomatic bacteriuriawhich does not bode well for antibiotic management, a new research paper found.

Even if tests show bacteria in a patient’s urine, treating asymptomatic bacteriuria is contraindicated. guidelines compiled by the Infectious Diseases Society of America. Prescribing antibiotics for asymptomatic bacteriuria may lead to negative resultsincluding the development of Clostridium difficile infection.

The new research paper, which was published in Open JAMA Network, examines survey data collected from more than 500 primary care clinicians. The survey included a clinical scenario of asymptomatic bacteriuria: a 65-year-old man who reported foul-smelling urine but no pain or difficulty urinating.

The study includes several key data points:

  • Of the 551 primary care clinicians surveyed, 71% said they would prescribe antibiotics in the asymptomatic bacteriuria scenario
  • Clinicians with family medicine training were more likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio of 2.93)
  • Clinicians with a high score on the Medical Maximizer-Minimizer Scalewho indicated a trend of high utilization of medical services, were more likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio 2.06)
  • Resident physicians were less likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio of 0.57)
  • Clinicians in the Pacific Northwest were less likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio 0.49)
  • Survey respondents who would prescribe antibiotics in the asymptomatic bacteriuria scenario estimated the likelihood of a urinary tract infection (UTI) to be 90%, and survey respondents who would not prescribe antibiotics estimated 15% chance of a UTI

“The results of this survey suggest that most primary care clinicians prescribe inappropriate antibiotic treatment for asymptomatic bacteriuria in the absence of risk factors. This tendency is more pronounced among family physicians and medical maximizers and is less common among resident physicians and clinicians in the Clinician characteristics should be considered when designing antibiotic management interventions,” wrote the co-authors of the study.

Interpret the data

Findings related to the likelihood of a UTI likely indicate a lack of knowledge, the study co-authors wrote. “The overwhelming majority of clinicians who indicated they would prescribe antibiotics believed that the patient had a high likelihood of having a UTI, although case details did not support this diagnosis. We suspect that many many clinicians in our sample were unaware of what constitutes UTI symptoms or did not know that symptoms are required to support a UTI diagnosis.”

The study results indicate that medical residents have fewer knowledge gaps than treating physicians, many of whom do not benefit from better education about bacteriuria, the co-authors wrote. “Given that current residents were less likely than treating physicians to prescribe antibiotics, greater clarity in recent literature on what constitutes a symptom and the evolution of higher medical education on the appropriate management of asymptomatic bacteriuria may mean that knowledge gaps will be less of a problem in the future.”

In terms of cultural impact, the study indicates that a culture of high-value care in the Pacific Northwest likely led to better prescribing practices in that region of the country. The study’s lead author told HealthLeaders that promoting an effective antibiotic stewardship culture can be done during clinicians’ training or early in their careers.

“Clinicians tend to model their behaviors on what they observe from their peers. One way to encourage the development of good habits would be to encourage trainees and early career clinicians to practice in different parts of the country or in different settings, such as safety net hospitals or veterans facilities. That way, clinicians are exposed to different ways of practicing before bad habits become too entrenched,” said Jonathan Baghdadi, MD , PhD, Assistant Professor in the Department of Epidemiology and Public Health, University of Maryland Medicine.

The survey data shows that clinicians’ attributes can impact their clinical decisions, study co-author Daniel Morgan, MD, MS, told HealthLeaders. “Our study demonstrates that doctors are human and not always rational. Human aspects like personality and culture can change the way we treat patients,” said Morgan, professor of epidemiology, public health and medicine at the University of Maryland School of Medicine.

The finding that clinicians who were medical maximizers were more likely to prescribe antibiotics for asymptomatic bacteriuria was not surprising, Baghdadi said. “I suspect that the inappropriate prescribing of antibiotics for asymptomatic bacteriuria is driven by the common but potentially dangerous attitude that doing more is better, even when doing more is not supported by evidence, known as ‘action bias’ or by others as ‘yes first.’ When faced with a patient and not knowing what to do, many clinicians will choose to do something, even if it it is not clear that this will be beneficial.

Consequences of antibiotic management

“It’s very problematic that the majority of clinicians administer antibiotics when a patient is healthy, and antibiotics are not necessary,” Morgan said.

The study’s findings are “shocking”, Baghdadi said. “It is widely recognized that outpatient antibiotics for suspected UTIs are commonly prescribed in non-guideline recommended situations, using non-guideline recommended agents, for non-guideline recommended durations. The results of our study are shocking because we present a patient case in which there is no ambiguity, and yet the clinicians still prescribed inappropriate antibiotics.”

For clinicians facing cases of asymptomatic bacteriuria, clinical decision support is needed to encourage antibiotic management, Baghdadi said. “Education alone is not the answer. Asymptomatic bacteriuria is poorly understood by clinicians, and efforts to improve awareness of who will benefit from antibiotics do not change behaviors consistently or sustainably. ‘antibiotics solutions need to be integrated with e-health systems that guide clinicians to the right choice.’

Related: How to Implement Antibiotic Stewardship in Urgent Care Clinics

Christopher Cheney is the Clinical Care Editor at HealthLeaders.