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What’s New in the Patient Safety World

July 2022

Asymptomatic Bacteriuria Still Problematic

 

 

Inappropriate antibiotic prescribing can lead to emergence of antibiotic resistance, adverse drug reactions, development of opportunistic infections like C. diff, and add to unnecessary healthcare costs. Hence, the need for antibiotic stewardship programs.

 

One area of inappropriate antibiotic prescribing where attention has been focused is asymptomatic bacteriuria. Guidelines from the Infectious Diseases Society of America (Nicolle 2019) and Choosing Wisely recommend we do not treat asymptomatic bacteriuria with antibiotics.

 

But University of Maryland researchers recently identified a disturbing trend regarding how physicians approach asymptomatic bacteriuria. Baghdadi and colleagues (Baghdadi 2022) reported the results of a survey of 723 primary care clinicians (physicians and advanced practice clinicians) in active practice regarding their approach to a hypothetical patient with asymptomatic bacteriuria. Results were striking. 71% of respondents indicated that they would prescribe antibiotic treatment for asymptomatic bacteriuria in the absence of an indication. The tendency was more pronounced among family medicine physicians and those with a high score on the Medical Maximizer-Minimizer Scale (individuals with a stronger orientation toward medical maximizing prefer treatment even when the value of treatment is ambiguous). The tendency was less common among resident physicians and clinicians in the US Pacific Northwest.

 

The authors suggest that clinician characteristics should be considered when designing antibiotic stewardship interventions. Specifically, physician culture (rather than urine culture) may be an important determinant of inappropriate prescribing. The concept of “medical maximizers” was especially of interest. “Medical maximizers favor errors of commission over errors of omission, preferring to treat even when treatment has uncertain value and may introduce a chance of harm.” The authors note that their finding of an association between medical maximizing and inappropriate antibiotic prescribing is important because it suggests that certain tendencies among clinicians may pose a barrier to initiatives, such as Choosing Wisely, that are intended to combat the emergence of antimicrobial resistance.

 

Though not specifically addressing the issue of prescribing antibiotics for asymptomatic bacteriuria, there have been several other recent studies addressing physician characteristics related to inappropriate antibiotic prescribing. In our May 24, 2022 Patient Safety Tip of the Week “Requiring Indication for Antibiotic Prescribing” we noted a study (Neels 2020) citing many factors that contribute to inappropriate antibiotic prescribing in general practice. These include automatic repeat prescriptions, inappropriate durations and quantities and the extended period of time during which a prescription may be filled. In addition, some prescriptions are dispensed more than 60 days after the prescription date, suggesting likely usage for an alternate indication to that intended by the prescriber. Patient expectations may also lead to inappropriate antibiotic prescribing. They implemented an educational intervention in a large general practice clinic in Australia. It included face-to-face education sessions with physicians on antimicrobial stewardship principles, antimicrobial resistance, current prescribing guidelines and microbiological testing. This resulted in a significant reduction in prescriptions without a listed indication for antimicrobial therapy, prescriptions without appropriate accompanying microbiological tests and the provision of unnecessary repeat prescriptions. There were significant improvements in appropriate antimicrobial selection, appropriate duration, and compliance with guidelines. And two recent studies in BMJ Quality & Safety discussed factors related to long-term and repeat antibiotic prescriptions in primary care in the UK (Krockow 2022, Van Staa 2022).

 

 

Some of our prior columns on antibiotic stewardship:

 

 

Our other columns on urinary catheter-associated UTI’s:

 

·       May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”

·       January 8, 2008 Tip of the Week “Urinary Catheter-Associated Infections”

·       April 2008 What’s New in the Patient Safety World column “More on Nosocomial UTI’s”

·       June 24, 2008 Tip of the Week “Urinary Catheter-Related UTI’s: Bladder Bundles”

·       April 21, 2009 Tip of the Week “Still Futzing with Foleys?”

·       June 9, 2009 Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”

·       March 2010 “IDSA CAUTI Guidelines”

·       February 2011 What’s New in the Patient Safety World column “Catheters Not Needed in C-Sections?”

·       January 2012 “CAUTI’s Still Get No Respect”

·       May 2012 “Foley Catheter Hazards”

·       November 2012 “CAUTI Conundrum”

·       December 18, 2012 “Unintended Consequences of the CAUTI Measure?”

·       January 2013 “Silver-Coated Urinary Catheters Don’t Reduce CAUTI’s”

·       June 2013 “Barriers to CAUTI Prevention”

·       November 2013 “Further Reducing Urinary Catheter Use”

·       June 2014 “Updated HAI Prevention Guidelines from SHEA/IDSA”

·       June 30, 2015 “What Are Appropriate Indications for Urinary Catheters?”

·       December 2015 “CAUTI Prevention Tools”

·       July 2016 “Holy Moly, My Patient has a FOLEY!”

·       December 2016 “The Joint Commission NPSG for CAUTI’s”

·       April 3, 2018 “Cost of a CAUTI”

·       September 25, 2018 “Foley Follies”

·       April 30, 2019 “Reducing Unnecessary Urine Cultures”

·       March 2, 2021 “Barriers to Timely Catheter Removal”

·       March 2022 “Urinary Catheter Reinsertion”

 

 

References:

 

 

Nicolle LE, Gupta K, Bradley SF, et al.  Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis 2019; 68(10): e83-e110

https://academic.oup.com/cid/article/68/10/1611/5481760

 

 

Choosing Wisely Campaign. Infectious Diseases Society of America. Don’t treat asymptomatic bacteruria with antibiotics. Released February 23, 2015

https://www.choosingwisely.org/clinician-lists/infectious-diseases-society-antibiotics-for-bacteruria/

 

 

Baghdadi JD, Korenstein D, Pineles L, et al. Exploration of Primary Care Clinician Attitudes and Cognitive Characteristics Associated With Prescribing Antibiotics for Asymptomatic Bacteriuria. JAMA Netw Open 2022; 5(5): e2214268

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2792752?resultClick=3

 

 

Neels AJ, Bloch AE, Gwini SM, Athen E. The effectiveness of a simple antimicrobial

stewardship intervention in general practice in Australia: a pilot study. BMC Infectious Diseases 2020; 20: 586

https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-020-05309-8

 

 

Krockow EM, Harvey EJ, Ashiru-Oredope D. Addressing long-term and repeat antibiotic prescriptions in primary care: considerations for a behavioural approach. BMJ Quality & Safety 2022; Published Online First: 15 June 2022

https://qualitysafety.bmj.com/content/early/2022/06/14/bmjqs-2022-014821

 

 

Van Staa T, Li Y, Gold N, et al. Comparing antibiotic prescribing between clinicians in UK primary care: an analysis in a cohort study of eight different measures of antibiotic prescribing. BMJ Quality & Safety 2022; Published Online First: 03 March 2022

https://qualitysafety.bmj.com/content/early/2022/03/02/bmjqs-2020-012108

 

 

 

 

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