Most Clinicians Prescribe Antibiotics Inappropriately for Asymptomatic Bacteriuria

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

In a survey study of primary care clinicians, a majority of survey respondents said they would prescribe antibiotics for asymptomatic bacteriuria, which does not bode well for antibiotic stewardship, a new research article found.

Even if testing shows bacteria in a patient's urine, treating asymptomatic bacteriuria is against guidelines set by the Infectious Diseases Society of America. Prescribing antibiotics for asymptomatic bacteriuria can lead to negative outcomes, including the development of Clostridium difficile infection.

The new research article, which was published in JAMA Network Open, 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 with urination.

The study includes several key data points:

• Among 551 primary care clinicians surveyed, 71% said they would prescribe antibiotics in the asymptomatic bacteriuria scenario
   
• Clinicians with a background in family medicine were more likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio 2.93)
   
• Clinicians with a high score on the Medical Maximizer-Minimizer Scale, which indicated a tendency toward 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 0.57)
   
• Pacific Northwest clinicians 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 a 90% likelihood of a urinary tract infection (UTI), and survey respondents who would not prescribe antibiotics estimated a 15% likelihood of a UTI

"The findings of this survey study 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 medicine physicians and medical maximizers and is less common among resident physicians and clinicians in the U.S. Pacific Northwest. Clinician characteristics should be considered when designing antibiotic stewardship interventions," the study's co-authors wrote.

Interpreting the data

The findings related to the likelihood of a UTI probably indicate a knowledge gap, the study's co-authors wrote. "Overwhelmingly, clinicians who indicated they would prescribe antibiotics estimated that the patient had a high probability of having a UTI, although the case details did not support this diagnosis. We suspect that many clinicians in our sample were not aware of what constitutes UTI symptoms or were not aware that symptoms are required to substantiate a UTI diagnosis."

The study's findings indicate that resident physicians have less of a knowledge gap than attending physicians, many of whom do not have the benefit of better education about bacteriuria, the co-authors wrote. "Given that current residents were less likely than attending physicians to prescribe antibiotics, greater clarity in the recent literature on what constitutes a symptom and evolving graduate medical education on appropriate management of asymptomatic bacteriuria may mean that knowledge gaps will be less of an issue moving forward."

Regarding cultural impact, the study says a culture of high-value care in the Pacific Northwest likely led to better prescribing practices in that region of the country. The lead author of the study told HealthLeaders that fostering an effective antibiotic stewardship culture can be achieved while clinicians are 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 different settings, such as safety net hospitals or Veterans Affairs facilities. That way, clinicians are exposed to different ways to practice before bad habits can become too ingrained," said Jonathan Baghdadi, MD, PhD, an assistant professor in the Department of Epidemiology and Public Health at University of Maryland School of Medicine.

The survey data shows clinician 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 how we treat patients," said Morgan, who is a professor of epidemiology and public health and medicine at University of Maryland School of Medicine.

The finding that clinicians who were medical maximizers were more inclined to prescribe antibiotics for asymptomatic bacteriuria was not surprising, Baghdadi said. "I suspect that inappropriate antibiotic prescribing for asymptomatic bacteriuria is driven by the common but potentially harmful attitude that doing more is better, even when doing more is not supported by evidence, known as 'action bias' or by others as the 'Yes, Prime Minister' effect. When facing a patient and not being sure what to do, many clinicians will opt to do something, even if it's not clear that doing that thing will be beneficial."

Antibiotic stewardship implications

"It is highly problematic that the majority of clinicians would give antibiotics when a patient is healthy, and antibiotics are unnecessary," Morgan said.

The study's findings are "shocking," Baghdadi said. "It is widely recognized that outpatient antibiotics for suspected urinary infections are commonly prescribed in situations not recommended by guidelines, using agents not recommended by guidelines, for durations not recommended by guidelines. The findings from our study are shocking because we present a case patient in which there is no ambiguity, and yet clinicians prescribed inappropriate antibiotics anyway."

For clinicians who face asymptomatic bacteriuria cases, clinical decision support is needed to encourage antibiotic stewardship, 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 consistently or sustainably change behavior. To change antibiotic prescribing, solutions need to be hard-wired into electronic health systems that guide clinicians toward making the right choice."

Related: How to Implement Antibiotic Stewardship at Urgent Care Clinics